Definition and purpose: Self-care ability is people’s ability to take care of themselves in life. The purpose is to understand the patient’s actual self-care ability and provide a basis for formulating personalized care plans.

Assessment points: Dynamic assessment can be carried out when the patient's condition changes through observation and direct questioning.

Timing of assessment: upon admission, after surgery, when conditions change, and before discharge. (Assessed within 2 hours of admission and completed within 5-10 minutes)

Assessment tools and grading: Barthel's self-care ability rating scale is commonly used, including ten items. Each item has four scoring criteria (completely independent, requires some help, requires great help, completely dependent, with scores decreasing in order). The scores are added together. That is the total score, ranging from 0-100. A total score of ≤40 is considered severe dependence, 41-60 is considered moderate dependence, 61-99 is considered mild dependence, and 100 is considered no dependence.

Nursing measures: Provide the basis for hierarchical care based on the patient's scoring results, with heavy reliance on first-level care, moderate reliance on second-level care, slight reliance on second- or third-level care, and no need to rely on third-level care.

Definition: An inpatient fall occurs when a patient unexpectedly falls to the ground or lower than the initial position in any setting of a medical institution, with or without trauma.

Assessment purpose: Provide a safe hospital environment and take targeted preventive measures based on fall risk levels and influencing factors.

Timing of assessment: upon admission, changes in condition, use of high fall risk medications, transfer to another department, and before discharge.

Assessment points: Focus on the assessment of fall risk factors and emphasize dynamic assessment to increase the comprehensiveness and timeliness of assessment.

Assessment Tools and Grading

Nursing measures

Definition: A pressure injury is defined as a localized injury to the skin and underlying soft tissue, typically seen over bony prominences or associated with medical or other devices.

Purpose of Assessment: To identify whether the patient is at risk of developing pressure ulcers

Timing of assessment: 1. First assessment: The assessment should be completed within 2 hours after the patient is admitted to the hospital. In case of special circumstances such as emergency surgery, the assessment should be completed in a timely manner after surgery. 2. Re-evaluation: Those at extremely high risk will be evaluated every 48 hours, those at high and medium risk will be evaluated twice a week, and those at low risk will be evaluated once a week. Patients should be evaluated at any time when their condition changes.

Assessment points: Check the skin all over the body, pay attention to easily overlooked places such as behind the pillow and behind the feet, and accurately stage pressure injuries if they occur.

Assessment tools and grading: The Braden assessment scale is commonly used. The assessment content includes 6 items: sensation, moisture, activity, mobility, nutritional intake, friction and shear force. Each item is scored from 1 to 4 points, with a total score of 23 points. , the lower the score, the higher the risk of developing pressure ulcers. 15-18 is classified as low risk, 13-14 is classified as moderate risk, 10-12 is classified as high risk, and <9 is classified as very dangerous.

Nursing measures

Definition: Tube slippage mainly refers to the detachment of gastric tubes, urinary tubes, drainage tubes, endotracheal tubes, tracheostomy, central venous catheters and peripherally inserted central venous catheters.

Purpose of evaluation: To identify high-risk groups for unplanned extubation and applying it in nursing care can effectively reduce the rate of unplanned extubation and reduce the occurrence of hidden catheter hazards.

Timing of assessment: For those with various indwelling catheters upon admission, transfer, or after surgery, the first assessment will be conducted. From now on, high-risk (Ⅲ degree) catheters will be assessed every shift, medium-risk (Ⅱ degree) catheters will be assessed every day, and low-risk (Ⅰ degree) catheters will be assessed every day. Evaluate twice a week, and evaluate at any time if there are abnormalities until extubation.

Assessment points: Clarify the classification of various types of catheters

Assessment tools and grading: Inpatient catheter detachment risk assessment form, including 8 items. A score of ≤8 points indicates mild risk, a score of 9 to 12 points indicates moderate risk, and a score of ≥13 points indicates high risk. Catheter slippage may occur at any time if the score is ≥ 9 points, and a warning sign to prevent catheter detachment is hung. The patient will be followed up and evaluated once a week according to the condition until the risk value is ≤ 8 points. If there is a risk change, the patient will be evaluated in a timely manner. Patients with a score of ≥ 13 points will be evaluated daily. .

Nursing measures

Anesthesiology Specialist Assessment

Definition: The patient transitions from a state of general anesthesia to an awake state.

Evaluation purpose: It has important clinical value to ensure smooth recovery, eliminate harmful stimuli in a timely manner, and reduce complications during the recovery period.

Assessment points: Understand the four stages of recovery from general anesthesia and judge the degree of recovery.

Assessment tools and grading: divided into 3 evaluation indicators, including breathing, consciousness, and movement. The total score is 6 points. The higher the score, the better the degree of awakening.

Nursing measures: Provide ventilator-assisted ventilation to patients with tracheal intubation. At the same time, ECG monitoring monitors the patient's vital signs, continuous body temperature monitoring, antagonist drugs, and measures to keep warm. After the operation, the effect of the anesthetic in the patient's body gradually wears off, until the patient gradually regains consciousness.

Definition: It is an unpleasant sensory and emotional experience, accompanied by existing or potential tissue damage, and is a protective defense response of the body against harmful stimuli.

Purpose of assessment: to correctly determine pain type, pain intensity and its impact, so as to relieve pain and increase comfort for patients.

Evaluation time

Assessment points

Assessment Tools and Grading

Nursing measures: Reduce or eliminate the causes of pain, rationally use methods to relieve or relieve pain, provide social and psychological support, and appropriately use psychological care and pain psychotherapy.

Definition: An existing or potential risk associated with a nutrient that may lead to adverse clinical outcomes for patients.

Purpose of assessment: Conduct nutritional risk screening on every admitted patient to assess whether they have nutritional risks, and take corresponding measures based on the screening results, such as formulating parenteral and enteral nutrition support plans.

Timing of assessment: All patients (except children) within 24 hours after admission.

Assessment Points: Choosing the Right Nutritional Screening Tool

Assessment tools and grading: Nutritional risk screening form NRS (adult), including three parts: disease severity score, nutritional status reduction score, and age score (one point is added for those over 70 years old). Higher scores represent poorer nutritional status.

Nursing measures

Definition: Blood clots abnormally in the veins, causing the blood vessels to be completely or incompletely blocked, which is a venous reflux disorder.

Purpose of assessment: The assessment of the risk of venous thromboembolism in different diseased groups can help further stratify the risk of embolism.

Timing of assessment: All patients should complete thrombosis risk assessment within 24 hours after admission. Patients should be re-assessed within 6 hours after surgery (including interventional surgery), within 6 hours after patients are transferred to another department, and before discharge. The patient should be assessed at any time when VTE risk factors change.

Key points of assessment: According to the changes in the condition, select the appropriate assessment time, conduct dynamic assessment, select appropriate assessment tools, and accurately make stratified judgments based on the assessment results.

Assessment tools and classification: VTE-Padua score, divided into 11 risk factors, risk levels: low risk: 0-3 points; high risk: ≥4 points.

Nursing measures