Puget Sound Nursing Services
What is a Nursing Assessment?
A Nursing Assessment is a written tool that is used by Registered Nurses and other qualified health care professionals to outline the medical history and to note the current care and health care needs of an individual.
A Nursing Assessment must be conducted prior to admission to an Assisted Living community or to an Adult Family Home.
Almost all assessment tools are laid out in the same manner. The State of Washington requires that assessments contain the following pieces of information.
Preferences and choices in daily life
Dementia-specific questions
Delirium, depression and cognition
Resident profile and contact information
Physician Information
Current Medications
Medical History
A Nursing Assessment is a written tool that is used by Registered Nurses and other qualified health care professionals to outline the medical history and to note the current care and health care needs of an individual.
A Nursing Assessment must be conducted prior to admission to an Assisted Living community or to an Adult Family Home.
Almost all assessment tools are laid out in the same manner. The State of Washington requires that assessments contain the following pieces of information.
Preferences and choices in daily life
- Involvement patterns, interactions with other people
- Family and Friends
- Social and Cultural preferences
- Usual sleep patterns
- Faith and beliefs
- Preferred household activities
- Preferred activity times
- Activity preferences
- Vision
- Hearing
- Communication making self understood
- Communication ability to understand others
- Oral
- Lungs and breathing
- Cardiovascular
- Gastrointestinal
- Kidney and urinary tract
- Bowel and bladder
- Muscular-skeletal
- Nervous system
- Communicable disease history
- Immunizations
- Pain management
- Alcohol and tobacco use
- Other
- Positioning (moving in bed)
- Transfers (getting in/out of bed, a chair, commode)
- Personal hygiene
- Dressing
- Ambulation and mobility
- Toileting
- Bathing
- Eating and drinking
- Therapies
- Medical treatments
- Medication self medication, medication monitoring
- Transportation & Appointments
Dementia-specific questions
Delirium, depression and cognition
Resident profile and contact information
Physician Information
Current Medications
Medical History
Puget Sound Nursing Services
PO Box 835
Milton WA 98354
Phone 206-595-9565
Fax 253-320-2117
[email protected]
PO Box 835
Milton WA 98354
Phone 206-595-9565
Fax 253-320-2117
[email protected]
