Must Be Completed at the Time of Arrival on the Nursing Unit for ALL Patients (Including

Patient Sticker

INITIAL ASSESSMENT AND DATA BASE

Must be completed at the time of arrival on the Nursing unit for ALL patients (including post op). Date: ____/____/____ Arrival Time: ______From: ______To – Room: ______Transport mode: Ambulatory Wheelchair Stretcher / bed Accompanied by: ______UNIT ORIENTATION: Bed controls Nurse call Bathroom/Emergency call Visiting hours Telephone TV ID Band on – Location: ______PEDS: Parent Guardian banded – Name: ______DISPOSITION OF BELONGINGS: Home Admitting safe Unit closet Family advised to take belongings home

T: P: R: BP – RA : _____/_____ LA: _____/_____ SpO2: % on Room air O2 @

INPATIENT DATA BASE – To be completed for all patients NOT Post Op/Post Procedure Stated reason for admission: Height: ______Weight: ______lbs. Actual Stated Head circumference - ( < 2 yrs): ______cm PSYCHOSOCIAL/ ENVIRONMENT ALLERGIES (document reaction if known): NKDA Relationship Status: Single Spouse/partner Widowed Latex ______Living Situation: Alone Family/friends Residential facility ______Homeless* (CM Screen) ______Allergy band applied Significant other: Name: ______CURRENT MEDICATIONS – include OTC and herbal meds Phone #: ______Medication Dose Frequency Last taken Children / Dependents in home (age, relationship): ______Are you currently in a relationship / living situation where you feel uncomfortable or afraid? No Prefers not to answer Yes*(CM Screen) Occupation: ______Concerns related to hospitalization? No Yes – describe: ______Cultural / spiritual factors influencing care? No Yes – describe: ______Spiritual Care visit requested* * Pharmacy Screen for: Language: English Spanish Other: ______Six (6) scheduled prescription or OTC meds* Interpreter required – Name: ______Use of herbal preparations* Phone #: ______Comments: ______Medication Disposition: N/A Home Pharmacy SUBSTANCE USE / ABUSE Tobacco: No Quit – year: ______Yes* - *Cigarettes (RT Screen) - Packs per day: ______How long? ______Other: ______Alcohol: No Yes – type: ______Frequency: Occasional Daily - # of drinks: ______Recreational drugs: Type: ______Frequency. Occasional Daily ______Immunizations/Year last received: Tetanus ______Influenza ______Pneumovax ______Referred to PCP Child: Completed 2 year 4 year Recent Illnesses: Cold Flu Infection Other: ______

INFORMATION SOURCE: Patient Other: ______Reason: ______

DOCUMENTATION BY: ______Date: ____/____/____

55-7525A #2 7-6 INITIAL ASSESSMENT AND DATA BASE PAST MEDICAL HISTORY Major illness, surgery / procedure Year Major illness, surgery / procedure Year

ASSESSMENT * = Screening recommended – Document on IPOC FALL RISK ASSESSMENT PSYCHOSOCIAL Fearful / anxious Agitated BASIC RISK (Caution)  Appropriate to History/findings suggestive of abuse / neglect* situation and normal Age: > 80 for pt. Inadequate home support to meet needs following discharge* Dizziness New devastating, chronic diagnosis* Other: ______Generalized weakness, Comments: ______unsteady gait, use of NEURO LOC: Confused / cognitive limitations - new chronic ambulatory assistive LOC:  Alert Responsive to: verbal stimuli simple commands pain device  Oriented Speech: clear slurred* rambling* aphasia* Other: ______Altered elimination – Speech:  Clear Tactile: Numbness Tingling incontinence, diarrhea, Tactile:  No deficit Comments: ______nocturia, frequency. MUSCULOSKELETAL Assistive devices / prosthesis used: ______INCREASED RISK (Alert)  States no Balance/Gait impairment* 1 or more falls in past 6 months* (other than slip/trip) Fall within past 6 problems Assistance required or dependent for*: mobility transfers bed mobility PT months eating dressing hygiene toileting OT Confusion/ Disorientation Limitations affecting function* ______RISK LEVEL Comments: ______Determination will be as GI / GU Abdomen: firm distended tender ostomy / tubes*: ______follows: Abdomen:  WNL Problems with:( nausea vomiting diarrhea: > 3 days*) chewing  CAUTION – Any one  States no swallowing* incontinence* constipation Other: ______basic risk criteria problems Comments: ______ ALERT – Two (2) or NUTRITION more basic risk criteria Diet at home: ______Requires dietary teaching* or one (1) increased risk  States no TPN/PPN* Poor intake > 3 days* Pregnant/lactating* criteria. problems Recent significant unintentional weight loss/gain (> 10 lbs.)* Comments: ______ENDOCRINE Diabetes – control with: insulin pills diet Thyroid - hypo hyper RESPIRATORY Respirations: irregular dyspneic Other: ______Resp:  Regular Breath sounds: rales ronchi wheezes Other: ______ Unlabored Cough Home oxygen therapy* – type/ amount: ______Breath sounds: Comments: ______ Clear bilaterally CARDIOVASCULAR Heart rhythm: irregular pacemaker automatic implanted cardioverter/defibrillator Heart rhythm: Pulses: (0 = absent, 1 = weak, 2 = slightly decreased, 3 = strong, 4 = bounding)  Regular Right: Radial: _____ DP: _____ PT: _____ Left: Radial: _____ DP: _____ PT: _____ Capillary refill (sec.): RLE: _____ LLE: ______Comments: ______PAIN Present – Location: ______Level (1-10): _____ Frequency: intermittent constant  Denies Description: burning dull sharp cramping pressure Other: ______How long? ______Pain made worse by: ______Managed/made better by: ______Pain related concerns/issues:  function/quality of life fear of medication addiction fear of inadequate pain relief Acceptable pain level: ______Comments: ______SKIN Skin integrity – See diagram pressure ulcers*  Smooth and intact KEY: use abbreviation to indicate appropriate place on  No edema or diagram swelling B = burn E = erythema S = scar/body marks  Good turgor BR = bruise I = incision T = tube in place  Warm and dry CS = cast / splint L = laceration U = pressure ulcer CT = contracture N = necrosis W = wound D = dressing P = petechiae X = amputation Ed = edema R = rash O = other Edema Scale: 1+ = 0 – ½” 2+ = ¼” - ½” 3+ = ½” – 1” 4+ = > 1” BRADEN SKIN ASSESSMENT – Circle appropriate score in each category. If TOTAL score < 16, document interventions on IPOC* TOTAL Score: Sensory Moisture Activity Mobility Nutrition Friction & Shear perception 1 = Constantly 1 = Bedfast 1 = Completely 1 = Very poor 1 = Problem 1 = Completely moist 2 = Chairfast immobile 2 = Probably 2 = Potential problem limited 2 = Very moist 3 = Walks 2 = Very limited inadequate 3 = No apparent 2 = Very Limited 3 = Occasionally occasionally 3 = Slightly limited 3 = Adequate problem 3 = Slightly limited moist 4 = Walks 4 = No limitation 4 = Excellent 4 = No impairment 4 = Rarely moist frequently ASSISTIVE DEVICES Location CAREGIVER ID Signature / Title Date Time Cane Walker ____/____/______/____/____ Wheelchair Documentation by: Glasses Contact lenses Completed / Reviewed by: RN ____/____/____ Hearing aid - Right Left MUST be within 24 hours of admission Dentures / partials - Upper Lower PRE OP DATA BASE /HEALTH HISTORY reviewed ______RN