NAME OF HOSPITAL
Nursing Admission Assessment
Date: __________Time: ___________
' Patient
' Other _______________ Phone #: _________________________________________________
Informant:
___________________________________________________
Mode of access: ' Ambulatory ' WC ' Stretcher ' Other
' Monitor
' IV
' Other ___________________________________________________
Transported with ' Oxygen
Accompanied by: ______________________
From: ' Home ' ER ' Dr. Off. ' AFC ' ECF ' Other __________________
Valuables:
' None ' Sent home with _____________________________________________________________
' Lock-up
Reason for Admission (Pts own words): _________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Vital Signs
T
O
R
A
T
Reg
Irreg
SaO2
BP
Ht
Wt
Kg
B
W/C
Allergies
Allergies
Reaction
Allergies
Reaction
Allergies
Reaction
Latex? Y or N
Chronic conditions:
' Lung Problems _____________ ' Stomach Problems _______________ ' Thyroid Problems _______________' Neurological Problems________ '
Heart Problems ______________ ' Liver Problems __________________ ' Vision Problems ______________ __' Kidney Problems ____________ '
Arthritis ' Diabetes ' Chronic infection _________________________ Treatment:
____________________________
' Cancer (where/type) _________________________________________ Treatment:
____________________________
Other Past Medical History or Surgeries: __________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
' Family history ' NSF ' Heart disease ' Hypertension ' Diabetes ' Stroke ' Seizures ' Kidney disease ' Liver disease
Medications
Medication
(include OTC)
Dose
Frequency
Taken
today?
Y or N
Brought
with?
Y or N
Medications
(include OTC)
Dose
Frequency
Taken today?
Y or N
Brought
with?
Y or N
Social History
' Lives alone ' Lives with ____________________________________________ Stairs at home ' Yes ' No
' Home with _______________________________
' Lock-up
Meds sent:
Sleep pattern ______________
' Not applicable
Last Tetanus toxoid? ______________________
Immunizations current? Yes ______ No ______
' No ' Yes How much? _______ How Long? ________________
Nicotine Use:
' No Do you live in a smoking environment?
' Yes ' No
Instructed on Name of Hospital No Smoking Policy? ' Yes
' No ' Yes How much? _____________ How Long? _____________ Last Drink? ______________________________________
Alcohol Use:
Social Drug Use: ' No ' Yes Type? _________________________________ Frequency? _____________________________________ ___________
Support Services: ' No ' Yes Type ' HHC ' Hospice ' Other __________________________________________________________________
Additional Help needed? ' No ' Yes Referral made to ____________________________________________________
Impairment / Disabilities
Yes
No
Yes
Impaired hearing
Hearing Aid
Impaired vision
Glasses
Can perform ADL?
Contacts
Can read?
Dentures
Can write?
Partial
No
L
Yes
No
Walker
Crutches
Wheelchair
Cane
Prosthesis
Rate:
Home O2
Other:
Dietary Habits
Special Diet: _________________________________ Supplements: ________________________________
Safety
' Yes ' No ID Band on ' Yes ' No Oriented to Unit
' Yes ' No Toiletry Supplies Offered
' Yes ' No Call Bell in Reach
Skin Integrity Assessment Scale: _______________________________________
Fall Risk Assessment Scale:
________________________________________
' Yes ' No IV pump
if 17 or below, Skin Risk intiated
if above 25, Fall Prevention initiated
Skin Risk Assessment Scale
Sensory Perception
Ability to respond to pressure related
discomfort
1. Completely limited
unresponsive to pain or limits ability
to feel pain over most of body
2. Very limited response to painful
stimuli or limits ability to feel pain over of
body, or paralysis present
3. Slightly limited response to
verbal command but cant always
communicate
4. No Impairment able to
verbalize feelings and complaints
Moisture
Skin exposed to moisture
1. Constantly moist (i.e.
perspiration, urine)
2. Very moist extra linen change
1x per shift
3. Occasionally moist linen
change 1x per day
4. Usually dry no extra linen
changes
Activity
Degree of physical activity
1. ABR
2. Chair fast NWB/WC must be
assisted to chair
3. Ambulates occasionally with
assist up in chair
4. Ambulates frequently
Mobility
Ability to change and control body
position
1. Completely immobile
2. Very limited unable to make
frequent changes independently
3. Slightly limited makes frequent
slight changes for self
4. No limitations
Nutrition
Food intake pattern
1. Very poor NPO, Clear liquids,
or IVs > 5 days. Takes fluids poorly.
Underweight, malnourished.
2. Inadequate eats < meal.
Takes less than optimum
3. Adequate eats > . Tube
feeding or TPN provides needs
4. Excellent
Friction
1. Problem requires assist in
moving. Frequent friction. History of
skin tears or pressure sores.
2. Potential requires minimum
assist, occasional friction
3. No apparent problem BRP
4. Up ad Lib
Fall Risk Assessment Scale
Confused - disoriented - hallucinating
20
Post-op condition - sedated
10
Narcotics, diuretics, antihypertensives, etc.
