PPG GDCH Nur 31 Assessment and Reassessment

GULF DIAGNOSTIC CENTER HOSPITAL
NURSING POLICY

Policy No: MED-NUR-P0031/12 Issue Date : May 2012 Revision No.: Original Revision Date : May 2012 Next Revision : May 2014 Page 1 of 10
TITLE: ADMISSION ASSESSMENT AND REASSESSMENT OF PATIENTS

Department Section Distribution : Nursing : Nursing Care : Hospital Wide
ADMISSION ASSESSMENT AND REASSESSMENT OF PATIENTS

APPROVAL SHEET Prepared by: Name Ms. Jennelyn Paderan Acting Charge Nurse, In-patient Ward Reviewed by: Name Ms. Gela Mocanu Acting Head of Nursing Department Mr. Zuher Arawi Quality Manager Signature Date Signature Date
Approved by: Name Dr Emad Yassin Al Rahmani Medical Director Mr. Rami Kaddoura Executive President & C.O.O Signature Date
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NURSING POLICY


DOCUMENT AMENDMENT RECORD SHEET

Date Description of Change Page Effected Revision Number
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NURSING POLICY


TABLE OF CONTENTS:
SUBJECTS PURPOSE POLICY SCOPE DEFINITIONS/ABBREVIATIONS PROCEDURE REFERNCES RELATED FORMS 5 5 10 10 PAGE NO. 4 4 4
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Department Section Distribution 1. : Nursing : Nursing Care : Hospital Wide
PURPOSE 1.1. To ensure the timely Interdisciplinary Assessment and Reassessment of each patients needs for care by qualified competent professionals. 1.2. To ensure that every patient of the hospital, whether an in-patient, emergency service patient, or an outpatient is provided care that meets generally acceptable standards of professional practice
2. POLICY 2.1. Data for assessment includes, but not limited to: 2.1.1. History and physical examination 2.1.2. Diagnostic testing 2.1.3. Multidisciplinary screen (such as nutritional, psychological, psychosocial, functional, socioeconomic and educational). 2.2. Interdisciplinary assessment of needs and determination of goals is the framework utilized to determine the plan of care that will be implemented with the patient. 2.3. Initial assessments are performed upon entry into the Emergency Room, In-patient Unit or Out-patient within a time frame determined by the patients conditions and current policy. 2.4. Patients are reassessed at intervals as indicated by their condition, course of treatment and their plan of care. These indications include but are not limited to: 2.4.1. When a significant change occurs in the patients condition and/or diagnosis. 2.4.2 Upon intra-hospital and inter-hospital transfer. 2.4.3 Prior to, during, and after operative and other invasive procedures. 2.4.4 When patients needs are identified. 2.4.5 Upon discharge. 3. SCOPE 3.1. Assessment and reassessments are performed by all providers of care, including but may not be limited to the physician, licensed nurse and anesthetist. 4. DEFINITIONS/ABBREVIATIONS 4.1 ASSESSMENT 4.1.1 Assessment includes the collection and analysis of data about the patient in order to determine the patient care and treatment needs. 4.1.2 Reassessment is conducted minimum once a day for non acute patients and more than once or continuous for acute patient life threatening conditions including Fridays and public Holidays. 4.2 REASSESSMENT 4.2.1 Reassessment is the re evaluation of the patient at regularly specified times according to the patients course of treatment, response to treatment or when a
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NURSING POLICY


