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    Nursing Administration Assessment

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    katnebrija89
    This document contains an admission assessment for a patient entering nursing care. It includes sections on the patient's admission information, orientation to the unit, allergies, current medications, medical history, assistive devices, valuables, psychological history, neurological assessment, musculoskeletal assessment, respiratory assessment, cardiovascular assessment, gastrointestinal assessment, genitourinary assessment, self-care needs, nutrition, skin assessment, and fall risk screening. The assessment collects comprehensive information about the patient's health status and care needs.

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    Nursing Administration Assessment

    Uploaded by

    katnebrija89
    295 views6 pages
    This document contains an admission assessment for a patient entering nursing care. It includes sections on the patient's admission information, orientation to the unit, allergies, current medications, medical history, assistive devices, valuables, psychological history, neurological assessment, musculoskeletal assessment, respiratory assessment, cardiovascular assessment, gastrointestinal assessment, genitourinary assessment, self-care needs, nutrition, skin assessment, and fall risk screening. The assessment collects comprehensive information about the patient's health status and care needs.

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    This document contains an admission assessment for a patient entering nursing care. It includes sections on the patient's admission information, orientation to the unit, allergies, current medications, medical history, assistive devices, valuables, psychological history, neurological assessment, musculoskeletal assessment, respiratory assessment, cardiovascular assessment, gastrointestinal assessment, genitourinary assessment, self-care needs, nutrition, skin assessment, and fall risk screening. The assessment collects comprehensive information about the patient's health status and care needs.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    295 views6 pages

    Nursing Administration Assessment

    Uploaded by

    katnebrija89
    This document contains an admission assessment for a patient entering nursing care. It includes sections on the patient's admission information, orientation to the unit, allergies, current medications, medical history, assistive devices, valuables, psychological history, neurological assessment, musculoskeletal assessment, respiratory assessment, cardiovascular assessment, gastrointestinal assessment, genitourinary assessment, self-care needs, nutrition, skin assessment, and fall risk screening. The assessment collects comprehensive information about the patient's health status and care needs.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
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    NURSING ADMINISTRATION ASSESSMENT

    ADMISSION DATA

    Patients Name: _______________________________________________________


    Date: __________________ Time: __________ Primary Language: ____________________
    Arrived Via: wheelchair stretcher ambulatory
    From: admitting ER home nursing home other: _________________
    Admitting M.D.:________________________ Time Notified:_______________________

    ORIENTATION TO UNIT
    Yes No Yes No
    Arm band correct Visiting Hours
    Telephone Smoking Policy
    Electrical Policy TV, lights, bedcontrol
    Education material Call lights, Side Rails
    Allergy Band Nurses Station

    Family M.D. ____________________________________________________________


    Weight: ______________Height: ______________ BP right: __________ left: ____________
    Temp: _______________ Pulse: _________________ Respi: ______________________
    Source of Providing Info: patient other: _________________________________
    Unable to Obtain History: ____________________________________________________
    Reason for admission (Onset, duration, patient’s perception) ____________________________
    _____________________________________________________________________________

    ALLERGY AND REACTIONS

    DRUGS: ________________________________________________________________
    FOOD/OTHER: __________________________________________________________
    SIGNS AND SYMPTOMS: _________________________________________________
    BLOOD REACTION: YES NO DYES/SHELLFISH: YES NO

    MEDICATIONS

    Current Meds Dose/Frequency Last Dose


    ____________________ ______________________ ______________________
    ____________________ ______________________ ______________________
    ____________________ ______________________ ______________________
    ____________________ ______________________ ______________________
    ____________________ ______________________ ______________________
    Disposition of Meds: home pharmacy safe at bedside other: _____________
    MEDICAL HISTORY

    NO MAJOR PROBLEM GASTRO ______________________


    CARDIAC_____________________ ARTHRITIS_____________________
    HYPER/HYPOTENSION_________ STROKE ______________________
    DIABETES_____________________ SEIZURES______________________
    CANCER ______________________ GLAUCOMA_____________________
    RESPIRATORY__________________ OTHERS_____________________
    SURGERY/PROCEDURE DATE
    _______________________________________ ____________________________
    _______________________________________ ____________________________
    _______________________________________ ____________________________

    SPECIAL ASSISTIVE DEVICES


    Wheelchair contacts venous access device DENTURES:
    braces hearing aid epidural catheter partial complete
    cane/crutches prosthesis upper
    Walker glasses lower

    VALUABLES

    PATIENT IS INFORMED HOSPITAL NOT RESPONSIBLE FOR PERSONAL


    BELONGINGS: ______________________________________________________________
    Valuable disposition: patient safe given to _________________________

