SHIFT ASSESSMENT WORKSHEET LEVEL 1

Student name: ______Patient initials:______Date:______

Highlight all abnormal data.

A question mark following any item should prompt you to obtain subjective data.

  1. Vital Signs
  2. Temperature
  3. Radial Pulse
  4. Respirations
Rate, depth & effort
  1. Blood Pressure
  2. Pain Assessment

Cognitive and Sensory
  1. Neurological System
  2. Level of Consciousness
Awake, Alert & Oriented x 3?
  1. Pupils
Size & Briskness
  1. Ability to see
Wears glasses to ambulate / socialize?
Wears glasses to read / eat?
  1. Ability to hear
Hard of hearing?
Hearing aids?
  1. Bilateral hand grip strength
  2. Lower extremity strength

Gas Exchange
  1. Respiratory System
  2. Bilateral Lung sounds
Front(4-6 fields)
Back(6-8 fields)
  1. Oxygen
Delivery & rate
Is patient wearing?
Causing discomfort?
  1. Buccal /peripheral cyanosis
  2. Capillary refill
  3. Cough?
Productive
Non-productive
Perfusion
  1. Cardiac System
  2. Radial pulses(Use 0-3 scale)
0 – 3+
Equal bilaterally
  1. Pedal pulses(Use 0-3 scale)
0-3+
Equal bilaterally
  1. Apical pulse(APTM)
S₁ - S₂
One full minute
  1. Jugular vein distention
  2. Skin/Mucous Membrane
Color
  1. Surface temperature of extremities

Elimination
  1. Gastrointestinal System
  2. Wears dentures to eat?
  3. Bowel sounds
4 quadrants
Active, hyperactive or hypoactive
  1. Palpate abdomen
Firmness
Masses
Tenderness?
  1. Continent?
Incontinence products?
  1. Last bowel movement (LBM)?
  2. Nausea/Vomiting/ Diarrhea?
  3. Ostomy
Appliance intact
Color, consistency & volume
  1. Genitourinary System
  2. Difficulty with urination?
Pain?
Burning?
Frequency?
Urgency?
Retention?
  1. Continent?
Incontinence products?
  1. When was last urination?
  2. Urine
Color?
Odor?
Consistency?
  1. Specimen needed
  2. Foley Catheter
Color, consistency & volume
Draining to bedside gravity
Pain / discomfort?
Mobility
  1. Musculoskeletal System
  2. Gait
Steady/Unsteady
Assistive devices for ambulation or transfer?
  1. Range of motion
RUE
LUE
RLE
LLE
  1. Pain with movement?
  2. Calf tenderness? & size
  3. Muscle strength
Equal bilaterally
RUE(0-5)
RLE(0-5)
LUE(0-5)
LLE(0-5)
Tissue Integrity
  1. Integumentary System
  2. Surface temperature of the skin
  3. Redness
boney prominences
  1. Skin tears
  2. Turgor
  3. Abnormal growths / moles?
  4. Rashes?
Urticaria
  1. Pruritus?
  2. Wounds
  3. Dressings

Subjective Data
Complaints / Discomforts?
Intake & Output
Total Liquid Intake: / Number / Size of Bowel Movement(s):
Total Liquid Output: / Emesis:
I & O Liquid Balance:
Breakfast / AM Snack / Lunch / PM Snack
Nurse Notes
Hand-off Report
Situation
Background
Assessment
Recommendation

Morse Fall Risk Assessment Tool

Fall Risk is based upon Fall Risk Factors and it is more than a Total Score. Determine Fall Risk Factors and Target Interventions to Reduce Risks. Complete on all patients at admission, at change of condition; transfer to a new unit, and after a fall.

Morse Fall Risk Assessment Tool / Score / Admission Date: / Review Date: / Review Date: / Review Date:
History of Falling / NO
YES / 0
25
Secondary Diagnosis / NO
YES / 0
25
Ambulatory Aid / None/bedrest/nurse assist / 0
Crutches/cane/walker / 15
Furniture / 30
IV or IV access / NO
YES / 0
25
Gait / Normal/bedrest/wheelchair / 0
Weak / 10
Impaired / 20
Mental
Status / Knows own limits / 0
Overestimates or forgets limits / 15
Total
Initial

To obtain the Morse Fall Score add the score from each category

Morse Fall Score
High Risk / 45 and higher
Moderate Risk / 25-44
Low Risk / 0-24

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