Basics of nursing initial assessment needed to be done when a patient is received in the department. Done by the registered nurse, initial assessment is the basis on which further care is planned.

1. PUNE ADVENTIST HOSPITAL
TRAINING ON: NURSING INITIAL
ASSESSMENT

2. Purpose
• To identify parameters and define
responsibilities to plan and deliver the
appropriate level of care to meet the patient’s
needs

3. Points to note
• Initial assessment should commence within 15
minutes of receiving patient
• The nurse assigned to the patient is responsible for
completion
• Documentation should be in permanent ink
(black/blue ink)
• The nurse must write her name and sign with the
date and time

5. Procedure
• Enter the patient’s name, MR no., age
• Enter time of admission, diagnosis, chief
complaints
• Document the source of information (patient,
family etc.)
• Enter previous hospitalization history
• Check vital signs, height and weight
• Assess and document location and severity of
pain

6. • Document history of allergy
• Check medicines brought to the hospital
• Document if they have valuables

7. Review of systems: Neuromuscular
• LOC and speech
• Pupils: reaction and appearance
• Extremity movement

8. Cardiovascular
• Heart sounds and rhythm
• Neck veins
• Pulse
• Presence of oedema
• Extremity coolness
• Capillary refill
• Cyanosis
• others

9. Respiratory
• Breath sounds and breathing pattern
• Quality of cough
• Character of sputum

10. Gastrointestinal
• Abdomen and bowel sounds
• Nausea, vomiting, diarrhoea

11. Genitourinary
• Presence of urinary device
• Character of voiding
• Urinary discharge
• Vaginal or penile discharge

12. Integumentary
• Turgor and integrity
• Colour and temperature

13. Fall risk assessment
• 45 or above
• Fall risk sign

14. Psychosocial screening
• Any ‘yes’ answer requires referral to the
physician
• Need watcher or carer

15. Nutritional screening
• Appetite
• Change in body weight
• Nutritional consultation