Having a good admission process will benefit the resident during their stay in the facility. Greet the resident by name and welcome him or her to your facility. It is vital that a good assessment should be completed and documented as quickly as possible post admission. Tell them your name and position. Ask them how they would like to be addressed (Robert versus Bob, for instance). Get as much information as possible directly from the resident if they are cognizant or from the accompanying relative or power of attorney (POA), including history of any past illness. Introduce the resident to their roommate if they are sharing a room. It is important to realize if the resident is having a difficult time transitioning from home, hospital or other long term care facility. The resident will be amongst strangers again and may be suspicious, cantankerous and not compliant. It is your responsibility to ease their distress by being polite and caring.
Always remember that first impressions go a long way. You need to do a head to toe assessment specifically concentrating on the admitting diagnosis.
Scalp and hair: Any lesions or dandruff present?
Eyes: Glasses, contact lenses, cataracts removed.
Ears: How is the resident’s hearing? Do they use hearing aids?
Nose: Any history of Epistaxis (nosebleeds)?
Mouth: Do they have their own teeth? Edentulous (possessing no teeth). Is there any sores or redness?
Neck: Check for any swelling.
Lungs: Auscultation(using a stethoscope) the chest thoroughly. Any complaints of cough or shortness of breath?
Does the resident have a pacemaker? When was it last checked.? Check apical and radial pulses and heart sounds.
Check nail beds for any signs of cyanosis.
Breast examination: Observe for symmetry, bulging, retraction or fixation. Palpate the breast in a clockwise rotary motion. The areolas should be palpated to determine the presence of underlying masses. The nipples should be gently compressed for any discharge.
Abdomen: should be assessed for contour and distention. Any signs of peristalsis. Respiratory movement should be assessed. Observe for lesions, scar tissue, striae veins, and pigmentation. Check the umbilicus for any swelling. You may see aortic pulsation in very thin residents.
Use your stethoscope lightly to detect bowel sounds. You should listen in all quadrants for at least five minutes. Check for tenderness and muscle guarding.
Extremities: Observe for involuntary movement. Check the size, contours and bilateral symmetry. Check for edema, color, temperature and pluses. Preform range of motion and check for muscle strength. Check for tonicity of muscle.
Skin: a complete skin sweep must be performed. Observe for skin tears, bruises, scratches, scars and any signs of pressure sores (We are all aware of the difference between “admitted with’ versus “acquired at facility”). If possible, measurements and photographs should be taken (if it is your facility’s policy).
The other assessments required by your facility, fall risk, bowel and bladder, pain, etc., should all be completed timely. All your observances should be in the documentation, signed and dated. Base height, weight and vital signs should be recorded. Check the ability of the resident to care for glasses, hearing aids and dentures, if present. Do they require assistance?
