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

Relationship Status: Single Spouse/partner Widowed
Living 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 / Year
ASSESSMENT * = 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