Doing an Admit Assessment

posted Oct 13, 2009, 12:52 AM by Kitty McKay   [ updated Oct 2, 2010, 12:32 AM ]

Things to consider when doing an admit assessment

  1. Introduce yourself and escort patient and family to assigned room.
  2. Assess patient's general appearance, psychological status, vital signs, height, and weight.
  3. Obtain nursing history, including patient's medical history, presenting signs and symptoms, health status, risk factors for illness and falling, allergies, medication history, knowledge of health problem, and expectations of care.
  4. Conduct physical assessment of appropriate body systems.
  5. Check physician's orders for immediate treatments.
  6. Orient patient to nursing division, including staff members and head nurse; visiting hours; smoking policy; use of bed, call light, and other room equipment; mealtimes; and services available. Escort patient to bathroom (if able to ambulate).
  7. Inform patient about procedures or treatments scheduled for the next shift or day (e.g., visits by physician or dietitian). These vary based on patient's condition.
  8. Give patient and family chance to ask questions about procedures or therapies. (If patient is unresponsive or cannot understand, review with family.)
  9. Collect valuables patient chooses to keep at facility. Complete belongings list (see institution policy) and have patient or family member sign it. Place valuables in institution safe or send home with family.
  10. Ensure patient and family have time together alone, if desired.
  11. Be sure call light is within easy reach and bed is in low position. (Check institution policy regarding use of side rails.)
  12. Confirm patient's understanding of institution policies, tests, and procedures through discussion and questions.