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Initial Nursing Assessment
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Initial Nursing Assessment
Initial Nursing Assessment
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Patient Name:
*
Fill in the patient name here
Date
*
MM slash DD slash YYYY
Visit Type
Admission Assessment
Primary Dx
Secondary Dx
Confirmation of services needed:
Medication pre-fill
Patient Teaching and Training
Assist family with MD visits
Skilled nursing needed
Nursing service needed
Medication Administration
HHA service needed
PCA service needed
Homemaking service needed
Housekeeping service needed
Vital signs monitoring for family’s assurance
Therapy with ADL’s/meal prep/homemaking/shopping/prescription pickups
VITAL SIGNS:
T___________(O/A/R)
PR___________
AR___________
RP___________
BP___________(I/R)
WT____________
CADIOVASCULAR:
Pulse (R.R.Q)
Edema
Pitting
Measurements
Cap. Refill WNL if no, sec loc
Comments
RESPIRATORY:
B. S.
Cough
SOB
O2 Sat
Oxygen
Comments
GENITOURINARY:
Urination
Abn. s/s
Untitled
Cont
Incont
Cath
Last Changed
Reinserted catheter this visit
Type/size/balloon
Comments
GASTROINTERESTINAL/NUTRITION:
Bowel sounds: present x4quads
Last BM
INC/DEC
Hypo/Hyper
Lax: Enema use
Abd:
soft
firm
distended
abd. girth
#meal/day
Diet ordered
Complaint
P
Patient has received written instructions on specialized diet
Comments
NEURO/PSYCHE:
A+OX3 Other
Anxiety/deprn
Level of Comprehension
Neuro exam
Sleep Pattern
Sensory
Comments
MOBILITY/FUNCTIONAL:
Untitled
Bed/WC
Assistant device
Gait/Bal
ADL's:
Self
Asst
Mx Asst w/all
Other Limitations
Comments
SAFETY/PRECAUTIONS:
Hazards/Issues
Untitled
Safe Environment
Equip needed
Interventions
MEDICATION:
Untitled
Reviewed
Refills needed
Pill box to be filled for the week
Called to
Complaint?
Comments
ENDOCRINE
Untitled
SS
WNL
IDDM/NIDDM
Cap BS
FBS
PP____hr
Prefilled insulin syringe with
units of insulin
Comments
PAIN:
Untitled
N/A
Location
Type
Severity(1-10)
Duration
Precip. By?
Relieved by
Comments
INTEGUMENTARY:
Tugor:
Good
Fair
Poor
Color
Skin
Muc. Men.
Abnorm.
WOUND
WOUND
SIZE
DRAIN AMT
TYPE
ODOR
Add
Remove
TASK COMPLETED:
Untitled
HHA Care Plan established (if applicable)
Pill box filled
Increase in services needed
New order for Services completed
Case discussed with Nsg Supervisor
Supervision of HMKR/PCA/HHA
Open Case Forms completed
Deposit Taken
Case Discharged
Other
DISCHARGE PLAN
THERAPY
PT
OT
SLP
Comments
EVAC PLAN: Enter Priority Class:
I
II
III
TAL LEVEL:
Stretcher / Vent / Bariartric
Wheelchair
Ambulatory
SIGNATURES
Employee Name / Title
Employee Signature
Date
MM slash DD slash YYYY
Patient Signature
Date
MM slash DD slash YYYY
