SCOPE OF SERVICE
For good planning and provision of patient- and family-centered care, all cases must start with an initial assessment by a registered nurse. The agency’s registered nurse assesses, plans, implements, and evaluates nursing care in collaboration with individuals and the multidisciplinary health care team to achieve results-oriented goals and excellent health outcomes.
This guideline aims to ensure all patients receive consistent and timely nursing assessments. The guideline specifically seeks to provide nurses with the following:
- Indications for assessment
- Types of assessments
- Structure for assessments
All assessments shall consider the history of current illness/injury (i.e., the reason for current admission), relevant past history, allergies and reactions, medications, immunization status, and family and social history.
For neonates and infant’s maternal history, antenatal history, delivery type, and complications, if any, shall be considered.
Each assessment process includes the overall physical, emotional, and behavioral state of the patient.
Considerations for all patients include looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture, and movement.
The assessment shall include:
- Assessment of the nursing needs of the client
- Obtaining information about the client’s medical history, physicians’ names, and contact information
- Observe signs and symptoms and diagnostic and preventive procedures
- Safety of the caregiver and the patient
- Assessment of availability of all necessary and needed equipment by the patient
- Vital signs – Temp, RR, HR, BP, 02 saturation, and pain
- Additional measurements – weight and height
- Well-being – Mood, emotional state, comfort objects, sleeping habits and outcome, coping strategies, support networks, reaction to admission, and other psychosocial assessments.
For more information, please feel free to contact us at your convenience.