Nursing Initial Assessment Sheetebb53456 84ef 4624 b09c 021596763c62
Nursing Initial Assessment Sheetebb53456 84ef 4624 b09c 021596763c62
Nursing Initial Assessment Sheetebb53456 84ef 4624 b09c 021596763c62
WARD/UNIT..........................................................................DIAGNOSIS..................................................................................
BASIC INFORMATION:
How admitted Walking / Wheelchair/ Stretcher
DIET PLAN:
Normal Liquid Renal Cardiac Light
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Atal Bihari Vajpayee Institute of Medical Sciences and
Dr Ram Manohar Lohia Hospital
Baba Kharak Singh Marg, New Delhi-110001
VULNERABILITY ASSESSMENT
Assessment
Vulnerable Category Needs & Action
(If "Yes" provide
Assistance in
Meeting needs as
listed)
Elderly > 75 yrs Yes No Eating
Toileting
Physically & Mentally Challenged Yes No Mobilization
Activities of Daily Living
Infectious/Communicable Disease Yes No Initiate Isolation/Reverse Barrier
Immuno Compromised Yes Nursing (as applicable)
Dietary Referral
Chronic / Intense Pain Yes No Refer to Physician
[ Pain Score(0-3)] Pain Medication
Provide comfort
Cannot Perform ADL Yes No Provide assistance based on further
functional assessment
Terminally ill Yes No Initiate End of Life Care
Special Religious / Cultural Needs
Suspected Drug and / or AlcoholDependence Yes No Refer to Physician
Presently at risk pressure ulcer Yes No If yes initiate action Plan with Braden
Scale
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Atal Bihari Vajpayee Institute of Medical Sciences and
Dr Ram Manohar Lohia Hospital
Baba Kharak Singh Marg, New Delhi-110001
1. History of falling No 0
Yes 25 .......................
Yes 15 .......................
3. Ambulatory Aid
None / Bed Rest / Nurse Assist 0
Crutches / Cane / Walker 15
Furniture 30 .......................
5. Gait
Normal / Bed rest / Wheel chair 0
Weak 10
Impaired 20 .......................
6. Mental Status
Oriented to Own ability 0
Overestimated of forgets limitations 15 .......................
0 to 24 (low risk) 25 to 44 (medium risk) Above 45 (high risk) Total fall scale score
If Score is > 24, patient family is educated for all prevention: Yes .......................... No. .............................
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