ASSESSMENT : The systematic and continuouscollection , organization, validation and documentationof data (information). It includes patients perceivedneeds ,health problems, related health practices, valuesand life styles.
1. To identify interdisciplinary assessment parameters(data elements and time requirement)and define responsibilities to plan and deliver the appropriate level of care to meet the patients needs, evaluate the response of care, support community care, and plan a safe discharge from hospital.2. To establish unified process of assessment and reassessment of patients admitted to the units.
4.Admission physical assessment shall be done with infour hour in general unit5.Admission physical assessment shall be done with inone hour in special care unit6.All data collected are entered on the NursingAdmission Assessment Sheet and available to all thoseinvolved in the care of the patient.7.Data that is not obtainable with in 4 hours ofadmission should be documented at the end of shift bythe assigned nurse.
8.The RN assigned to the patient is responsible toensure that the form is completed with in the timeframe specified.9. Documentation should be in permanent ink(blue orblack).10.The nurse should write her/his name, RN andsignature.
The registered nurse will give patient care based ondocumented assessment and reassessment of patient’sneeds/current status.1.Admission physical assessment2. Data received from the patient as well as from thefamily/ significant others are include in theassessment.3.The Nursing Admission Assessment Sheet will becompleted on all patients by a Registered Nurse.
REASSESSMENT1.The reassessment of the outcome of care/and ortreatment needs of the patient will be continuousthroughout the patient’s hospitalization.2.Reassessment shall be done to determine patientsresponse to the treatment or if a significant change inthe patient’s condition .3.Prior to discharge from the unit ,all patients shall bereassessed to determine if they are fit for discharge.4.Consultation of medical staff other than nursing shallbe done to determine the validity of initial datacollection and the on-going reassessment.
PROCEDURENURSING ADMISSION ASSESSMENT1.At the time of admission , the registered Nurseperforms complete assessment of the patient.2.Enter patient’s name, medical record number and ageat the upper left corner of the form.3.Enter date and time of admission, medical diagnosisand chief complaint in the appropriate spaces in theform.4.Document the source of information (patient, family,caregiver or health care person or significant person).
5.Chek and document if patient has previoushospitalization and write patient history including pastmajor illnesses.6.Indicate if patient was admitted from ER, home, clinic,other and accompanied by whom.7. Take patients vital signs(temperature, pulse,respiration ),height ,weight .8.Asess and document the location and the severity ofthe pain using the pain scale.
9.Document if patient has history of allergy, if yes,check ,whether its due to medication , food or others.10.Document patient brought medicine to the hospital.If yes, check whether it was send to pharmacy.11.Document if patient and family has valuablesbrought to the hospital . If yes , check it was sent toadmission office.12.At the time of arrival to the room , patient andfamily will be given orientation to the unit , anexplanation to the patients rights and responsibilities.13.Check the activities of daily living and need ofmobility aid.
14.REVIEW OF SYSTEM. • LOC and speech NEUROMUSCULAR • pupils: reaction, appearance • extremity movement • Heart sounds and rhythm CARDIOVASCULAR • neck vein • pulse • presence of edema • extremity coolness • capillary refill • cyanosis and others. RESPIRATORY • Breath sounds and breathing pattern • Quality of cough • character of sputum
GASTROINTESTINAL • Abdomen and bowel sounds • Nausea, vomiting, diarrhea • Presence of urinary device • Character of voiding GENITOURINARY • Urinary discharge • vaginal or penile discharge • Turgor and integrity INTEGUMENTARY • Colour and temperature
FALL RISK ASSESSMENT• 45 or above• Fall risk signPSYCHOSOCIAL SCREENING• Any ‘yes’ answer requires referral to attending physician• Need sitter or watcherNUTRITIONAL SCREENING• Appetite• Change in body weight• ?Nutritional consultation
DISCHARGE PLANNING• MODE OF TRANSPORT• ACCOMPANIED BY• FUNCTIONAL STATUS