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Initial assessment
- 1. PUNE ADVENTIST HOSPITAL TRAININGON: NURSING INITIAL ASSESSMENT
- 2. Purpose • To identifyparameters 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 thepatient’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 historyof 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 soundsand rhythm • Neck veins • Pulse • Presence of oedema • Extremity coolness • Capillary refill • Cyanosis • others
- 9. Respiratory • Breath soundsand breathing pattern • Quality of cough • Character of sputum
- 10. Gastrointestinal • Abdomen andbowel sounds • Nausea, vomiting, diarrhoea
- 11. Genitourinary • Presence ofurinary device • Character of voiding • Urinary discharge • Vaginal or penile discharge
- 12. Integumentary • Turgor andintegrity • 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