DOWNTIME DAILY NURSING ASSESSMENT & CARE PLAN (Patient Label)
1 of 5
Date: Time:
PAIN No Pain
Pain Present Other
Location: Score: Scale:__________ Numeric NVPS
Pain Description:___________________________________________ Pain Intervention:-_____________ Pain Reassessment:_______________
Sedation Level(ICU Only)________________
POSS Sedation Assessment: ________________Intervention:_______________ POSS Reassessment:____________________
Sedation level > 3 Intervention: ______________________________________
SAFETY
Fall Risk Screen:
Unsteady gait 20-up and go takes over 20 seconds 0- steady gait
Disoriented 10-disoriented 0- oriented
At risk behavior 20-at risk 0- not at risk
Assistance w/ BR or has Foley 10- yes 0- no
Fall risk meds 10- yes 0- no
More than 4 medications 10- yes 0- no
2 or more falls in the last 12 months 20- yes 0- no
Total (if 30 or over patient is at risk)_______________________
Interventions:
Protocol Initiated Protocol Reviewed Protocol Discontinued Fall Risk ID on Bed exit alarm on Safety Checks
Near nursing station Toileting assist
Isolation Type___________________________ Precautions: _____________________________________________
Restraints Type_____________________________________
NEURO WNL WNL Except
Orientation: Oriented:_____________ confused:______________________________________________________________________________
LOC: lethargic unresponsive responds to pain follows commands sedated unable to assess___
Pupils R size 1 2 3 4 5 6 shape_____________ reaction _____________
L size 1 2 3 4 5 6 shape_____________ reaction _____________
Speech: normal slurred impediment aphasic other ___________
Sensation: R Arm absent patchy L Arm absent patchy R Leg absent patchy L Leg absent patchy
Reflexes corneal R L gag present absent cough present absent Dolls eyes present absent
Occulovestibular present absent Babinski R L bilateral
Swallow Screen: pass fail
Seizures: Type generalized partial/complex partial/simple witnessed y n duration _______min postictal _________min
Other:__________________________________________________________________________________________________________________
Interventions neuro checks room darkened seizure precautions 24 h EEG monitoring Other _______________________ SLP notified
MUSCULOSKELETAL WNL WNL Except
Activity Restriction: ___________________________________________Activity Aids:____________________________________________________
Motor Strength Extremities: R Arm __/5 L Arm __/5 R Leg __/5 L Leg __/5 Speech:___________________________________________________
Support Device: Type:__________________________________________Location:_____________________________________________________
Other:___________________________________________________________________________________________________________________
Interventions: __________________________________________________________________________________________________ PT OT
Ortho / Vasc WNL WNL Except
Motor, Sensitivity, Color, Pulse, Temp
R Arm L Arm R Leg L Leg R Foot L Foot
Interventions: _________________________________________________________________________________
RESPIRATORY WNL WNL Except
Abnormal findings: accessory muscles agonal Cheyne-Stokes irregular Kussmaul
labored nasal flaring retractions shallow tachypnea
Exceptions: cannot breathe chest tight cough smothering SOB other__________________________________
Breath Sounds rhonchi R L diminished R L crackles R L wheezes R L stridor absent R L coarse R L
Cough description_____________________________________________ nonproductive productive____________________________________
Chest tube: type _____________location ___________site assess _____________suction ___________drainage:_____________ air leak yes no
Chest tube: type _____________location ___________site assess _____________suction ___________drainage_____________ air leak yes no
Chest tube: type _____________location ___________site assess _____________suction ___________drainage_____________ air leak yes no
Other:____________________________________________________________________________________________________________________
Interventions: O2 ____________ Vent ETT ____size ____cm R L O N Trach _______Type ________ size ________
Other:___________________________________________________________________________________________________
RN Signature:_____________________________________________________
*1514*
Origin: 9/05 revised: 1/09; 5/09; 7/10; 9/11; 10/14; 1/15; 6/15
DOWNTIME DAILY NURSING ASSESSMENT & CARE PLAN (Patient Label)
2 of 5
Date: Time:
CARDIOVASCULAR WNL WNL Except
Heart Sounds: S1 S2 S3 S4 Murmur______ irregular distant rub Rhythm:___________________Ectopy:__________________
Pacemaker: yes no temporary permanent ICD other___________________
Edema: RUE trace 1 2 3 4 pit non-pit LUE trace 1 2 3 4 pit non-pit RLE trace 1 2 3 4 pit non-pit LLE trace 1 2 3 4 pit non-pit
generalized sacral facial other__________________________________________________________________________
Pulses: R radial 0 1 2 3 4 dop L radial 0 1 2 3 4 dop R dorsalis pedis 0 1 2 3 4 dop L dorsalis pedis 0 1 2 3 4 dop
Chest Pain: Rating (0-10):________ Location:_______________ Description:__________________ Associated
Symptoms:____________Intervention:________________________________________________ SCD’s applied R Leg L Leg
Tele: Rhythm____________________________________ Intervention:________________________________________________
Other:__________________________________________________________________________________________________________
