BKJ-BOR-PPK-21 (pind.1/2017) BAHAGIAN KEJURURAWATAN KEMENTERIAN KESIHATAN MALAYSIA. NURSING ASSESSMENT ON ADMISSION FOR PAEDIATRIC PART 1: ADMISSION INFORMATION Name’ WG (Mother VC) RN MyKick Date of Bit Sex Ethnic: (_)Malay() Chinese (_)indian(_) Age Male ( ) Others: Religion Weight Height Female ( ) Nationality: a) Malaysian ( ) Others: COH Date & Time of Arrival to ward: Mode of Admission: | Admit Via: ‘Accompa ‘Accompanied item(s): Bassinet () |eTo (| Family ) | Admission Form ( ) Incubator CY | clinic: Guardian () | Referral Letter «) Walking C2 | sreneferfReferr Paramedic ) Waking ais (_-)_| FransforReteral nee Podiatric Clinic = () Wheel Chair = (_) 7 X-Rays Stretcher () | others: i Laboratory results ( ) Others: Others: Patfané ont Allergy: Previous Adee yn: | Medical Diagnosis Os CY] ¥esC ) NOC) | yes ( ) monthiyear: fy () | state Reason for current admission cvp c) Roa Cee (| Unabie to Assess ( ) AV Fistula () Old Notes Available: ceo (| Please state: Medication from Home: Yes( ) Yes( ) No( ) Others, specify Nate Vital sign: GCS Score: Prosthesis Upper limbs Abnormalities Temperatureno"C | Eve Open Yes ( ) No( ) Pulse Rate: min | [Nes CD, Verbal Response: Specify Respiration: Jenin Speci Motor Response: BP. mmHg oa Total No ( } Inform doctor i abnormalities ain Score: poore. detected. sPo2 i (ontonan Time informed: Name of Dr.PART 2: NURSING ASSESSMENT 4. Mental Status: 2, Emotional Status: 3. Orientated : 4, Mobility Level: ‘Conscious () Cooperative: () | Yes a) Able to Ambulate ( Alert () | Anxious ©) Ino (| Walking Aids ( Confused () Depressed () Wheelchair rt Drowsy () | Restless > Bedbound ( Unconscious = (_-)_‘| Irritable ()_ | No. please specify 5. Ability to perform 6. Res 7. Skin condition : 8. Hearing ADL: Normal () | Norma (| Normal «) Independent (_) Pallor () | impaired () Assisted (| Abnormal () | Jaundice Cy eee De Cynosis () eee }ependent ©) | specity ‘Skin Integrity i Needs Oxygen Therapy | (at 1) pee Rashes () Good ta Yes () Septic Spot () No. () Ne (i) | Bruises () | Ito, please specity Petechiae () Pressure Ulcer ( ) Others, please specify: 10. Fontanelie 11. Hair 12. Face 13. Eye (Below 18 Months) | ciean Gace c)_ | Norma ) Normal () | Lice ©) | Abnormat () | Discharge ) ‘Sunken () | Dandrutt ©) | Phessa epecty ‘Abnormal () Bulging () Please specify: 14. Nose 15. Oral i 16. Dental carries 17. Ear Noral () [cea () |Yes ¢ ) No( ) Normal () pei (oy | Thrush () Discharge OO Specify Ulcer () Abnormal ) Bad Breath () Please specify: 18. Neck 19. Upper /Lower 20. Abdomen 21. Spine Limbs ‘Normal () | Normal () | Soft () | Normal () Abnormal () Abnormal ( Distended () Abnormal () Please specify Please specify: Others () | Please specify: Please specify: ee 232.2017Cont... Part 2: NURSING ASSESSMENT 22. Vision 23. Nutritional status: | 24, Nutrition: Good Breast Feeding impated | snuston ( ) | Formule Feeding Poor () | Weaning Diet Glasses: Yes(_ ) Others, specify Solid Diet No¢ ) Others: | 25. Speech: Normal Delayed Slurred ( ( ( ‘ Others: ) ) ) ) 26. Bladder Pattern: | 27. Bowel Pattern Micturition : Normal i3 Abnormal ou Normal C) Specify Abnormal (| SPAR Signature Please specily i Date & Time. Toilet Training Toilet Training Yes( ) No( ) Yes( ) No ( ) Immediate Assessment by: Social Back Ground 4. Occupation Father /Mother /Guardian Social Background Name of Father Occupation Name of Mother: ‘Occupation No of Sibling Child is sibling no, Status of child ‘Abandoned ( ) Adopted ( ) None of the above( Social Problem /Domestic Problem No. () Yes () Specify: 2. Emotional Status a). Reaction from family regarding admission Caim( } — Worted ¢ ) Parent's understanding on patient's sickness ©) Others 2322017FALL RISK ASSESSMENT TOOL FOR PAEDIATRIC (HUMPTY DUMPTY TOOL) Parameter Criteria ‘Score . Less than 