Assessment is done upon admission to find out why should the individual be admitted. What is the reason or purpose of admission?. Does his or her condition warranty admission?. Does the patient need a bed in the hospital?.What level of care will the patient need ( ICU, MedTelemetry, Trauma, Orthopedic, Neurosurgery)
PHYSICAL CONDITION: Functional status, pain,blood pressure, nutrition, hydration, allergy and vital signs. What are the symptoms exhibited to warrant admission?.Patient history and medical records.
PSYCHOLOGICAL:Psychosocial status, behavioral, cognitive, emotional, spiritual, cultural issues.
EDUCATION: What is patient level of understanding of the disease process?.Education level, language barrier?.Need interpreter or the blue phone?.Orientation to the room,patient rights, medication, discharge planning needs, social, rehabilitation. Abuse or suspicion of abuse, assessment done and referrals made.
CODE STATUS: DNR. When is end of life assessment appropriate?.What are the physical, social, emotional,cultural and social variables that influence our perception on how family or individuals grief. In every culture the method of grieving is different and it is based on the environmental factors.
Questions
What do you need to assess during patient assessment?.
You need to yourself for the data collection.
The patient willingness to answer questions.
The vital sign machine.
Stethoscope.
Pen and paper or the computer.
Diagnostics test results.
Nurses You Move Me 