10
Unstable gait, weakness
20
Drug or alcohol withdrawal
10
Bowel, bladder urgency - incontinence
10
Hx of syncope or seizures
15
Use of walker, cane, crutches, etc.
10
Age 70 or above
Recent hx of falls
15
Postural hypotension
10
Uncooperative, impaired judgement
Age 12 or younger
15
Poor eyesight
10
Language barrier
Paralysis, hemiplegia, stroke
15
New meds (i.e. sedative, antihypertensive)
15
Poor hearing
Part II Systems Review
* NSF = No significant findings-
Pediatrics:
' NA
Check appropriate box if present if box not checked, sign/symptom not present
' NSF
' Yes ' No Special Diet?___________
' Yes ' No Formula ____________ Type of Bottle __________ Type of Nipple ________
' Yes ' No Warmed?
' Yes ' No Teeth/Teething
' Yes ' No Feeding Problems _________________
' Yes ' No Diapers
' Yes ' No Toilet Training
Word used for BM ____________________________
' Yes ' No Immunizations current?
' Yes ' No Copy to chart?
For children under 2 yrs: Head circ ___________________ Chest circ ___________________ Abd Circ
_______________________
Page 2 of 5
Eyes: ' NSF
' Yes ' No Blurred Vision ' Yes ' No Double vision ' Yes ' No Inflammation
' Yes ' No Pain
' Yes ' No Color blind
' Yes ' No Itching
' Yes ' No Pupils abnormal
' Yes ' No Drainage -- Color ____________ Amount ____________
' Yes ' No Other ___________________________________
Ears: ' NSF
' Yes ' No HOH (R) (L) ' Yes ' No Deaf
' Yes ' No Tinnitus
' Yes ' No Dizziness
' Yes ' No Drainage _________________________
' Yes ' No ' sense of balance
' Yes ' No Pain
' Yes ' No Other ______________________________________________________________________________________________
Nose: ' NSF
' Yes
' Yes
' Yes
' Yes
' No
' No
' No
' No
Congestion
' Yes ' No Pain
' Yes ' No Sinus problems
Nasal Flaring
' Yes ' No Alignment
' Yes ' No Nosebleeds frequency ___________________________
Drainage color _______________________________________amount
______________________________________
Other _____________________________________________________________________________________________
Mouth:
' NSF
' Yes ' No Halitosis
' Yes ' No Pain
' Yes ' No Bleeding gums
' Yes ' No Lesions
' Yes ' No 9 sense of taste
Dental Hygeine ______________________________________ Last Dental Exam __________________________________________
Throat/Neck: ' NSF
' Yes ' No Sore throat
' Yes ' No Hoarseness ' Yes ' No Lumps
' Yes ' No Swollen glands
' Yes ' No Stiffness
' Yes ' No Pain
' Yes ' No Dysphagia
' Other ___________________________________________________ _________________________________________________
Neurological: ' NSF
' Yes ' No Cooperative
' Yes ' No Memory Changes
' Yes ' No Dizziness
' Yes ' No Headaches
' Yes ' No Oriented
' Yes ' No Other _________________
' Yes ' No Person ' Yes ' No Place ' Yes ' No Time
Oriented to:
Pupils Size: __________________ Deviation: _____________________
' Yes ' No PEARLA
Reaction: ' Brisk ' Sluggish ' No Response
' Alert ' Confused
' Sedated
' Somnolent
'
LOC
Co
' Other _____________
matose ' Agitated
' Slurred
' Aphasic
' Dysphasia
' None
' Other: _____________________
Speech ' Clear
Grips: _______________ Foot pushes: ________________ Gag reflex: ___________________ ' Other: _____________________
Respiratory: ' NSF
Lung sounds: _________________________________________________________________________________________________
' None
' With activity ' At rest
' Lying down
' Retractions
Dyspnea
' None
' Non-productive
' Productive Color ______________ Amount __________________
Cough
' No ' Barrel
' Funnel
' Other ____________________________________
Chest Symmetry ' Yes
' Yes ' No Night Sweats
' Yes ' No Hemoptysis
' Yes ' No Cyanosis Where ________________________
' Other: ____________________________________________________________________________________________________
Cardiovascular:
' NSF
Cardiac Rate or Monitor pattern: _____________________________
' Regular
' Irregular
' Irregularly irregular
' Yes ' No Chest Discomfort
Where:__________________
Intensity (1 - 10)___________
Onset _______________
Duration_____________________ Resolution _________________________________________
' Yes ' No Pulse Radial (R)/(L)
' Yes ' No Pulse Pedal (R)/(L)
' Yes ' No JVD (R)/(L)
' Yes ' No Edema Location ______________________________________
' Pitting
' Non-pitting
' Yes ' No Pacemaker Date Inserted ________________ Type: ______________________ Where:
_________________________
' Yes ' No Murmur ___________________________________________________________________________________________
Skin Extremities Musculoskeletal:
' NSF
Skin
' Warm
' Cool
' Dry
' Firm
' Flaccid
Color: ______________________________________________ ________________________________________________________
' Yes ' No History DVT
' Yes ' No Homans (R)/(L)
' Yes ' No Tingling
' Yes ' No Weakness
' Yes ' No Deformity
' Yes ' No Contractures ________
Extremities
' Yes ' No Pain
' Yes ' No Stiffness Location: _____________________________________________
Joints
' Yes ' No Replacement Date ________________________ Where: ____________________________________
' WNL
' Other (location/ range): __________________________________________________________
ROM
Page 3 of 5
' NSF
Physical Findings:
Describe and graph all abnormalities by number:
1.