3 years old 30 less than 7 years old Age 7 to less than 13 years old 13 years and above Neurological diagnosis, 4 ‘Alterations in Oxygenation (Respiratory diagnosis, 3 Diagnosis Dehydration, Anaemia, Anorexia, Syncope/Dizziness, et. Psychological’ Behavioural Disorder 2 Other diagnosis 1 Not aware of limitations 3 Cognitive Forgets limitations 2 Impairments | Orientated to own ability 1 History of falls or nfanv toddler placed in bed 4 Environmental Palient uses assistive devices or infani/ toddler in crib or 3 Factors furniturefabsent or dim lighting | Patient placed in bed ‘Outpatient area / Play roomi Ward Within 24 hours Response to surgery! | Within 48 hours Sedation’ anaesthesia |More than 48 hours/ none Multiple usage oF ~ Sedatives (excluding ICU, sedated and paralysed patients) - Hypnotics 4 Medication usage - Barbiturates - Phenothiazines ~ Antidepressants + Laxatives! Diuretics = _Nareotios One of medication listed above Other medications! none Total Humpty Dumpty Score: tents (Minimum score 7; Maximum score 23) ( Initiate Low Risk Fall Standard & Care Plan for score 7-11) (Initiate High Risk Fall Standard & Care Pian for score 12 or more) Deborah HR, etal. 2008 NAME & SIGNATURE OF NURSE: DATE & TIME: 23/2/2017CONT... PART 2: NURSING ASSESSMENT 22. IMMUNISATION : Complete Incomplete IMMUNISATION SCHEDULE 1.BCG New Born No Scar 2.Hepatitis 1" Dose 2" Dose 3" Dose 3. DTAP & HIB & IPV 1" Dose 2" Dose 3 Dose Booster Dose 4, Measle (Sabah Only) 5.MMR 1" Dose 2" Dose 6. MR & DT (Booster) 7.HPV (Female only) New Born 4 Month 6 Month 2 Month 3 Month 5 Month 18 Month 6 Month ‘9 Month 12 Month 7 Years 13 Years None W227(toro. puepuers ie 951 4am 2002: wH yoga (Wosoyosd prepues ey ys mol aYeN ) anogeso 21 -¥st4 HOH ) 24008 TE LAST MOT SN NYONVIVONVE a8esn uonesipon (psn ue Sana uonepas ‘ostune ex 2suodsoy sone) ony 0 Fag wauuosa ‘suowouedua, ‘aagnuzen sisonowia ‘NOWSIWGW 30 3109 739 "SisonowIG “aww FON 5a (ORLWIGAVd) LUVHD JTVOS LNSINSSASSV TIV4 ALINNG ALG VISAVIVN NVLVHIS3N NVRISLNAWSH nvuvmvununnsx nmovive 9 1les-dd-YOR-NIBPatient Falls Safety Protocol Low Risk Standard Protocol (Score 7-11) No. ‘Action Plan wm 1. | Identify patient with a “Yellow” signage at the patient's bed head 2. | Orientation of patient/ parents to room 3. | Bed in low position, brakes on is 4, | Side rails up, assess large gaps such as that a patient could get extremity or other body part entrapped. 5. | Use of non -skid footwear for ambulating patients, use of appropriate size clothing to prevent risk of tripping 6. | Assess elimination need, assist as needed i 1s Call light is within reach, educate patient / family on its functionality 8. _| Environment clear of unused equipment, furniture’s in place, clear of hazards ‘9. | Assess for adequate lighting, leave nightlight on 10. | Patient and family education available to parents and patient 77. | Document fail prevention teaching and include in plan of care. High Risk Standard Protocol (Score 12 and above) No. Action Plan a) 1. | Identify patient with a “Red” signage at the patient's bed head 2. | Educate patient/parents of falls protocol precautions 3._| Check patient minimum every 1 hour 4. | Accompany patient with ambulation 5. | Placed patient in appropriate bed with side rails 6. | Consider moving patient closer to nurses’ station 7. | Assess need for supervision of parents/carer 8. | Evaluate medication administration times 9. | Remove all unused equipment out of the room 10. | Protective barriers to close off spaces, gaps in the bed 11. | Keep door open at all times unless specified isolation precautions are in use 12. | Keep bed in the lowest position, unless patient is directly attended 13. | Document fall prevention teaching and include in plan of care. ‘Adapied Deborah HR et al 2008