02 INITIAL ASSSESSMENT.pptx

NURSING INITIAL ASSESSMENT

1. NURSING ASSESSMENT INITIAL ASSESSMENT FOCUSED ASSESSMENT TIME LAPSED ASSESSMENT EMERGENCY ASSESSMENT

2. INITIAL ASSESSMENT

3. Definition The process used to identify and treat life-threatening problems, ABCCS Assessment concentrating on, Airway, Breathing , Level of Consciousness, Cervical Spinal Stabilization, and Circulation. And also be forming a General Impression of the patient to determine the priority of care based on immediate assessment and determining if the patient is a medical or trauma patient. The components of the initial assessment may be altered based on the patient presentation.

4. Nursing assessment Purpose of Assessment A comprehensive admission assessment, also referred to as an initial database, nursing history, or nursing assessment is completed when the client is admitted to the nursing unit.

5. Process Identify significant findings of a health history and physical assessment of a patient HISTORY PAST HEALTH HISTORY FAMILY HISTORY MEDICAL HISTORY Do the nursing assessment within 30 minutes of admission in the presence of relatives. Take the history from the patient and from the relatives if the patient is unstable or is a pediatric patient. Enter the findings in the Nursing Initial Assessment Form.- Adult/ Pediatric

6. General Examination: General Appearance: Thin-built Moderate-built Obesity Skin: Colour: Pallor Jaundice Cyanosis Flushing Texture: Dryness Flaking Wrinkling Eye: Conjunctiva: Pale Redness Purulent Sclera: Paleness Redness Ear: Discharge Lesions Hearing acuity Nose: Crusts Discharges Mouth: Dry Halitosis Cyanosis Ulcerated

7. For the First Admission of the patient to the hospital carry out the detailed Assessment. (Since the form is introduced lately carry out the complete assessment for all those patients who do not have the complete written assessment done in their files.) Fill the patient details such as Name, Age, Sex, Consultant etc. Write the reason for admission whether Emergency or First Time or for Observation or Supportive Therapy, etc.

8. Enter the vital signs, weight, height of the patient in the both the Nursing Initial Assessment Form and Vital Signs Recording Form. Mention the mode by which patient came in . If by walk ambulatory, otherwise wheelchair, stretcher, bedridden etc.

9. VITAL SIGNS Pulse Temperature Respiration BP SPO2

10. Chief Complaints : Ask the patient what was the complaint that made them to come to the hospital. (E.g.: breathlessness, pain in any part of the body, fever, cold, cough, diarrhea, etc). In case there are no complaints, (For e.g.; Diagnosed to have a disease during the routine check up or has got admitted for the subsequent cycles of treatment), mention the same.

11. Mention the allergies to any food and drugs (specify) if any, and history of Adverse Reactions if known; if no allergy write not known. Ask for history of any major disease such as cardiac, renal, diabetes, hypertension, etc and also for the familial history of cancer. If yes, the relationship also needs to be mentioned. Family History

12. Functional Assessment ( Activities of Daily Living) - Check for ability to perform ADL & apply Fall risk assessmen t / Vulnerable Criteria Physiological status, nursing needs & risk of pressure ulcer has to be documented. Alcohol intake: Regular/occasional, if stopped, since when? Smoking Habit: Smoker or not? If stopped, since when? When he was smoking how many cigarettes per day? If any habits of tobacco chewing or drugs addiction is to be written.

13. Systemic Assessment of the Patient : Carry out the systemic assessment of Eyes & ENT, Respiratory, Cardiovascular, Breast, Gastrointestinal, Genitourinary, Neurological, Skin and Extremities and put a tick mark in the appropriate box. If no abnormality detected put a tick mark in the box next to “No Abnormality Detected” If you are not able to assess a particular system indicate the reason. Ask if the patient wants to consult a Dietician, Counselor, Yoga therapist, Physiotherapist or Pain Management Consultant.

14. PAIN ASSESSMENT

15. NUTRITIONAL ASSESMENT Built: ________________________ Nutrition Advice: _________________________________________

16. CARDIOVASCULAR ASSESSMENT Chest Pain: Absent Present: Since: ___________________ Edema: Absent Present: If present site: ____________________ Pedal Pulse: Felt Well Feeble Absent

17. RESPIRATORY ASSESSMENT Respirations: Regular Irregular Use of accessory muscles Abnormal Breath Sounds: Absent Present: Cough: Absent Present: Productive Non Productive Since when:

18. GENITOURINARY ASSESSMENT Self Voiding Anuric Catheter AV Fistula Other: __

19. NUEROLOGIC ASSESSMENT Speech: Clear Slurred LOC: Alert/Oriented Drowsy Sedated UnresponsiveDisoriented

20. MUSCULOSKELETAL ASSESSMENT Full range of Motion: Yes No Joint Swelling/Tenderness: Absent Present: Site: ______________

21. For the subsequent admissions check the vitals and ask for the changes from the previous assessment. Wherever abnormality was detected earlier ask specifically for the changes. For other systems ask all the questions as mentioned in the complete assessment form and write only if there are any new findings. Tie the ID band to the left wrist in case not possible tie it in the right wrist, Right ankle, left ankle or any other body part which is visible.

22. Any valuable and belongings to be handed over to the relatives & it should be documented. Write your name, time, date along with the signature & file it in the case file.

23. PROVISIONAL DIAGNOSIS: A provisional diagnosis means that a doctor is not 100% sure of a diagnosis because more information is needed . With a provisional diagnosis, a doctor makes an educated guess about the diagnosis you most likely have. FINAL DIAGNOSIS: A final diagnosis that is made after getting the results of tests, such as blood tests and biopsies, that are done to find out if a certain disease or condition is present .