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