CALHOUN COMMUNITY COLLEGE

NURSING DEPARTMENT

STUDENT NAME____________________
DATE OF EXPERIENCE_______________
PATIENT INITIALS__________________
MEDICAL DIAGNOSES_______________
SURGICAL PROCEDURE______________

DAILY ASSESSMENT GUIDE

DIRECTIONS: FOR ABNORMAL FINDINGS GIVE DETAILS IN NARRATIVE FORM ON

SEPARATE SHEET

How are you feeling?

Are you having any problems?

How was your night?

Are you having any pain?

INTEGUMENTARY SYSTEM:
Color______ Texture_________ Moisture__________ Temperature__________
Turgor_______ Rashes/Lesions__________ Pruritus___________
Bruising________________

CIRCULATORY SYSTEM:
T___________ P/rate________________ Rhythm________________
Strength________________ B/P________
(Describe any abnormals)
(a)Jugular Vein Distension - absent/present
(b)Apical pulse - rate_________ Rhythm___________ Strength__________________
Pedal Pulses: Present Absent
Dorsalis Pedis LR LR
Posterior Tibial LR LR

RESPIRATORY SYSTEM:
Describe Respirations: Rate______ Rhythm____________ Effort_____________
Auscultate Breath Sounds & Describe___________________________________
Respritory Equipment________________________________________________

GASTROINTESTINAL SYSTEM:
Diet(Type, amount eaten)________________
P.O. Fluids(Type, amount)________________ Last Bowel Movement___________
Any changes from normal pattern__________ Any nausea____________________
Vomiting__________ Distension____________ Passing Flatus_________________
Other Observations(tenderness, rigidity)__________________________________
Auscultate bowel sounds & describe______________________________________
Enteral feeings NG____________ Gastro____________ Jejunostomy____________
NG for decompression____________
GENITOURINARY SYSTEM:
Are you voiding?________ Is there any pain?___________ Burning?_____________
Urgency?____________ Frequency___________ Amount voided________________
Color of urine______________________ Characteristics_______________________
Foley amount_________________

MUSCULO-SKELETAL SYSTEM:
Activity for today_______________________________________________________
Ambulation aids__________________________________Weakness______________
Limited ROM?_________________________________

NEUROLOGICAL SYSTEM:
Symmetry/Bilateral_____________________________ Numbness_________________
Dizziness______________________ Tingling_____________ Other________________
Orientation___________________LOC(Level of Consciousness)__________________

HEENT:
Discharge/Drainage______________________ Are you able to swallow?____________
Condition of teeth/dentures?_______________Hearing ability_____________________
Vision(glasses)______________________PERRLA Yes__________ No_______________

ASSESS THE FOLLOWING:

Type of Fluid________________________Volume of Fluid________________________
Rate of Infusion_______________________Infusing per pump_____________________
Gravity______________________________TPN_________________________________
IV Site___________________ Site Assessment_________________________________
Type of IVPB______________________
Heparin/Saline Lock__________________
Surgical Drainage Tubes__________________ Incision Site________________________
Dressings___________________________Other_________________________________

EKG Report________________________________________________________________
X-Ray Report______________________________________________________________
Allergies_________________________________s/s_______________________________

Current Medications_________________________________________________________
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ADDITIONAL ASSESSMENT DATA:

List expected developmental stage and task(Erikson)