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Assessment

Assessment

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Published by E
Nurse's Admission Assessment
Nurse's Admission Assessment

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Published by: E on Oct 01, 2008
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11/09/2012

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Student Name:6) Reason for hospitalization (face sheet):Describe reason for hospitalization: (expandon back of page)Medical Dx:
Pathophysiology: All signs and symptoms: Highlight those your  patient exhibits
7) Chonic illnesses ( physician’s history andphysical notes in chart; nursing intakeassessment and Kardex)8) Surgical procedures (consent forms andKardex): Describe surgical procedure (expandon back of page)Name of surgical procedure:
Describe surgery:
9) Advanced directives(NURSE’S ADMISSION ASSESSMENTS):Living will: Yes___No____ Power of attorney: Yes___ No___ Do not resuscitate (DNR) order (Kardex): Yes____ No_____ ALLERGIES/PAINS13) Allergies: Type of Reaction:(medication administration record):14) When was the last time pain medication given?(medication administration record)14) Where is the pain?(nurse’s notes)14) How much pain is the patient in on a scale 0-10?(nurse’s notes, flow sheet): TREATMENTS15) List treatments (Kardex): Rationale for treatmentsDressing changesIceFoley
 
NGPosition changes q2h Ted HoseSCDsIS q1h while awakeC&DB q1h while awake Tx. Cont.16) Support services (Kardex) What do support services provide for the patient?17) What does the consultant do for the patient?18) DIET/FLUIDS Type of Diet(Kardex):Restrictions(Kardex):Gag Reflexintact: __Yes __NoAppetite: __Good __Fair __PoorBreakfast ___%Lunch ___%Dinner ___%What type of diet is this?What types of foods are included in this diet and what foods should be avoided?
Circle Those Problems That Apply:
Prior 8 housFluid intake: (Oral & IV)
Problems: swallowing, chewing, dentures(nurse’s notes)
 
Fluid Out put(flow sheet) Tube Feedings: Type and rate (Kardex)
Needs assistances with feeding (nurse’snotes)
Nausea or vomiting (nurse’s notes)
Overhydrated or dehydrated (evaluate totalintake and output on flow sheet
Belching:
Other:19) INTRAVENOUS FLUIDS (IV therapy record) Type and Rate: IV dressing dry, no edema, redness of site: ___Yes ___NoOther:20) ELIMINATION (flow sheet)Last bowel movement:Foley/condom catheter: ___Yes ___NoCircle Those Problems That Apply:
Bowel: constipation diarrhea flatus incontinence belching
Urinary: hesitancy frequency burning incontinence odor
Other: _________________________________________________________ 
What is causing the problem inelimination?___________________________________________________________ 21) ACTIVITY (Kardex, flow sheet)Ability to walk(gait): Type of activityorders:Use of assistance devices:cane, walker, crutches,prosthesis:Falls-risk assessmentrating:No. of side railsrequired (flowsheet)Restraints(flow sheet) ___Yes ___NoWeakness ___Yes ___No Trouble sleeping(nurse’s notes): ___Yes ___NoWhat does activity order mean?: ___________________________________________________________________ Why isn’t the patient up ad lib?: ____________________________________________________________________ 

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