significant change occurs in the patients condition and/or diagnosis. Patients are assessed against the goals established for the patient initial assessment. 5. PROCEDURE Each member of the interdisciplinary team will assess and/or reassess the patient as per policy, on the appropriate hospital specific form(s). 5.1. Assessment and Reassessment of Patients by PHYSICIAN 5.1.1. EMERGENCY Triage Assessment reassessment should be done on endorsement and when needed if there is change in patients condition and upon discharge. 5.1.1.1. Category 1 RESCUCITATION Assessment should be immediate; Reassessment should be continuous. 5.1.1.2. Category 2 EMERGENT Assessment should be 15 minutes; should be after 15 minutes 5.1.1.3. Category 3 URGENT Assessment should be 30 minutes; Reassessment should be after 30 minutes 5.1.1.4. Category 4 LESS URGENT Assessment should be 60 minutes; Reassessment should be after 60 minutes 5.1.1.5. Category 5 NON URGENT Assessment should be 120 minutes; reassessment should be after 20 minutes 5.1.2. OUT-PATIENT CLINIC 5.1.2.1. Assessment with each visit and on follow up visits using Patient Screening Form 5.1.2.2. Pre-admission assessment within 30 days prior to admission. Brief assessment notes upon admission. 5.1.3. IN-PATIENT 5.1.3.1. Initial Admission Assessment is to be done within 24 hours with attending counter signature and stamp. Patients for which surgery is planned, have a medical assessment performed before the surgery. The initial medical assessment is documented before anesthesia or surgical treatment. Reassessment is on endorsement and when needed if there is a change on patients condition and upon discharge. Admission Assessment Form can be used. 5.1.3.2. Physician assess an acute care patient at least daily, including weekends. Reassessment should be done when there has been a change in the patients condition or if the patients diagnosis has changed or the care needs require revised planning and in a response to a significant change in the patients condition. Also, reassessment is done to determine if the medications and other
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NURSING POLICY


treatments have been successful and the patient can be transferred or discharged. Form to be use is Doctors Progress/Treatment Notes. 5.1.3.3. Physician assess on pre-operative period, intra-operative period and postoperative period. Reassessment should be done prior to induction and every 5 minutes while in O.R. Post operative in recovery room reassessment is according to ALDRETE Criteria for discharge from the Recovery Room. 5.2. Assessment and Reassessment of Patients by NURSES 5.2.1. EMERGENCY - Triage Assessment reassessment should be done on endorsement and when needed if there is change in patients condition and upon discharge. 5.2.1.1. Category 1 RESCUCITATION Assessment should be immediate; Reassessment should be continuous. 5.2.1.2. Category 2 EMERGENT Assessment should be 15 minutes; Reassessment should be after 15 minutes 5.2.1.3. Category 3 URGENT Assessment should be 30 minutes; Reassessment should be after 30 minutes 5.2.1.4. Category 4 LESS URGENT Assessment should be 60 minutes; Reassessment should be after 60 minutes 5.2.1.5. Category 5 NON URGENT Assessment should be 120 minutes; reassessment should be after 20 minutes 5.2.2. OUT-PATIENT CLINIC 5.2.2.1. Assessment with each visit and on follow up visits using Patient Form Assessment and Patient Assessment Form 5.2.3. IN-PATIENT 5.2.3.1. Initial assessment is done within 24 hours of admission. Reassessment is done upon patient admission. Form to be use is Admission Assessment Form. 5.2.3.2. Assessment using nurses notes should be done every shift. Reassessment is every shift and can be more frequent according to significant findings in the patients condition. 5.2.3.3. Assessment of pain using pain Assessment form is upon admission and reassessment is every shift (within first 4 hours from the start of the shift) hourly for 4 hours after surgery and on invasive procedure. Reassessment is also done upon patients request for analgesia and 30 minutes to 1 hour after giving pain relief (medical/non-medical) until pain subsides. Reassess pain every 2 hours while pain is active. 5.2.3.4. Assessment of fall risk using Fall Risk assessment form is upon admission and the reassessment will be every shift (within first 4 hours) from the start of the shift. If risk score is more than 3 reassess every 4 hours. If risk score is less
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NURSING POLICY