Interventions:______________________________________________________________________________________________________
IV CARE WNL WNL Except
#1 IV EDP PICC Port HD Site Assessment Dressing Changed V Blood
Intervention:______________________________________________________________________________________________________
#2 IV EDP PICC Port HD Site Assessment Dressing Changed V Blood
Intervention:______________________________________________________________________________________________________
#3 IV EDP PICC Port HD Site Assessment Dressing Changed V Blood
Intervention:______________________________________________________________________________________________________
GI/NUTRITION WNL WNL Except
Bowel sounds: hyperactive hypoactive absent Abdomen: soft flat distended tender
Exceptions: bleeding incontinent diarrhea emesis nausea other:_____________________________________________________
C-diff screen: No continued daily assessment C-diff protocol in progress Greater than 3 watery stools
Ostomy: type: __________________________________stoma description:_______________________________
Stool:______________________________________________________________________________ Last BM
Tube: type ______________location _____________site assess_____________suction___________drainage______________________________
Tube: type ______________location _____________site assess_____________suction___________drainage______________________________
Tube: type ______________location _____________site assess_____________suction___________drainage______________________________
Other:
Interventions RD notified
GU WNL WNL Except
Urinary Symptoms: hematuria incontinent oliguria dysuria frequency nocturia urgency hesitancy spasms other:
Urine description: Bladder: Distended Palpable
Catheter type__________________Size_________________________Location:_________________________________Date:__________________
Catheter Necessity: acute retention/bladder obstruction accurate urine output surg proc. > 2 hrs healing sacral/perineal wound in incont pt
improve comfort of end of life care
HD Access type:_________________location:___________________assessment:____________________________________ thrill bruit
Peritoneal type:_________________location:___________________fluid:_______________________site assess:___________________________
Other:___________________________________________________________________________________________________________________
Interventions:
REPRODUCTIVE WNL WNL Except
Assess: ________________________________________________________
Discharge: ______________________________________________Breast Exam:_____________________________________________________
Antepartum _____________________________________________Post Partum:______________________________________________________
Infant Feeding Preference ____________________Mom/emotional Status _________________Infant Attachment:____________________________
Other:__________________________________________________________________________________________________________________
Interventions: ________
SKIN Risk Screen WNL WNL Except
Skin Assess: Appearance: dry/flaky petechiae rash ecchymosis Color: pale pink cyanotic ashen mottled jaundiced
Temp: warm dry moist clammy other complaints:______________________________________________________________
Skin Protection:__________________________________________________________________________________________________________
Daily Skin Risk (Braden Score) - circle
Mobility: 1=Completely Immobile 2=Very Limited 3=Slight limited 4=No limitations
Sensory Perception 1=Completely Limited 2=Very Limited 3=Slight limited 4=No impairment
Nutrition 1=Very Poor 2=Probably Inadequate 3=Adequate 4=Excellent
Moisture 1=Constantly Moist 2= Moist 3=Occasionally Moist 4=Rarely Moist
Friction and Shear 1=Problem 2=Potential Problem 3=No apparent problem
Activity 1=Bedfast 2=Chairfast 3=Walks Occasionally 4=Walks frequently
Braden Score If less than <18 = Skin Precautions
Interventions:
RN Signature:_______________________________________
Origin: 9/05 revised: 1/09; 5/09; 7/10; 9/11; 10/14; 5/15; 6/15 *1514*
DOWNTIME DAILY NURSING ASSESSMENT & CARE PLAN (Patient Label)
3 of 5
Date: Time:
WOUNDS WNL WNL Except
Wound 1: type: location: ________ appearance:_____________________closures:__________________________
drainage:______________________intervention:______________________________________________________________________________
Wound 2: type: location: ________ appearance:_____________________closures:__________________________
drainage:______________________intervention:______________________________________________________________________________
Wound 3 type: location: ________ appearance:_____________________closures:__________________________
drainage:______________________intervention:______________________________________________________________________________
Wound 4: type: location: ________ appearance:_____________________closures:__________________________
drainage:______________________intervention:______________________________________________________________________________
DRAINS WNL WNL Except
Drain 1: type: location: ________ appearance:_____________________closures:__________________________
drainage:______________________intervention:______________________________________________________________________________
Drain 2: type: location: ________ appearance:_____________________closures:__________________________