    PSYCHOLOGICAL HISTORY
    Recent stress _________________________________________________________________
    Coping Mechanism_____________________________________________________________
    Support System _______________________________________________________________
    Calm: YES NO
    Anxious: YES NO
    Religion: _____________________________________________________________________
    Tobacco Use: YES NO
    Alcohol Use: YES NO
    Drug Use: YES NO

    NEUROLOGICAL
    ORIENTED: person place time confused sedated
    alert restlesslethargic comatose
    PUPILS: equal unequal lethargic sluggish other___________
    EXTREMITY STRENGHT: equal unequal
    SPEECH: clear slurred other: ______________________________
    MUSCULOSKELETAL

    Normal ROM of extremities: yes no


    weakness ___________________________________________________________________
    Paralysis ___________________________________________________________________
    Contracture _________________________________________________________________
    Joint swelling _______________________________________________________________
    Pain _______________________________________________________________________
    Other ______________________________________________________________________

    RESPIRATORY

    PATTERN: even uneven shallow dyspnea other: _______________


    BREATHING SOUND: clear other
    SECRETION: none other
    COUGH: none productive non productive

    CARDIOVASCULAR SYSTEM

    Pulses: Apical pulse______________ regular irregular pacemaker


    S= strong W=weak A=absent D=Doppler
    Radial: right_______ left ________ Pedal: right ______________ left _____________
    Edema: absent present site: _________________________________
    Perfusion: warm dry diaphoretic cool

    GASTROINTESTINAL

    Oral Mucosa: normal other ______________________________________


    Bowel Sounds: normal other ______________________________________
    Weight Change: yes no
    N/V ____________________________________________________
    Stool frequency/ character ___________________________________
    Last B/M _________________________ Ostomy (type) ______________________________
    Equipment: ___________________________________________________________________

    GENITOURINARY
    URINE: last voided ___________________________________________________________
    Normal anuria hematuria dysuria incontinence
    Catheter type __________________________ other ______________________________
    LMP ________________________________________ vaginal/ penile discharge
    OTHER ______________________________________________________________________
    SELF CARE

    NEED ASSIST WITH: Ambulating elimination meals hygiene dressing

    NUTRITION

    GENERAL APPEARANCE: well nourished emaciated other _________________


    APPETITE: good fair poor
    DIET: ______________________ MEAL PATTERN: _______________________________
    feed self assist total feed

    SKIN ASSESSMENT

    COLOR: normal flushed pale dusky cyanotic


    jaundice other ______________________________________________
    GENERAL DESCRIPTION: ____________________________________________________
    ______________________________________________________________________________
    ______________________________________________________________________________
    NOTE CULTURE OBTAINED: _________________________________________________
    ______________________________________________________________________________
    ______________________________________________________________________________

    PRESSURE SORE “AT RISK” SCREENING CRITERIA

    GRADE- OVERALL SKIN CONDITION

    Turgor ( elasticity adequate, skin warm and moist )


    0
    Poor Turgor, skin cold and dry
    1 Areas Mottled, red or denuded
    Existing Skin Ulcer
    2
    GRADE BOWEL AND BLADDER CONTROL
    3 Always able to ask for bed pan
    0 Incontinence of urine
    Incontinence of feces
    1 Total incontinence, confined to bed
    2

    3 GRADE REHABILITATIVE STATE

    Fully ambulatory
    0
    Ambulated with assistance
    1 Chair to bed ambulation only
    Immobile to bed
    2

    3
    GRADES NUTRITIONAL STATE

    Eats well
    0
    Eats very little
    1 Refuses food often
    Tube feeding
    2 Intravenous feeding

    3 GRADES MENTAL STATE


    4
    Alert and Clear
    0
    Confused
    1 Disoriented/ senile
    Stupurous
    2 Unconscious

    3 GRADES CHRONIC DISEASE (COPD, ASCVD, PVD, cancer, diabetes,


    renal disease and sensory deficits, elderly, other)
    4
    Absent
    0
    One present
    1 Two present
    Three or more
    2

    3 TOTAL:
    ____________________________________________________________________
    REFER TO SKIN CARE PROTOCOL:
    ___________________________________________

    FALL SCREENING

    IF ONE OR MORE OF THE FOLLOWING ARE CHECKED INSTITUTE FALL


    PRECAUTIONS/ PLAN OF CARE:

    history of falls unsteady gait confused/ disoriented dizziness

    IF ONE OR MORE OF THE FOLLOWING ARE CHECKED INSTITUTE FALL


    PRECAUTIONS/ PLAN OF CARE:

    age over 80 utilizes cane, walker sleeplessness impaired vision


    impaired hearing multiple diagnosis urgency/ frequency of elimination
    inability to understand or follow direction medications/ sedative/ diuretics

    NURSES SIGNATURE/ TITLE DATE TIME


    __________________________________ ________________ _______________
    __________________________________ ________________ _______________

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