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Form from HIS OpenVista

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  1. 3/9/12
  2. 6/8/17
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June 8, 2017

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Creative Commons BY-NC 3.0
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NURSING ASSESSMENT (adult)

HIS

  1. StudyEvent: HIS
    1. HIS
Adult Nursing Assessment
see initial Admission Assessment
Neuro / Psychosocial
Normal Baseline: Alert, responsive to stimuli, sensation intact, speech clear and appropriate, PERRLA, hand grips equal, can follow directions, oriented X4, cooperative with treatment plan, hygiene and grooming adequate, maintains eye contact, poses no danger to self or to others, normal affect.
GLASGOW COMA SCALE ADULT
EYES OPEN
BEST VERBAL RESPONSE
BEST MOTOR RESPONSE
Pupils
mm
mm
ORIENTATION
Cardiovascular system
NORMAL BASELINE: Regular rate and rhythm, no edema, capillary refill less than 3 seconds, rate: 60-100 per minute, BP normotensive.
TEDS ON
SCDS ON
Cardiac Pacemaker
Eyes Ear Nose & Throat
Normal Baseline EYES: Without drainage, sclera white.
Normal Baseline EARS: No complaint of pain.
Normal Baseline NOSE: No drainage or congestion.
Normal Baseline THROAT: No complaint of pain.
Eyes
Drainage
EARS
C/O Pain
Hard of Hearing
Hearing Loss
Deafness
Hearing Aids
Patent
Dizziness
Tinnitus, Ear noises, Ear ringing
Drainage
Nose
Nares patent
Nares Drainage
Pharynx, Throat
Sore throat, Pain in throat, Pharyngeal pain
Mouth Sores
Respiratory
Normal Baseline: Regular, unlabored, symmetrical, no accessory muscles used, no abnormal breathsounds, rate 12-20 per minute.
CHEST EXPANSION
INCENTIVE SPIROMETRY DONE
Pulse Oximeter present with alarms set
Cardio-Respriratory Monitor present with alarms set
CHEST TUBE PRESENT
CHEST TUBE LOCATION
Air Leak
Gastrointestinal
Normal Baseline GI: Abdomen soft, non-distended, bowel tones present X4, continent, stool soft, brown and formed, states regular bowel movements.
FLATUS
NG placement checked
RECTAL BAG PRESENT
Genitourinary system, Urogenital system
Normal Baseline Genitourinary: Voids without pain, burning, or hesitation, urine clear, no strong odor, no distention, continent.
Sex
INCONTINENT
VOIDS SUFFICIENT QUANITY
IS PATIENT RECEIVING DIALYSIS
ODOR PRESENT
catheter present
SEXUALLY ACTIVE
CURRENTLY ON MENSES
Discharge (Dx)
Musculoskeletal System, Musculo-skeletal system
Normal Baseline Musculoskeletal: Full ROM, no muscle weakness, long bones intact, gait steady.
GENERALIZED WEAKNESS
LIMITED ROM
LIMITED MOBILITY
CONTRACTURES
Hemiplegia Side
GRIPS EQUAL
UNSTEADY GAIT
Integument
NORMAL BASELINE: Warm, dry, turgor elastic, pink undertone to skin or mucosa, no lesions, skin smooth and intact, moist mucous membranes.
MOIST
PRESSURE ULCER ASSESSMENT
Bony Prominences Assessed
At risk for skin breakdown
Braden Score 18 or less
Pressure ulcer(s) present
Wound
Wound healed
Undermining
Tunneling
Odor: Before Cleaning
Odor: After Cleaning
Surgical incision
Dressing Changed
Nutrition
Tube feeding (TF)
NPO
intravenous therapy
IV HEPLOCKED
IV DISCONTINUED
CATHETER INTACT
PLACED ON IMED
patient safety
SIDE RAILS UP
IN LOW POSTION
CALL BELL WITHIN REACH
ALLERGY BAND ON
NAME BAND ON
BLOOD BAND ON
Hendrich II Fall Risk Assessment
Confusion/Disorientation/Impulsivity +4
Symptomatic Depression +2
Altered Elimination +1
Dizziness/Vertigo +1
Gender (male) +1
