UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES MEDICAL CENTER AND CLINICAL PROGRAMS
PROFESSIONAL NURSING ORGANIZATION
POLICY STANDARDS

I.        MAINTENANCE OF PROFESSIONAL PRACTICE SYSTEM

    3.  RN ASSESSMENT

    1. Inpatient

  1. All inpatients shall have a comprehensive nursing assessment completed by an RN, to determine their nursing care needs, within 24 hours of hospital admission.  Elective surgical patients admitted on the day of surgery will be assessed prior to the surgical procedure.   This patient profile will provide the basis for the establishment of the patient’s nursing plan of care.

  2. Development of the  patient’s nursing plan of care shall include consideration of the following:

      • Biophysical Assessment

      • Psychosocial Assessment

      • Environmental Factors

      • Self Care Ability

      • Educational Needs Assessment

      • Discharge Planning Needs

      • Population Specific Needs

      • Braden Skin Assessment

      • Pain Assessment

      • Falls Risk Assessment

  3. Patient population specific time frames for initial completion and   periodic re-assessment of components of the comprehensive nursing assessment are based on  the following factors:

    • The anticipated length of stay for the major patient population(s) served

    • The complexity of the nursing care needs of the major patient population(s) served

    • The dynamics of the condition(s) of the major patient population(s) served.

  4. Required minimum assessment/ reassessment time frames for inpatient populations are as specified below and as prescribed by nursing protocols integrated into the individual patient’s plan of care.

 Biophysical Assessment: 

o       ICU – initial assessment within one hour of arrival to the unit; reassess – every four hours; reassess with change in patient condition; reassess with change in RN care giver; reassess as prescribed by patient’s plan of care.

o       Intermediate – initial assessment within one hour of arrival to the unit; reassess – every four hours; reassess with change in patient condition; reassess with change in RN care giver; reassess as prescribed by patient’s plan of care.

o       Medical/ Surgical – initial assessment within two hours of arrival to the unit; reassess – every 12 hour shift; reassess with change in RN care giver; reassess with change in patient condition; reassess as prescribed by plan of care of individual patients.

o       Maternal – initial assessment within two hours of arrival to the unit; and every 12 hours for inactive labor or post-partum patients; reassess with change in RN care giver; reassess with change in patient condition/status; reassess as prescribed by plan of care of individual patients.

o       Normal Newborn – initial assessment within one hour of delivery; reassess – every 12 hours; reassess with change in RN care giver; reassess as prescribed by plan of care of individual infants.

o       Neonatal Intensive Care – initial assessment within 15 minutes of arrival to the unit; reassess with every vital signs, reassess as condition warrants; reassess with change in RN care giver; reassess as prescribed by plan of care of individual neonates.

Braden Skin Risk Assessments are performed:

o       Admission

o       Changes in clinical condition

o       Every 12 hours

 Pain Assessments are performed:

o       Admission when patient has a positive pain screen

o       Every 12 hour shift

o       As directed by patient’s plan of care

o       As clinically indicated by patient’s plan of care

o       Before and after any pharmacologic or nonpharmacologic intervention for pain

Falls Risk Assessment are completed on:

o       Admission

o       Transfer

o       Each shift and PRN

o       Changes in clinical condition

o       As needed post-procedure

  1. Information related to the assessment of nursing care needs shall be obtained from the patient or their designee.

  2. The analysis/interpretation of the data collected must be performed by the RN and is the assessment which provides the basis for the development of the nursing plan of care.

  3. Each patient’s nursing plan of care may consist of pre determined hospital approved standards of care/practice appropriate to the patient or be developed as an individualized action plan. 

  4. Assessment data from the comprehensive nursing assessment and ongoing periodic reassessments of the patient by RNs will be incorporated into the interdisciplinary care planning process through the unit based interdisciplinary care meetings. .

  5. A plan of care will be instituted within 24 hours of admission (see Addendum I.1).

  6. Exceptions to the requirement for documentation to protocols include those patients on observation or interventional status.

b.      Outpatient

  1. All patients will have an assessment by a Registered Nurse or designated care provider on their first clinic visit and problems identified and documented with reassessments on subsequent clinic visits.

  2. All ED and Short Stay Unit patients will have an initial assessment performed by an RN.

  3. The assessment of the patient’s nursing care needs shall include consideration of these factors:

    • Psychosocial

    • Environmental

    • Self-Care

    • Educational

    • Age-Specific Needs

    • Follow-up Care/Discharge Planning

    • Pain Assessment

    • Falls Risk Assessment

  1. Patient care is provided by utilizing an interdisciplinary team approach.

 

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