NURSING INITIAL ASSESSMENT

3. NURSING ASSESSMENT
1. INITIAL ASSESSMENT
2. FOCUSED ASSESSMENT
3. TIME LAPSED ASSESSMENT
4. EMERGENCY ASSESSMENT

4. INITIAL ASSESSMENT

5. Definition
• The process used to identify and treat life-threatening
problems,
• ABCCS
• Assessment concentrating on,
• Airway, Breathing, Level of Consciousness, Cervical Spinal
Stabilization, and Circulation. And also be forming a
General Impression of the patient to determine the
priority of care based on immediate assessment and
determining if the patient is a medical or trauma patient.
The components of the initial assessment may be altered
based on the patient presentation.

6. Nursing assessment
Purpose of Assessment
A comprehensive admission
assessment, also referred to as an
initial database, nursing history, or
nursing assessment is completed
when the client is admitted to the
nursing unit.

7. Process
• Identify significant findings of a health history and physical
assessment of a patient
• HISTORY
PAST HEALTH HISTORY
FAMILY HISTORY
MEDICAL HISTORY
• Do the nursing assessment within 30 minutes of admission in the
presence of relatives.
• Take the history from the patient and from the relatives if the patient
is unstable or is a pediatric patient.
• Enter the findings in the Nursing Initial Assessment Form.- Adult/
Pediatric

8. General Examination:
General Appearance: Thin-built Moderate-built Obesity
Skin: Colour: Pallor Jaundice Cyanosis Flushing
Texture: Dryness Flaking Wrinkling
Eye: Conjunctiva: Pale Redness Purulent
Sclera: Paleness Redness
Ear: Discharge Lesions Hearing acuity
Nose: Crusts Discharges
Mouth: Dry Halitosis Cyanosis Ulcerated

9. • For the First Admission of the patient to the
hospital carry out the detailed Assessment. (Since
the form is introduced lately carry out the complete
assessment for all those patients who do not have
the complete written assessment done in their
files.)
• Fill the patient details such as Name, Age, Sex,
Consultant etc.
• Write the reason for admission whether Emergency
or First Time or for Observation or Supportive
Therapy, etc.

10. • Enter the vital signs, weight, height of the
patient in the both the Nursing Initial
Assessment Form and Vital Signs Recording
Form.
• Mention the mode by which patient came in.
If by walk ambulatory, otherwise wheelchair,
stretcher, bedridden etc.

11. VITAL SIGNS
1. Pulse
2. Temperature
3. Respiration
4. BP
5. SPO2

12. • Chief Complaints: Ask the patient what was
the complaint that made them to come to the
hospital. (E.g.: breathlessness, pain in any part
of the body, fever, cold, cough, diarrhea, etc).
In case there are no complaints, (For e.g.;
Diagnosed to have a disease during the routine
check up or has got admitted for the
subsequent cycles of treatment), mention the
same.

13. • Mention the allergies to any food and drugs
(specify) if any, and history of Adverse
Reactions if known; if no allergy write not
known.
• Ask for history of any major disease such as
cardiac, renal, diabetes, hypertension, etc and
also for the familial history of cancer. If yes,
the relationship also needs to be mentioned.
• Family History

14. • Functional Assessment (Activities of Daily Living) -
Check for ability to perform ADL & apply Fall risk
assessment / Vulnerable Criteria
• Physiological status, nursing needs & risk of
pressure ulcer has to be documented.
• Alcohol intake: Regular/occasional, if stopped,
since when?
• Smoking Habit: Smoker or not? If stopped, since
when? When he was smoking how many cigarettes
per day? If any habits of tobacco chewing or drugs
addiction is to be written.

15. • Systemic Assessment of the Patient: Carry out the
systemic assessment of Eyes & ENT, Respiratory,
Cardiovascular, Breast, Gastrointestinal, Genitourinary,
Neurological, Skin and Extremities and put a tick mark in
the appropriate box.
• If no abnormality detected put a tick mark in the box next
to “No Abnormality Detected”
• If you are not able to assess a particular system indicate
the reason.
• Ask if the patient wants to consult a Dietician, Counselor,
Yoga therapist, Physiotherapist or Pain Management
Consultant.

16. PAIN ASSESSMENT

18. NUTRITIONAL ASSESMENT
Built: ________________________
Nutrition Advice:
_________________________________________

19. CARDIOVASCULAR ASSESSMENT
Chest Pain: Absent Present: Since: ___________________
Edema: Absent Present: If present site: ____________________
Pedal Pulse: Felt Well Feeble Absent

20. RESPIRATORY ASSESSMENT
Respirations: Regular Irregular Use of accessory muscles
Abnormal Breath Sounds: Absent Present:
Cough: Absent Present:
Productive Non Productive Since when:

21. GENITOURINARY ASSESSMENT
Self Voiding Anuric Catheter AV Fistula Other: __

22. NUEROLOGIC ASSESSMENT
Speech: Clear Slurred
LOC: Alert/Oriented Drowsy Sedated
UnresponsiveDisoriented

23. MUSCULOSKELETAL ASSESSMENT
Full range of Motion:Yes No
Joint Swelling/Tenderness: Absent Present: Site:
______________

24. • For the subsequent admissions check the vitals and
ask for the changes from the previous assessment.
Wherever abnormality was detected earlier ask
specifically for the changes.
• For other systems ask all the questions as
mentioned in the complete assessment form and
write only if there are any new findings.
• Tie the ID band to the left wrist in case not possible
tie it in the right wrist, Right ankle, left ankle or any
other body part which is visible.

25. • Any valuable and belongings to be handed
over to the relatives & it should be
documented.
• Write your name, time, date along with the
signature & file it in the case file.

26. • PROVISIONAL DIAGNOSIS: A provisional diagnosis
means that a doctor is not 100% sure of a diagnosis
because more information is needed. With a
provisional diagnosis, a doctor makes an educated
guess about the diagnosis you most likely have.
• FINAL DIAGNOSIS: A final diagnosis that is made
after getting the results of tests, such as blood
tests and biopsies, that are done to find out if a
certain disease or condition is present.