Must Be Completed at the Time of Arrival on the Nursing Unit for ALL Patients (Including
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): ______cmPSYCHOSOCIAL/ ENVIRONMENT
Relationship Status: Single Spouse/partner WidowedLiving Situation: Alone Family/friends Residential facility
Homeless* (CM Screen)
Significant other: Name: ______
Phone #: ______
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*
Language: English Spanish Other: ______
Interpreter required – Name: ______
Phone #: ______Comments: ______/ ALLERGIES (document reaction if known): NKDA
Latex ______
______Allergy band applied
CURRENT MEDICATIONS – include OTC and herbal meds
Medication / Dose / Frequency / Last taken
* Pharmacy Screen for:
Six (6) scheduled prescription or OTC meds*
Use of herbal preparations*
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 ______
Child: Completed 2 year 4 year / Referred to PCP
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 / YearASSESSMENT * = Screening recommended – Document on IPOC / FALL RISK ASSESSMENT
PSYCHOSOCIAL
Appropriate to situation and normal for pt. / Fearful / anxious Agitated
History/findings suggestive of abuse / neglect*
Inadequate home support to meet needs following discharge*
New devastating, chronic diagnosis* Other: ______
Comments: ______/ BASIC RISK (Caution)
Age: > 80
Dizziness
Generalized weakness,
unsteady gait, use of
ambulatory assistive
device
Altered elimination –
incontinence, diarrhea,
nocturia, frequency.
INCREASED RISK (Alert)
Fall within past 6
months
Confusion/ Disorientation
RISK LEVEL Determination will be as follows:
· CAUTION – Any one basic risk criteria
· ALERT – Two (2) or more basic risk criteria or one (1) increased risk criteria.
NEURO
LOC: Alert
Oriented
Speech: Clear
Tactile: No deficit / LOC: Confused / cognitive limitations - new chronic
Responsive to: verbal stimuli simple commands pain
Speech: clear slurred* rambling* aphasia* Other: ______
Tactile: Numbness Tingling
Comments: ______
MUSCULOSKELETAL
States no
problems / Assistive devices / prosthesis used: ______
Balance/Gait impairment* 1 or more falls in past 6 months* (other than slip/trip)
Assistance required or dependent for*: mobility transfers bed mobility PT
eating dressing hygiene toileting OT
Limitations affecting function* ______
Comments: ______
GI / GU
Abdomen: WNL
States no
problems / Abdomen: firm distended tender ostomy / tubes*: ______Problems with:( nausea vomiting diarrhea: > 3 days*) chewing
swallowing* incontinence* constipation Other: ______
Comments: ______
NUTRITION
States no
problems / Diet at home: ______ Requires dietary teaching*
TPN/PPN* Poor intake > 3 days* Pregnant/lactating*
Recent significant unintentional weight loss/gain (> 10 lbs.)*
Comments: ______
ENDOCRINE / Diabetes – control with: insulin pills diet Thyroid - hypo hyper
RESPIRATORY
Resp: Regular
Unlabored
Breath sounds:
Clear bilaterally / Respirations: irregular dyspneic Other: ______
Breath sounds: rales ronchi wheezes Other: ______
Cough Home oxygen therapy* – type/ amount: ______
Comments: ______
CARDIOVASCULAR
Heart rhythm:
Regular / Heart rhythm: irregular pacemaker automatic implanted cardioverter/defibrillator
Pulses: (0 = absent, 1 = weak, 2 = slightly decreased, 3 = strong, 4 = bounding)
Right: Radial: _____ DP: _____ PT: _____ Left: Radial: _____ DP: _____ PT: _____
Capillary refill (sec.): RLE: _____ LLE: ______Comments: ______
PAIN
Denies / Present – Location: ______Level (1-10): _____ Frequency: intermittent constant
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
Smooth and intact No edema or
swelling
Good turgor
Warm and dry / Skin integrity – See diagram pressure ulcers*
KEY: use abbreviation to indicate appropriate place on diagram
B = burn
BR = bruise
CS = cast / splint
CT = contracture
D = dressing
Ed = edema / E = erythema
I = incision
L = laceration
N = necrosis
P = petechiae
R = rash / S = scar/body marks
T = tube in place
U = pressure ulcer
W = wound
X = amputation
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 perception
1 = Completely limited
2 = Very Limited
3 = Slightly limited
4 = No impairment / Moisture
1 = Constantly moist
2 = Very moist
3 = Occasionally moist
4 = Rarely moist / Activity
1 = Bedfast
2 = Chairfast
3 = Walks occasionally
4 = Walks frequently / Mobility
1 = Completely immobile
2 = Very limited
3 = Slightly limited
4 = No limitation / Nutrition
1 = Very poor
2 = Probably inadequate
3 = Adequate
4 = Excellent / Friction & Shear
1 = Problem
2 = Potential problem
3 = No apparent problem
ASSISTIVE DEVICES / Location / CAREGIVER ID / Signature / Title / Date / Time
Cane Walker / Documentation by: / ____/____/____
Wheelchair / ____/____/____
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