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 Subjective Data List Need and Nursing Dx
I. Physiological Needs Need: Met
A. Oxygenation
1. Respiratory

-Rate of Resp/Min O1 13
(day #1 & day #2)
-Depth (volume) of
respirations(shallow/deep) O2 Deep
-Rhythm of respiration, O3 Regular
regular / irregular
-Ease of respirations,
O4 Unlabored
labored / unlabored
-Chest movements:
even / uneven O5 Even
-lung sounds--describe O6 Lung sounds normal
gurgles / wheezing/ crackles
-Cough: Absent/present
O7 Absent
nonproductive/productive
if productive describe
sputum
-skin color O8 Normal

Other pertinent data (all O9 Right hip surgery

influencing factors, e.g. lab O10 Kidney Disease
work, X-rays, med history,
meds, present surgery, etc.): O11 Diabetes
 Basic Needs Objective Data Subjective Data List Need and Nursing Dx
A. Oxygenation Need: Met
2. Cardiovascular
-HeartRate
Apical: Rate: O12 76
Rhythm: O13 Regular
Volume:
Radial: Rate: O14 78
Rhythm O15 Regular
Volume:
Pedal:
Rhythm
Symmetry
Equality
Volume
-General color of skin O16 Uniform
and/or color of extremities:
-Nails: (Color) O17
-Mucous Membranes:
O18 Pink & Moist
-Color
-Capillary refill:
prompt/sluggish O19 Prompt
-Skin Temperature O20
-Blood Pressure: 24 hr O21 148/78
Readings (day #1 & #2)
Other pertinent data:
(All influencing factors, e.g. O22 Blood Glucose 89
lab work, x-rays, med hx, O24 R Chest VAD
meds, present surgery etc.) O25 L Mastectomy
O26 Refer to O9 for surgery data

Basic Needs Objective Data Subjective Data List Need and Nursing Dx
B. Rest
-Sleep medication ordered
-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:
Need: Unmet
Nursing Diagnosis:
O27 None  Disturbed Sleep Pattern
S1 I got to bed every night at 8
o’clock.
S2 I sleep around 6 hours R/T: unfamiliar surroundings
S3 I take a nap after brunch As indicated by: fatigue.
S4 I close the drapes and lay in bed
S5 Not too much, they keep waking
me up for this and that.

Other Pertinent Data:

All influencing factors,
O28 Depression
concurrent stressors, mood,
treatments, drug interactions,
etc., medical history
 Basic Needs Objective Data Subjective Data List Need and Nursing Dx
C. Mobility Need: Met or Unmet
-Age O29 80 y/o
-Diagnosis O30 Refer to O9  Impaired physical mobility
-Activity ordered O31 Currently seeing a P.T.
 Self-care deficit: feeding,
-Pre-illness activity S6 I love going to the stores. Even if I
bathing/hygiene, dressing/
-Activity -how well O32 Somewhat tolerated don’t buy anything.
grooming/toileting
tolerated
-Able to move all extremities O33 No movement with right leg
R/T: hip surgery.
-Assistance needed/ devices O34 Two person assist
Non weight bearing
-Degree of range of motion
-Contractures/ deformities
-Body alignment As indicated by: inability to
-Amputations/ fractures O35 Refer to O9
ambulate.
-Pain O36 Yes S7 A nine
-Balance
-Steady/unsteady gait O37 Unsteady
-Weight bearing O38 No
-Sensations – numbness/
tingling
-What degree of self care of Moderate
ADL’s

Other pertinent data:

environmental obstacles O39 Amiodarone, Aspirin, Senna
meds Pod, Vitamin E, Fenobrite,
treatments Diltiazem HCL, Fluoxetine HCL,
procedures Heparin, Ramipril, Glipizide, Lispro
Insulin, Fluocinonide, Oxycodone-
APAP