Initial assessment

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

4. 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

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

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

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

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

9. Gastrointestinal Abdomen and bowel sounds Nausea, vomiting, diarrhoea

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

11. Integumentary Turgor and integrity Colour and temperature

12. Fall risk assessment 45 or above Fall risk sign

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

14. Nutritional screening Appetite Change in body weight Nutritional consultation