Daily Assessment Guide, My First

Daily Assessment Guide (Update Appropriately Daily) Student Name:

Dates of care: 21 October 2009

Client Initials: I.N.

Age:

80

Sex: Female

Admitting Diagnosis: Re-fracture Right Femur (Include date) 20 October 2009 Current Medical Diagnosis: Diabetes, Kidney Disease (Include Dates) Past Medical History: Diabetes, Kidney Disease, Depression, Constipation (Include Dates) Allergies:

Food: NKDA

Drugs:

Morphine

Other:

Client's main concern today: Day 1: Patient is frustrated about the re-fracture of her hip and is concerned about it happening again. Student’s main concern today: Day 1:

Nervous about taking care of patient for the first time.

Learning Needs: Last grade completed: 1. Identify at least one overt learning need for this client each day. Day 1: Techniques for position changes 2. Write a knowledge deficit nursing diagnosis with a R/T statement that corresponds to your client's learning need. Day 1: Knowledge Deficit: Risk for impaired skin integrity r/t hip surgery AEB inability to move leg. 3. State the appropriate level and basic need (Maslow) that corresponds to the identified learning need. Day 1: Physiological. Safety & Security 4. State your client's developmental level. Stage Integrity vs. Despair 5. Write a brief definition of each current medical diagnosis listed and those listed in Past Medical History on a separate piece of paper and include with assessment. Document source of definitions using APA (American Psychological Association) format.

Basic Needs

Objective Data

I. Physiological Needs A. Oxygenation 1. Respiratory -Rate of Resp/Min (day #1 & day #2) -Depth (volume) of respirations(shallow/deep) -Rhythm of respiration, regular / irregular -Ease of respirations, labored / unlabored -Chest movements: even / uneven -lung sounds--describe gurgles / wheezing/ crackles -Cough: Absent/present nonproductive/productive if productive describe sputum -skin color Other pertinent data (all influencing factors, e.g. lab work, X-rays, med history, meds, present surgery, etc.):

Subjective Data

List Need and Nursing Dx Need: Met

O1

13

O2

Deep

O3

Regular

O4

Unlabored

O5

Even

O6

Lung sounds normal

O7

Absent

O8

Normal

O9

Right hip surgery

O10

Kidney Disease

O11

Diabetes

Basic Needs A.

Objective Data

Subjective Data

List Need and Nursing Dx Need: Met

Oxygenation 2. Cardiovascular

-HeartRate Apical: Rate: Rhythm: Volume: Radial: Rate: Rhythm Volume: Pedal: Rhythm Symmetry Equality

O12 O13

76 Regular

O14 O15

78 Regular

Volume -General color of skin and/or color of extremities: -Nails: (Color) -Mucous Membranes: -Color -Capillary refill: prompt/sluggish -Skin Temperature -Blood Pressure: 24 hr Readings (day #1 & #2) Other pertinent data: (All influencing factors, e.g. lab work, x-rays, med hx, meds, present surgery etc.)

Basic Needs

O16

Uniform

O17 O18

Pink & Moist

O19 O20 O21

Prompt

O22 O24 O25 O26

Blood Glucose 89 R Chest VAD L Mastectomy Refer to O9 for surgery data

148/78

Objective Data

Subjective Data

List Need and Nursing Dx

B. Rest -Sleep medication ordered

O27

None S1 I got to bed every night at 8 o’clock. S2 I sleep around 6 hours

-Usual sleep pattern: -Usual total time of sleep: -Usual hours of sleep: (give times) -Naps, yes/no: time(s) of nap (s): -Usual sleep habits/rituals -Usual sleep environment -Sleep while hospitalized -Quality of sleep & quantity:

Other Pertinent Data: All influencing factors, concurrent stressors, mood, treatments, drug interactions, etc., medical history

S3

I take a nap after brunch

S4 I close the drapes and lay in bed S5 Not too much, they keep waking me up for this and that.

O28 Depression

Need: Unmet Nursing Diagnosis:  Disturbed Sleep Pattern R/T: unfamiliar surroundings As indicated by: fatigue.

Basic Needs

C. Mobility -Age -Diagnosis -Activity ordered -Pre-illness activity -Activity -how well tolerated -Able to move all extremities -Assistance needed/ devices -Degree of range of motion -Contractures/ deformities -Body alignment -Amputations/ fractures -Pain -Balance -Steady/unsteady gait -Weight bearing -Sensations – numbness/ tingling -What degree of self care of ADL’s Other pertinent data: environmental obstacles meds treatments procedures

Objective Data O29 O30 O31

80 y/o Refer to O9 Currently seeing a P.T.

O32

Somewhat tolerated

O33 O34

No movement with right leg Two person assist

O35 O36

Refer to O9 Yes

O37 O38

Unsteady No

Moderate

O39 Amiodarone, Aspirin, Senna Pod, Vitamin E, Fenobrite, Diltiazem HCL, Fluoxetine HCL, Heparin, Ramipril, Glipizide, Lispro Insulin, Fluocinonide, OxycodoneAPAP

Subjective Data

List Need and Nursing Dx Need: Met or Unmet

 Impaired physical mobility  Self-care deficit: feeding, S6 I love going to the stores. Even if I bathing/hygiene, dressing/ don’t buy anything. grooming/toileting R/T: hip surgery. Non weight bearing

S7 A nine

As indicated by: inability to ambulate.