Gastrointestinal: Bowel sounds, abdominal tenderness, any masses, scars, character of bowel movements, color, consistency, appetite poor or good, weight loss, weight gain, nausea, vomiting, abdominal pain, presence of feeding tube Respiratory: Breath sounds, breathing pattern, cough, character of sputum, shallow or labored respirations, agonal breathing, gasps, retractions present, shallow, asymmetrical chest rise, dyspnea on exertion Vital signs: Temperature recorded in Celsius, heart rate, respiratory rate, blood pressure, pain level on admission, oxygen saturationĪny handoff information from other departmentsĬardiovascular: Heart sounds pulse irregular, regular, weak, thready, bounding, absent extremity coolness capillary refill delayed or brisk presence of swelling, edema, or cyanosis Nutritional: Appetite, changes in body weight, need for nutritional consultation based on body mass index calculated from measured height and weight on admission Psychosocial: Evaluate need for a sitter or video monitoring, any signs of agitation, restlessness, hallucinations, depression, suicidal ideations, or substance abuse Rights: Orient patient, caregivers, and family to location, rights, and responsibilities goal of admission and discharge goalĪctivities: Check daily activity limits and need for mobility aidsįalls: Assess Morse Fall Risk and initiate fall precautions as dictated by institutional policy
Valuables: Record and send to appropriate safe storage or send home with family following any institutional policies on the secure management of patient belongings provide and label denture cups Medications: Confirm accuracy of the list, names, and dosages of medications by reconciling all medications promptly using electronic data confirmation, if available, from local pharmacies include supplements and over-the-counter medications Past medical history: Prior hospitalizations and major illnesses and surgeriesĪssess pain: Location, severity, and use of a pain scaleĪllergies: Medications, foods, and environmental nature of the reaction and seriousness intolerances to medications apply allergy band and confirm all prepopulated allergies in the electronic medical record with the patient or caregiver
The function of the initial nursing assessment is to identify the assessment parameters and responsibilities needed to plan and deliver appropriate, individualized care to the patient.Īppropriate level of care to meet the client's or patient’s needs in a linguistically appropriate, culturally competent mannerĪssessment and reassessment once admittedĪdmission history and physical assessment as soon as the patient arrives at the unit or status is changed to an inpatientĭata collected should be entered on the Nursing Admission Assessment Sheet and may vary slightly depending on the facilityĪdditional data collected should be addedĭocumentation and signature either written or electronic by the nurse performing the assessmentĭocumentation: Name, medical record number, age, date, time, probable medical diagnosis, chief complaint, the source of information The nurse recognizes normal and abnormal patient physiology and helps prioritize interventions and care.Īssessment Īnalysis or diagnosis The assessment identifies current and future care needs of the patient by allowing the formation of a nursing diagnosis. Part of the assessment includes data collection by obtaining vital signs such as temperature, respiratory rate, heart rate, blood pressure, and pain level using an age or condition appropriate pain scale.
Subjective and objective data collection are an integral part of this process. It is the first step in the successful evaluation of a patient. The nursing assessment includes gathering information concerning the patient's individual physiological, psychological, sociological, and spiritual needs.
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This concept of precision education to tailor care based on an individual's unique cultural, spiritual, and physical needs, rather than a trial by error, one size fits all approach results in a more favorable outcome. Critical thinking skills applied during the nursing process provide a decision-making framework to develop and guide a plan of care for the patient incorporating evidence-based practice concepts.
The initial nursing assessment, the first step in the five steps of the nursing process, involves the systematic and continuous collection of data sorting, analyzing, and organizing that data and the documentation and communication of the data collected.