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INTRODUCTION
The initial nursing assessment, the first step in the five steps of the nursing
process, involves the systematic and continuous collection of data; sorting,
analyzing, and organizing that data; and the documentation and communication
of the data collected. The nursing assessment includes gathering information
concerning the patient's individual physiological, psychological, sociological,
and spiritual needs. It is the first step in the successful evaluation of a patient.
Subjective and objective data collection are an integral part of this process.
NURSING PROCESS
 Assessment
 Analysis or diagnosis
 Planning
 Implementation
 Evaluation
FUNCTION
The function of the initial nursing assessment is to identify the
assessment parameters and responsibilities needed to plan and deliver
appropriate, individualized care to thepatient.This includes
documenting:
 Appropriate level of care to meet the client's or patient’s needs in a linguistically
appropriate, culturally competent manner
 Evaluating response to care
 Community support
 Assessment and reassessment once admitted
 Safe plan of discharge
THE NURSE SHOULD STRIVE TO COMPLETE
 Admission history and physical assessment as soon as the patient arrives at the unit or
status is changed to an inpatient
 Data collected should be entered on the Nursing Admission Assessment Sheet and
may vary slightly depending on the facility
 Additional data collected should be added
 Documentation and signature either written or electronic by the nurse performing the
assessment
NURSING ADMISSION ASSESSMENT
 Documentation
 Past medical history
 Assess pain
 Allergies
 Medications
 Activities
 Falls
 Nutritional
 Vital signs
EXAMPLE CASE
Patients come to the surgical clinic for the control and treatment of
appendectomy postoperative wounds. Day 2 postoperative patient. The
patient complains of pain in the lower right abdomen (the area of ​the
surgical wound), pain disappears, usually appears when the patient
changes position or moves, pain scale 3 (0-10). During the assessment,
the wound appeared dry and clean, there were no signs of infection
THANK YOU