Bruises
2.
Incisions
3.
Lacerations
4.
Rashes
5.
Decubitus
6.
Dryness
7.
Scars
8.
Lesions
9.
Abnormal color
10.
Other : ____________________________________
11.
Tattoos
12.
Body Piercing
13.
Skin Tear/ Duoderm/Op-Site
Gastrointestinal:
Appetite
Last BM
' Yes ' No
' Yes ' No
' Yes ' No
' Yes ' No
' Yes ' No
' Good
' NSF
' Poor
' Recent change _____________________________
Bowel sounds
Date: _________ Color _______________________ Frequency: ___________________
Laxative use Type __________ Frequency ___________________ How long ___________________
Constipation ' Yes ' No Diarrhea
' Yes ' No Nausea
' Yes ' No Vomiting
Distention
' Yes ' No Hemorrhoids ' Yes ' No Heartburn
' Yes ' No Flatus
Colostomy
' Yes ' No Ileostomy
' Yes ' No Pain
' Yes ' No Rectal Bleeding
Weight gain/loss Reason: _______________________________________________________
Genitourinary:
' NSF
Reproductive:
' NSF
Color of urine _________________ ' Yes ' No Odor _________________________________________
' Yes ' No Frequency
' Yes ' No Flank pain
' Yes ' No Burning
' Yes ' No Difficulty starting
' Yes ' No Urgency
' Yes ' No Incontinence ' Yes ' No Itching
' Yes ' No Nocturia
' Yes ' No Urostomy
' Yes ' No Hx of calculi ' Yes ' No Hx UTI
' Yes ' No Foley Date
_____________________________________________________________________________________
FEMALE
LMP_______________________ G _____ P _____ A ______
Last PAP ____________________
' Yes ' No Menopausal How long? __________________________ ' Yes ' No Hormone replacement
' Yes ' No Vaginal discharge
' Yes ' No Itching
' Yes ' No Dysmenorrhea
' Yes ' No Hx STD exposure
' Yes ' No Lumps
Last Dr. exam ________________
Breast ' Yes ' No Do SBE Monthly?
' Yes ' No Breast feeding
' Yes ' No Nipple discharge
' Yes ' No Dimpling
' Yes ' No Symmetry
' Yes ' No Nipple inversion
' Yes ' No Birth control
' Yes ' No Lesions
' Yes ' No' Amenorrhea
Last mammogram ______
' Yes ' No Family Hx
' Yes ' No Pain
MALE
Last prostate exam _________________ Last PSA _____________________
' Yes ' No Penile discharge ' Yes ' No Hernias
' Yes ' No Sores
' Yes ' No Testicular lumps
' Yes ' No Hx STD exposure
Hygiene _____________________________________________________________________________________________________
' Yes ' No Pain
' Yes ' No Lumps
' Yes ' No Swelling
' Yes ' No Nipple discharge
Breast
Hematological:
' NSF
' Yes ' No Bruising
' Yes ' No Anticoagulant use
Nurse doing Assessment
Page 4 of 5
' Yes ' No Anemia - Hx
' Yes ' No Anemia - Current
' Yes ' No Blood Transfusion - Hx
Date:
Advanced Directive
Does the patient have an Advanced Directive?
' No
Advanced Directive form on chart? ' Yes ' No explain
' Yes ' No explain
Additional information given?
' Yes Is copy on file? ' No ' Yes -where? ____________________
___________________________________________________________
___________________________________________________________
After assessing the above data and interviewing the patient, the R.N. will complete the following:
The following Nursing care plans will be instituted:
_________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
____________________________________________________________
Patient would like further information regarding:
' Medication ' Exercise ' Mental Health Services ' Diet ' Smoking Cessation ' Weight Control ' Drug/Alcohol Abuse
The following educational needs have been identified and will require further
follow-up: ____
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
__________________________________________________
Patients / Familys perceived discharge needs (ADLs, meals,
___________________
etc.):
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
__________________________________________________Additional
Comments:_______________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
________________________________________
R.N. Signature:
_______________________________________________________________
Date: __________________
Time:_______________________
Page 5 of 5
Admissi3rev2.wpd
January 6, 1999