than 3 reassessment is done every shift. If condition changes, reassess (e.g. pain medication, post operative cases). 5.2.3.5. Assessment using Nursing Care Plan Form is upon admission and the reassessment will be every shift for all cases. 5.2.3.6. Nutritional assessment which is part of the nursing assessment should be done upon admission. Patient in all wards who requires nutritional assessment is done by the dietitian on a daily basis. Reassessment should be as needed. For patients with long stay in hospital, follow up is done. 5.2.4. RECOVERY ROOM 5.2.4.1. Assessment in the Recovery Room is immediately after the surgery and the reassessment is upon admission at the recovery Room, after 10 minutes, 20 minutes, 45 minutes and at the time of discharge from PACU according to Aldrete post anesthesia score. 5.3. The Minimum Content of assessment performed in In-patient setting is defined below. 5.3.1. PHYSICIAN - SCOPE OF ASSESSMENT 5.3.1.1. Chief Complain 5.3.1.2. History of present illness 5.3.1.3. Health history (current and past health history); Physical history 5.3.1.4. Allergies 5.3.1.5. Family/Social history; other risk factors and previous hospitalizations 5.3.1.6. Review of systems 5.3.1.7. General appearance of the patient 5.3.1.8. Physician assessment and plan 5.3.1.9. Exposure to infectious disease, immunization and prenatal and birth history (in pediatric cases) 5.3.1.10. Obs/gynae history, ante-natal. Anti-D, rectal and pelvic examination (in obs/gynae cases) 5.3.2. PHYSCIAN - SCOPE OF REASSESSMENT 5.3.2.1. Daily reassessment of all patients 5.3.2.2. Reassessment can occur more than daily as appropriate individual patient needs and acuity and it is documented in the patients record (refer to table 5.1.1). 5.3.3. NURSES -SCOPE OF ASSESSMENT: Assessment includes: 5.3.3.1. Vital signs 5.3.3.2. Medication history 5.3.3.3. Psychological assessment
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NURSING POLICY


5.3.3.4. Sleep/rest assessment 5.3.3.5. Education needs 5.3.3.6. Discharge planning needs 5.3.3.7. Pain assessment (e.g location, intensity, character, frequency, duration and radiation) when applicable 5.3.3.8. Nutritional Screen/assessment 5.3.3.9. Growth and development 5.3.3.10. Functional screen assessment 5.3.3.11. Orientation to the unit 5.3.3.12. Skin integrity 5.3.3.13. Patient rights and responsibilities 5.3.3.14. Fall/safety risk valuables/equipments 5.3.3.15. Socio-economic 5.3.3.16. Dependence level or infants less than 1 year 5.3.4. NURSES - SCOPE OF REASSESSMENT 5.3.4.1. Vital signs every shift according to doctors order 5.3.4.2. Pain assessment once per shift if there is no pain or if pain noted 5.3.4.3. Educational need assessment 5.3.4.4. Nursing patient reassessment/ nurses note every shift 5.3.4.5. Fall risk assessment once per shift if no fall risk identified or if risk identified. 5.4. The Minimum Content of Assessments performed in out-patient settings: For Out-patient Visits, Patient is assessed for 5.4.1. Vital signs (e.g. weight, height. BMI, immunization status when applicable) 5.4.2. Pain scale (e.g. location, intensity, character. Frequency, duration and radiation) 5.4.3. Current medication 5.4.4. Allergies 5.4.5. Head circumference for newborns and pediatric cases 5.4.6. Ultrasound findings in antenatal care and gynecology cases 5.4.7. Additional assessment such as (e.g. educational, functional, nutritional, psychological). 5.4.8. History of present illness 5.4.9. Past medical history 5.4.10. Past surgical history 5.4.11. Family history 5.4.12. Social history 5.4.13. Review of system 5.4.14. Triage category (E.R patients) 5.4.15. Procedures and treatments performed 5.4.16. Final diagnosis
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NURSING POLICY