drainage:______________________intervention:______________________________________________________________________________
Drain 3: type: location: ________ appearance:_____________________closures:__________________________
drainage:______________________intervention:______________________________________________________________________________
Other:__________________________________________________________________________________________________________________
EMOTIONAL / MENTAL WNL WNL Except
Mood/affect: angry anxious agitated inappropriate response labile sad withdrawn hopeless
Intervention: CIWA protocol encourage expression limit visitors active listen reassure reinforce other________________________
Self Harm Screen: irritability uncontrolled symptoms refusing social interaction refusing ordered tx requesting early d/c
Current MD Dx/disease dementia chronic pain end stage CA active psych illness new dx of chronic illness late stage chronic illness
Self Harm Screen outcome: no risks-cont.daily self harm screen identified risks-complete suicide screen
End of life care Interventions:________________________________________________________________________________________
ENDOCRINE WNL WNL Except
diaphoresis blurred vision dizziness hot/cold fatigue polydipsia polyuria other__________________________________________
Assess: diabetes exophthalmos goiter gynecomastia jaundice moon face hirsutism nailbed changes
Other:________________________________________________________________________________________________________________
Interventions:________________________________________________________________________________________________ DTC notified
ONCOLOGY WNL WNL Except
Infusion: access blood return:___________________type:_____________reaction:____________
interventions:______________________________________________________________________________________________________
Adverse Event: ____________________________________________
PATIENT EDUCATION
Preferred Methodology: verbal written visual demonstration other
Identified barriers none language cognitive hearing/visual physiological psychological culture/ethnic reading difficulty
uninterested
Taught whom patient significant other family friend other_____________________
How provided verbal written other___________________________________________ Learning needs: current new discharge review
Content: bathroom equipment room how to call RRT fall prevention/amb hand hygiene resp hygiene contact precautions
VTE prevention BSI prevention CAUTI unit/room orientation anticoagulation
Other_________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Understanding: understands need reinforcement
Other:__________________________________________________________________________________________________________________
Interventions:_____________________________________________________________________________________________________________
Special Events:
Critical Results Off Unit Transfer / Handoff Belongings Coordination of Care
Rapid Response Other:_________________________________ Intervention______________________________________________
D/C Planning: D/C Home D/C Planner Notified
Additional Observations (for more notes see Interdisciplinary Progress Notes) :
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
RN Signature:_______________________________________
Origin: 9/05 revised: 1/09; 5/09; 7/10; 9/11; 10/14; 5/15; 6/15 *1514*
DOWNTIME DAILY NURSING ASSESSMENT & CARE PLAN (Patient Label)
4 of 5
Date: Time:
CARE PLANS
1- extreme deviation from normal limit 2- severe deviation from normal limit 3-moderate deviation from normal limit
4-mild deviation from normal limit 5-no deviation from normal limit
Pain
Nursing diagnosis:
Goal
Intervention
Evaluation 1 2 3 4 5
Safety
Nursing diagnosis:
Goal
Intervention
Evaluation 1 2 3 4 5
Restraint Prevention
Nursing diagnosis:
Goal
Intervention
Evaluation 1 2 3 4 5
Nutrition
Nursing diagnosis:
Goal
Intervention
Evaluation 1 2 3 4 5
Neuro/Cognition
Nursing diagnosis:
Goal
Intervention
Evaluation 1 2 3 4 5
Respiratory
Nursing diagnosis:
Goal
Intervention
Evaluation 1 2 3 4 5
Cardiovascular
Nursing diagnosis:
Goal
Intervention
Evaluation 1 2 3 4 5
GI/Elimination
Nursing diagnosis:
Goal
Intervention
Evaluation 1 2 3 4 5
GU/Elimination
Nursing diagnosis:
Goal
Intervention
Evaluation 1 2 3 4 5
RN Signature:_______________________________________
Origin: 9/05 revised: 1/09; 5/09; 7/10; 9/11; 10/14; 5/15; 6/15 *1514*
DOWNTIME DAILY NURSING ASSESSMENT & CARE PLAN (Patient Label)
5 of 5
Date: Time:
CARE PLANS (continued)
1- extreme deviation from normal limit 2- severe deviation from normal limit 3-moderate deviation from normal limit
4-mild deviation from normal limit 5-no deviation from normal limit
Reproductive
Nursing diagnosis:
Goal
Intervention
Evaluation 1 2 3 4 5
Skin/Wound
Nursing diagnosis:
Goal
Intervention
Evaluation 1 2 3 4 5
Emotional/Mental
Nursing diagnosis:
Goal
Intervention
Evaluation 1 2 3 4 5
Suicide Prevention
Nursing diagnosis:
Goal
Intervention
Evaluation 1 2 3 4 5
Activity/Rest
Nursing diagnosis:
Goal
Intervention
Evaluation 1 2 3 4 5
Health Promotion
Nursing diagnosis:
Goal
Intervention
Evaluation 1 2 3 4 5
Ped Socialization
Nursing diagnosis:
Goal
Intervention
Evaluation 1 2 3 4 5
Prioritization:
Problem #1 Nursing Diagnosis:
Problem #2 Nursing Diagnosis:
Problem #3 Nursing Diagnosis:
RN Signature:_______________________________________
Origin: 9/05 revised: 1/09; 5/09; 7/10; 9/11; 10/14; 5/15; 6/15 *1514*