Any Administered Antiepileptics (Anticonvulsants) +2
Any Administered Benzodiazepines +1
GET UP AND GO TEST: RISING FROM A CHAIR
INTERVENTIONS
Assist with Ambulation
Reorient Q2H or Less
Gait Belt
ID Patient at Risk
Restraints (see policy)
Multi-personnel Transfer
Close Observation
Non-slip Footwear
Bed in lowest position
Lock wheels of vehicles of conveyance during transfer
Upper siderails raised
Call light in reach
Assist with ambulation
Offer toileting at least every 2 hours
Offer fluid/nutrition every 2 hours
Place frequently used objects within reach
Provide adequate lighting
Provide sensory impairment/orientation devices (clocks,etc)
Provide adequate rest periods
Use age appropriate distractions for confusion/disorientation
Remove harmful hazards
Provide appropriate and least restrictive patient supervision/surveillance
Communicate information about fall risk to caregivers
Encourage family/support system to participate in care
Teach/educate family/support system Fall Prevention information
Implement Fall Prevention Protocol for Hendrich II Score>5
IMPAIRED MOBILITY RISK
Implement Universal Fall Prevention Intervention
Monitor transfers to/from bed/chair(etc.)
Use appropriate assistance for transfers to/from bed/chair
Use chairs with armrests and of proper height for transfers
Implement progressive ambulation(unless contraindicated by condition/orders)
Encourage/Provide self-care assistance
Remain in attendance during toileting/ADL's
Provide assistive devices for ambulation (canes/walkers/etc.)
Gait Belt during transport/ambulation
Teach patient/family to call for help and WAIT for help before
attempting any transfer/ambulation
ALTERED ELIMINATION
Implement Universal Fall Prevention Interventions
Remain in attendance during toileting/ADL's
Assist with post-elimination hygiene
Remove non-essential clothing
Instruct patient on importance of toileting when offered by staff
Monitor for 'patient's normal' bladder/bowel habits
Monitor for causes of incontinence (diuretics,cathartics,etc.)
Monitor skin integrity
HIGH RISK FALL MEDICATIONS (ANTIEPILEPTICS & BENZODIAZEPINES)
Implement Universal Fall Prevention Interventions
Monitor drug dosages
Evaluate sensory functions
Monitor/Assess for drug overdose
Monitor response to exercise
Educate patient/support system about drug classification, side effects,precautions, toxic symptoms of overdose.
INTERVENTIONS (FOR ONCOLOGY USE ONLY)
UNIVERSAL FALL PRECAUTIONS
Neutropenic Precautions taken.
Radiation Safety Precautions taken.
ONN Unit specific
Antepartum specific
Fetal movement
Headaches
Abdominal Cramps
Uterine Contraction
Epigastric Pain
Vaginal Discharge
Post partum specific
Post Surgical
ADOLESCENT INTERACTION
Prepared for treatment/procedure as soon as possible.
Provided detailed information about events/procedures/treatments.
Allowed contact with peer group.
GERIATRIC INTERVENTION (65+)
Involved in decision process regarding pain control/medication/care decisions
Encouraged family/S.O.to visit
Independence promoted.
Hendrich Fall Risk
Confusion/Disorientation +3
Depression +4
Altered Elimination (incontinence, nocturia) +3
Non-Adaptive Mobility/Generalized Weakness +2
Dizziness/Vertigo +3
Primary Cancer Diagnosis +3
RECENT HISTORY of FALLS +7
SUGGESTED INTERVENTIONS
Assist with Ambulation
Toileting Q2H
Sensory Impairment Device
Reorient Q2H or Less
Gait Belt
ID Patient at Risk
Restraints (see policy)
Multi-personnel Transfer
Close Observation
Non-slip Footwear