5.3.2 Reassessment of patients attending OPD will be done during follow up visits. 5.5. Nutritional Services: 5.5.1. SCOPE OF ASSESSMENT Nutritional Assessment includes: 5.5.1.1. Admitting height and weight 5.5.1.2. BMI 5.5.1.3. Diet history 5.5.1.4. Medications 5.5.1.5. Physical activity 5.5.1.6. Food allergy 5.5.1.7. Preferred diet 5.5.1.8. Appetite 5.5.1.9. Physical findings 5.5.1.10. Risk factor assessment 5.5.2. SCOPE OF REASSESSMENT 5.5.2.1. Follow up of patients response to dietary regime 5.6. Rehabilitation Medicine: 5.6.1. SCOPE OF ASSESSMENT: Initial Assessment includes: 5.6.1.1. Medical history 5.6.1.2. Physical examination 5.6.1.3. Treatment plan 5.6.2. SCOPE OF REASSESSMENT 5.5.2.1 Follow up of patients response to rehabilitative treatment. 5.7. Respiratory Care 5.7.1. SCOPE OF ASSESSMENT 5.7.1.1. Mechanical ventilation patient care 5.7.1.1.1. Assessment of patients respiratory status 5.7.1.1.2. Assessment of ventilation parameters 5.7.1.1.3. Assessment of response to treatment 5.7.2. SCOPE OF REASSESSMENT 5.7.2.1. Reassessment of patients response to respiratory therapy 5.8. Outcome of Care 5.8.1. The patient and his and her family are informed of the planned care and treatment and participate in the decisions about the priority needs to be met.
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NURSING POLICY


5.8.2. The patient and his and her family are informed of the outcomes of the assessment process and any confirmed diagnosis by the attending physician. 6. REFERENCES: 6.1. JCIA Assessment of Patient 7. RELATED FORMS AND DOCUMENTS 7.1. OPD Patient Assessment Form 7.2. Pre-oeparative Doctors Orders 7.3. Admission Assessment Form (Adult, Pediatric and Obs/Gyne) 7.4. Doctors Progress/Treatment notes 7.5. Nurses Notes 7.6. Nutrition assessment In-patient Record 7.7. Fall risk Assessment/re-assessment Form 7.8. Vital signs Sheet 7.9. Interdisciplinary Patient Family Education Record 7.10. Nursing care Plan 7.11. Anesthetic Record
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PPG GDCH Nur 31 Assessment and Reassessment

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GULF DIAGNOSTIC CENTER HOSPITAL

TITLE: ADMISSION ASSESSMENT AND REASSESSMENT OF PATIENTS

ADMISSION ASSESSMENT AND REASSESSMENT OF PATIENTS

GULF DIAGNOSTIC CENTER HOSPITAL

TITLE: ADMISSION ASSESSMENT AND REASSESSMENT OF PATIENTS

DOCUMENT AMENDMENT RECORD SHEET

GULF DIAGNOSTIC CENTER HOSPITAL

TITLE: ADMISSION ASSESSMENT AND REASSESSMENT OF PATIENTS

GULF DIAGNOSTIC CENTER HOSPITAL

TITLE: ADMISSION ASSESSMENT AND REASSESSMENT OF PATIENTS

GULF DIAGNOSTIC CENTER HOSPITAL

TITLE: ADMISSION ASSESSMENT AND REASSESSMENT OF PATIENTS

GULF DIAGNOSTIC CENTER HOSPITAL

TITLE: ADMISSION ASSESSMENT AND REASSESSMENT OF PATIENTS

GULF DIAGNOSTIC CENTER HOSPITAL

TITLE: ADMISSION ASSESSMENT AND REASSESSMENT OF PATIENTS

GULF DIAGNOSTIC CENTER HOSPITAL

TITLE: ADMISSION ASSESSMENT AND REASSESSMENT OF PATIENTS

GULF DIAGNOSTIC CENTER HOSPITAL

TITLE: ADMISSION ASSESSMENT AND REASSESSMENT OF PATIENTS

GULF DIAGNOSTIC CENTER HOSPITAL

TITLE: ADMISSION ASSESSMENT AND REASSESSMENT OF PATIENTS

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