Nursing Admission Assessment and Examination

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

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.
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
 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)
 Planning (develop a care plan which incorporates goals, potential
outcomes, interventions)
 Implementation (perform the task or intervention)
 Evaluation (was the intervention successful or unsuccessful)

Function
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.
This includes documenting:
 Appropriate level of care to meet the client's or patient’s needs in a
linguistically appropriate, culturally competent manner
 Evaluating response to care
 Community support
 Assessment and reassessment once admitted
 Safe plan of discharge
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
 Additional data collected should be added
 Documentation and signature either written or electronic by
Summary Nursing Admission Assessment
1. Documentation: Name, medical record number, age, date, time, probable
medical diagnosis, chief complaint, the source of information (two patient
identifiers)
2. Past medical history: Prior hospitalizations and major illnesses and
surgeries
3. Assess pain: Location, severity, and use of a pain scale
4. 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
5. 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
6. 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
7. Rights: Orient patient, caregivers, and family to location, rights, and
responsibilities; goal of admission and discharge goal
8. Activities: Check daily activity limits and need for mobility aids
9. Falls: Assess Morse Fall Risk and initiate fall precautions as dictated by
institutional policy
10.Psychosocial: Evaluate need for a sitter or video monitoring, any signs of
agitation, restlessness, hallucinations, depression, suicidal ideations, or
substance abuse
11.Nutritional: Appetite, changes in body weight, need for nutritional
consultation based on body mass index (BMI) calculated from measured
height and weight on admission
12.Vital signs: Temperature recorded in Celsius, heart rate, respiratory rate,
blood pressure, pain level on admission, oxygen saturation
13.Any handoff information from other departments
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
Steps in Evaluating a New Patient
 Record chief complaint and history
 Perform physical examination
 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: 70%
 Physical: 15% to 20%
 Diagnostic tests: 10% to 15%
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?
S-A-M-P-L-E
 S: Signs and symptoms
  A: Allergies
 M: Medications
 P: Past medical history
 L: Last meal or oral intake
 E: Events before the acute situation
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
 Restlessness or pacing
 Groaning or moaning
 Crying
 Gasping or grunting
 Nausea or vomiting
 Diaphoresis
 Clenching of the teeth and facial expressions
 Tachycardia or blood pressure changes
 Panting or increased respiratory rate
 Clutching or protecting a part of the body
 Unable to speak or open eyes
 Decreased interest in activities, social gatherings, or old routines
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
 Ambulatory aids
 Environmental concerns, home safety
 Domestic and family violence risk, human trafficking risks, elder or child
abuse risk
 Fall risk
 Suicidal ideation (initiate suicide precautions as directed by institutional
policy)
Therapeutic Communication Techniques Used to Take a Good History
Multiple strategies are employed that will include:
 Active, attentive listening
 Reflection, sharing observations
 Empathy
 Share hope 
 Share humor
 Touch
 Therapeutic silence
 Provide information
 Clarification
 Focusing
 Paraphrasing
 Asking relevant questions
 Summarizing
 Self-disclosure
 Confrontation

Cultural Assessment
The cultural competency assessment will identify factors that may impede the
implementation of nursing diagnosis and care. Information obtained should include:
 Ethnic origin, languages spoken, and need for an interpreter
 Primary language preferred for written and verbal instructions
 Support system, decision makers
  Living arrangements
 Religious practices
 Emotional responses
 Special food requirements, dietary considerations
 Cultural customs or taboos such as unwanted touching or eye contact
Physical Examination Techniques
Initial evaluation or the general survey may include:
 Stature
 Overall health status
 Body habitus
 Personal hygiene, grooming
 Skin condition such as signs of breakdown or chronic wounds
 Breath and body odor
 Overall mood and psychological state
 Initial vital sign measurements: temperature recorded in Celsius in most
institutions, respiratory rate, pulse rate, blood pressure with appropriate
sized cuff, pulse oximetry reading and note if on room air or oxygen;
accurately measured weight in kilograms with the proper scale and height
measurement, so body mass index (BMI) is calculable for dosing weights
and nutritional guidelines
Secondary Assessment
 Cardiovascular
 Pulmonary
 Gastrointestinal
 Musculoskeletal
 Neurological
 Genitourinary/Pelvic
 Integumentary
 Mental status and behavioral
Techniques
Inspection
 Look at all areas of the skin, including those under clothing or gowns
 Ensure patient is undressed, allowing for privacy, uncover one body part at
a time if possible
 Lighting should be bright
 Be alert for any malodors from the body including the oral cavity; fecal
odor, fruity-smell, odor of alcohol or tobacco on the breath
 Compare one side to the other, and ask the patient about any
asymmetrical areas
  Observe for color, rashes, skin breakdown, tubes and drains, scars,
bruising, burns
 Grade any edema present
 Document pertinent normal and abnormal findings
Palpation
 Texture
 Size
 Consistency
 Crepitus
 Any masses
 Turgor
 Tenderness 
 Temperature and moisture (warm, moist or cool, and dry)
 Distention
 Tactile fremitus
Percussion
 Good hand and finger technique
 Good striking and listening technique
 Especially important in the pulmonary and gastrointestinal systems
 Dull, flat, resonance, hyper-resonance, or tympany sounds
 Percussion is an advanced technique requiring a specific skill set to
perform. Therefore, it is a skill practiced by advanced practice nurses as
opposed to a bedside nurse on a routine basis
Auscultation
 Listening to body sounds such as bowel sounds, breath sounds, and heart
sounds
 Important in examination of the heart, blood pressure, and gastrointestinal
system
 Listen for bruits, murmurs, friction rubs, and irregularities in pulse
What are important things to remember about the physical exam?
 Physical exam length can vary depending on complexity
 Physical exam extends from passive observation to hands-on 
 Be systematic and thorough
 Ensure privacy and comfort
 Warm hands for patient comfort
 Avoid long fingernails to prevent patient injury during the exam
 Palpate areas that are tender or painful last
 Be alert for any signs of maltreatment or abuse, and follow mandatory
reporting guidelines
  Abdominal assessment follows the techniques in this sequence: inspection,
auscultation, percussion, and palpation
 Auscultate bowel sounds for at least 15 seconds in each quadrant using
the diaphragm of the stethoscope, starting with the lower right-hand
quadrant and moving clockwise
 If a fistula is present for hemodialysis, assess for a thrill or bruit, document
presence or absence. Notify managing healthcare provider immediately if
absent
 Steps in a comprehensive lung exam include PIPPA; Positioning of the
patient, Inspection, Palpation, Percussion, Auscultation
Diagnostic Studies
Driven by findings on the history and physical examination; options include:
 Blood tests (CBC, chemistry, bedside glucose, pregnancy test, urinalysis,
cardiac enzymes, coagulation studies)
 Imaging studies (X-rays, CT, MRI, ultrasound)
 Other diagnostic studies (ECG, EEG, lumbar puncture, etc.,)
Discharge Planning
 Document mode of transport
 Who is accompanying the patient?
 Transfer forms/EMTALA considerations
 Functional status
 Financial considerations
 Discharge medications and instructions
 Follow up information, referrals, hotline numbers, shelter information
 Barriers to learning
 Document verbalization that discharge instructions were understood by
caregiver or surrogate
 Provide translators and language appropriate discharge instructions or
paperwork

After studying the lesson, the students can answer the following questions:
1. What is a new patient assessment in nursing?
2. What is a nursing initial assessment?
3. What is mental health admission assessment?
4. What are the components of a patient assessment?
5. How to do patient assessment?
6. Why is patient assessment important in nursing?
7. Find new patient admission questionnaire in the internet and fill
in the form!