Shift	Shift 1: 7am - 3pm Shift 2: 3pm - 11pm Shift 3: 11pm - 7am
Demographic factors	Weight

Ongoing Assessments:	Minimal ( < daily) Moderate (Hands on q 4-6 hrs.) Frequent visual monitoring < 2 hrs.
VS/GLU/NEURO/RESP Assessment*	Number of assessments per shift: 0 1 2 3 4 Assess q 4 - 6 hours Assess q 1 - 2 hours
Complicated med schedule q 2 hrs or more frequent	Present
Central Line/Groshong catheter/Port-a-cath	Present w/ TPN I.V. pain medicines Regular blood draws/IV/Peripheral site Regular blood draws IV central

Oxygen Therapy	Nasal canal @ >= 4 l/m Humidification
Ventilator	On Ventilator Total Assist CPAP/IMV < q 12 hrs. CPAP/IMV > q 12 hrs. Standby CPT or Neb Tx <= 1 q 4 hrs.* CPT or Neb Tx > q 4 hrs.* ( = 2/8 hr period) CPT or Neb Tx > q 2 hrs.* ( = 4/8 hr period) Transition from ventilator to Oxygen Aspiration precautions Suctioning <= q 2 hrs Suctioning > q 2 hrs Tracheostomy (routine care)
Wound Care	Decubitus Dressing Changes - Complicated Surgical Site Dressing Changes - Complicated

Nutrition	Eats with slight assistance Simple tube feeding q 4hrs or longer Occasional Reflux Gastrostomy/PEG tube (Routine Care) Gastrostomy/PEG medications >= 2 hrs Gastrostomy/PEG tube feeding pump q 2-4 hrs Stoma Care Bowel Training Bladder Training Intermittent straight catheter Uncontrolled Incontinence (frequent linen change) Peritoneal dialysis Foley catheter
NEURO	Communication deficit (not cognitive or verbal) Disorientation/combative (Strikes out, attempts to hurt self) Development delay mobility
Grand Mal Seizures	Frequency <= 4 x day Frequency 4 - 6 x day Severe Seizure > 6 x day Moderate sleep disturbance (awake/turned < q 2hrs) Severe sleep disturbance (awake/turned > 2hrs.) Quadraplegia Paraplegia
MUSCULOSKELETAL	Fracture or casted limb Body cast Acute mobility problems (potential for skin breakdown) ( e.g., spacity, rigidity) Traction (skeletal, skin, etc)

Medical Management	Requires periodic medical specialty consultation Requires multidisciplinary team approach
Primary Caregivers	Other caregivers available outside of home by arrangement No other caregivers available
Wage Earner	AT least 2 responsible adults in the home and primary caregiver contributes to wage earnings or is primary wage earner. Primary caregiver may or may not be primary wage earner. Only one responsible adult in the home.
Family Constellation	1 - 3 dependants with moderate medical or emotional needs Greater than 3 dependants in the home with intense medical or emotional needs.
Problem Solving Skills	Requires assistance in identifying problem/problem solving Requires extensive assistance to recognize problems and identify solution.
Coping	Needs encouragement to follow through on recommendations. Inconsistent in keeping appointments. Family follows through on recommendations only with extensive support and assistance.
Support Systems	Support system present but needs encouragement to utilize. Support systems absent.
Stressors	History of mental illness or behavior problems among family members. Current diagnosis of mental illness and/or behavior problems.
Finances	Family finances are inadequate, barely meets its needs for security and physical survival. Able to buy only necessities. Family does not meet it's needs for security and physical survival. Unable to buy the necessities.
Resourse Utilization and/or Private Insurance	Requires assistance in identification and utilization of resourses. Requires intensive assistance to identify and utilize resources.
Safety/Shelter	Needs assistance to correct safety and health hazards. Home inadequate to meet minimum safety and health standards
ADL's	Inconsistent in meeting ADL's ADL's not met

Shift
PDN Acuity
PDN Psychosocial
PDN Grand Totals
Summary: