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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Nursing Admission Assessment and Examination

Tammy J. Toney-Butler ; Wendy J. Unison-Pace .

Last Update: August 28, 2023 .

Definition/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. Critical thinking skills applied during the nursing process provide a decision-making framework to develop and guide a plan of care for the patient incorporating evidence-based practice concepts. This concept of precision education to tailor care based on an individual's unique cultural, spiritual, and physical needs, rather than a trial by error, one size fits all approach results in a more favorable outcome.[1][2][3]

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. Part of the assessment includes data collection by obtaining vital signs such as temperature, respiratory rate, heart rate, blood pressure, and pain level using an age or condition appropriate pain scale. The assessment identifies current and future care needs of the patient by allowing the formation of a nursing diagnosis. The nurse recognizes normal and abnormal patient physiology and helps prioritize interventions and care.[4][5]

Nursing Process

Assessment (gather subjective and objective data, family history, surgical history, medical history, medication history, psychosocial history)

Analysis or diagnosis (formulate a nursing diagnosis by using clinical judgment; what is wrong with the patient)

Issues of Concern

The function of the initial nursing assessment is to identify the assessment parameters and responsibilities needed to plan and deliver appropriate, individualized care to the patient.[6][7][8][9]

This includes documenting:

Appropriate level of care to meet the client's or patient’s needs in a linguistically appropriate, culturally competent manner

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

Summary Nursing Admission Assessment

Documentation: Name, medical record number, age, date, time, probable medical diagnosis, chief complaint, the source of information (two patient identifiers)

Allergies: Medications, foods, and environmental; nature of the reaction and seriousness; intolerances to medications; apply allergy band and confirm all prepopulated allergies in the electronic medical record (EMR) with the patient or caregiver

Medications: Confirm accuracy of the list, names, and dosages of medications by reconciling all medications promptly using electronic data confirmation, if available, from local pharmacies; include supplements and over-the-counter medications

Valuables: Record and send to appropriate safe storage or send home with family following any institutional policies on the secure management of patient belongings; provide and label denture cups

Rights: Orient patient, caregivers, and family to location, rights, and responsibilities; goal of admission and discharge goal

Psychosocial: Evaluate need for a sitter or video monitoring, any signs of agitation, restlessness, hallucinations, depression, suicidal ideations, or substance abuse

Nutritional: Appetite, changes in body weight, need for nutritional consultation based on body mass index (BMI) calculated from measured height and weight on admission

Vital signs: Temperature recorded in Celsius, heart rate, respiratory rate, blood pressure, pain level on admission, oxygen saturation

Physical Exam

Cardiovascular: Heart sounds; pulse irregular, regular, weak, thready, bounding, absent; extremity coolness; capillary refill delayed or brisk; presence of swelling, edema, or cyanosis

Respiratory: Breath sounds, breathing pattern, cough, character of sputum, shallow or labored respirations, agonal breathing, gasps, retractions present, shallow, asymmetrical chest rise, dyspnea on exertion

Gastrointestinal: Bowel sounds, abdominal tenderness, any masses, scars, character of bowel movements, color, consistency, appetite poor or good, weight loss, weight gain, nausea, vomiting, abdominal pain, presence of feeding tube

Genitourinary: Character of voiding, discharge, vaginal bleeding (pad count), last menstrual period or date of menopause or hysterectomy, rashes, itching, burning, painful intercourse, urinary frequency, hesitancy, presence of catheter

Neuromuscular: Level of consciousness using AVPU (alert, voice, pain, unresponsive); Glasgow coma scale (GCS); speech clear, slurred, or difficult; pupil reactivity and appearance; extremity movement equal or unequal; steady gait; trouble swallowing

Integument: Turgor, integrity, color, and temperature, Braden Risk Assessment, diaphoresis, cold, warm, flushed, mottled, jaundiced, cyanotic, pale, ruddy, any signs of skin breakdown, chronic wounds

Initial Assessment[10][11][12]

Steps in Evaluating a New Patient

Complete an initial psychological evaluation; screen for intimate partner violence; CAGE questionnaire and CIWA (Clinical Institute Withdrawal Assessment for Alcohol) scoring if indicated; suicide risk assessment

Provide a certified translator if a language barrier exists; ensure culturally competent care and privacy

Ensure the healthcare provider has ordered the appropriate tests for the suspected diagnosis, and initiate any predetermined protocols according to the hospital or institutional policy

Which provides the diagnosis most often: history, physical, or diagnostic tests?

History Taking Techniques

Record chief complaint

History of the present illness, presence of pain

P-Q-R-S-T Tool to Evaluate Pain

P: What provokes symptoms? What improves or exacerbates the condition? What were you doing when it started? Does position or activity make it worse?

Q: Quality and Quantity of symptoms: Is it dull, sharp, constant, intermittent, throbbing, pulsating, aching, tearing or stabbing?

R: Radiation or Region of symptoms: Does the pain travel, or is it only in one location? Has it always been in the same area, or did it start somewhere else?

S: Severity of symptoms or rating on a pain scale. Does it affect activities of daily living such as walking, sitting, eating, or sleeping?

T: Time or how long have they had the symptoms. Is it worse after eating, changes in weather, or time of day?

Pain Assessment

Pain, or the fifth vital sign, is a crucial component in providing the appropriate care to the patient. Pain assessment may be subjective and difficult to measure. Pain is anything the patient or client states that it is to them. As nurses, you should be aware of the many factors that can influence the patient's pain. Systematic pain assessment, measurement, and reassessment enhance the ability to keep the patient comfortable. Pain scales that are age appropriate assist in the concise measurement and communication of pain among providers. Improvement of communication regarding pain assessment and reassessment during admission and discharge processes facilitate pain management, thus enhancing overall function and quality of life in a trickle-down fashion.

According to one performance and improvement outpatient project in 2017, areas for improvement in pain reassessment policies and procedures were identified in a clinic setting. The study concluded compliance rates for the 30-minute time requirement outlined in the clinic policy for pain reassessment were found to be low. Heavy patient load, staff memory rather than documentation, and a lack of standardized procedures in the electronic health record (EHR) design played a role in low compliance with the reassessment of pain. Barriers to pain assessment and reassessment are important benchmarks in quality improvement projects. Key performance indicators (KPIs) to improve pain management goals and overall patient satisfaction, balanced with the challenges of an opioid crisis and oversedation risks, all play a role in future research studies and quality of care projects. Recognition of indicators of pain and comprehensive knowledge in pain assessment will guide care and pain management protocols.

Indicators of Pain

Psychosocial Assessment

The primary consideration is the health and emotional needs of the patient. Assessment of cognitive function, checking for hallucinations and delusions, evaluating concentration levels, and inquiring into interests and level of activity constitute a mental or emotional health assessment. Asking about how the client feels and their response to those feelings is part of a psychological assessment. Are they agitated, irritable, speaking in loud vocal tones, demanding, depressed, suicidal, unable to talk, have a flat affect, crying, overwhelmed, or are there any signs of substance abuse? The psychological examination may include perceptions, whether justifiable or not, on the part of the patient or client. Religion and cultural beliefs are critical areas to consider. Screening for delirium is essential because symptoms are often subtle and easily overlooked, or explained away as fatigue or depression.

Safety Assessment

Therapeutic Communication Techniques Used to Take a Good History

Multiple strategies are employed that will include: