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    Daily Nursing Assessment

    Uploaded by

    kiku_lai
    This document contains a daily nursing assessment flowsheet to be completed each shift. It includes sections to document the patient's mental status, physical status, vital signs, diet, sleep, activities of daily living, and hygiene. Nursing staff are to observe and record the patient's orientation, mood, behavior, appearance, ambulation, speech, and more at 0700-1900 and 1900-0700 to monitor their condition over time.

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    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Daily Nursing Assessment

    Uploaded by

    kiku_lai
    620 views2 pages
    This document contains a daily nursing assessment flowsheet to be completed each shift. It includes sections to document the patient's mental status, physical status, vital signs, diet, sleep, activities of daily living, and hygiene. Nursing staff are to observe and record the patient's orientation, mood, behavior, appearance, ambulation, speech, and more at 0700-1900 and 1900-0700 to monitor their condition over time.

    Original Title

    DAILY NURSING ASSESSMENT

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    This document contains a daily nursing assessment flowsheet to be completed each shift. It includes sections to document the patient's mental status, physical status, vital signs, diet, sleep, activities of daily living, and hygiene. Nursing staff are to observe and record the patient's orientation, mood, behavior, appearance, ambulation, speech, and more at 0700-1900 and 1900-0700 to monitor their condition over time.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    620 views2 pages

    Daily Nursing Assessment

    Uploaded by

    kiku_lai
    This document contains a daily nursing assessment flowsheet to be completed each shift. It includes sections to document the patient's mental status, physical status, vital signs, diet, sleep, activities of daily living, and hygiene. Nursing staff are to observe and record the patient's orientation, mood, behavior, appearance, ambulation, speech, and more at 0700-1900 and 1900-0700 to monitor their condition over time.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    DAILY NURSING ASSESSMENT

    FLOWSHEET
    (complete each shift)
    0700 – 1900 1900 - 0700
    MENTAL STATUS MENTAL STATUS
    Orientation: Memory: Activity: Orientation: Memory: Activity:
    Time/Date Impaired Cooperative Time/Date Impaired Cooperative
    Place Intact Uncooperative Place Intact Uncooperative
    Person Threatening Person Threatening
    Social Social
    Affect: Thinking: Withdrawn Affect: Thinking: Withdrawn
    Inappropriate Logical Aggressive Inappropriate Logical Aggressive
    Appropriate Grandiose Lethargic Appropriate Grandiose Lethargic
    Depressed Concrete Hyperactive Depressed Concrete Hyperactive
    Euphoric Tangential Limit-testing Euphoric Tangential Limit-testing
    Frightened Blocked Manipulative Frightened Blocked Manipulative
    Sarcastic Confused Disruptive Sarcastic Confused Disruptive
    Labile Loose Labile Loose
    Flat/blunted Persecutory Eye Contact: Flat/blunted Persecutory Eye Contact:
    Anxious Paranoid Good Anxious Paranoid Good
    Constrict Pressured Fair Constrict Pressured Fair
    Suspicious Fleeting Suspicious Fleeting
    Angry Judgement: None Angry Judgement: None
    Poor Poor
    Adequate Adequate
    Suicidal (describe): Suicidal (describe):

    Self Injurious (describe): Self Injurious (describe):

    Homicidal (describe): Homicidal (describe):

    Hallucinations (describe): Hallucinations (describe):

    Delusions (describe): Delusions (describe):

    0700 – 1900 1900 - 0700


    Attend 2 or more groups: Y N Y N
    Attention to task (10 minutes +): Y N Y N
    Can retain 1 step directions : Y N Y N
    Responds beyond YES or NO: Y N Y N
    Initiates conversation: Y N Y N
    Short-term memory: WNL Impaired Intact Y N Y N

    ________________________________
    Patient Name

    ________________________________
    Date
    PHYSICAL STATUS PHYSICAL STATUS
    Appearance: Gait: Ambulation: Appearance: Gait: Ambulation:
    Neat Steady Unassisted Neat Steady Unassisted
    Clean Shuffling Assisted Clean Shuffling Assisted
    Disheveled Unsteady Wheelchair Disheveled Unsteady Wheelchair
    Bizarre Walker Bizarre Walker

    Speech: E.P.S. Eval: Other: Speech: E.P.S. Eval: Other:


    Clear/norm N/A ___________ Clear/norm N/A ___________
    Pressured No signs ___________ Pressured No signs ___________
    Slow Fine Tremor ___________ Slow Fine Tremor ___________
    Soft Facial twitch Soft Facial twitch
    Mute Restlessness Mute Restlessness
    Fast Rigidity Fast Rigidity
    Loud Drooling Loud Drooling
    Slurred Shuffling Slurred Shuffling

    Vital Signs
    B/P
    Time T P R B/P lying B/P sitting standing Initial

    Lab Drawn: Yes No UA Obtained: Yes No

    Weight: _______________________

    0700 – 1900 1900 - 0700


    Diet: document % taken (S = snack, B = breakfast, L = lunch, D = dinner B=% S=%
    L=%
    [ I ] Independent [A] Assist S=%
    D=%
    Health Shake: Yes No
    Last Date of Mensus: Currently on Mensus Yes No
    Output / Stool:
    Output / Urine: [ C ] Continent [ I ] Incontinent
    Hours of Sleep: (write number of hours slept) Onset
    ADL’s: [ S ] Self [ A ] Assist [ TC ] Total Care
    Shower: [ S ] Self [ A ] Assist [ TC ] Total Care

    0700 – 1900 1900 - 0700

    Staff Signature Initials Staff Signature Initials

    revised 7/22/99 f:group\phf\forms\flowsheet

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