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OKLAHOMA DEPARTMENT OF CORRECTIONS NURSING PRACTICE PROTOCOLSMSRM 140117.01.2.15 (R2/20)SUNBURN Subjective Data:Allergies: ___Chief complaint: ___ Onset: ___ Anatomical location: ___ Approx. Length
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How to fill out nursing assessment protocols

01
Gather all necessary information about the patient, including medical history, current medications, and any previous assessments.
02
Review the nursing assessment protocol to ensure you understand all sections and components.
03
Begin by documenting the patient's demographics, such as age, gender, and primary language.
04
Move on to assessing the patient's vital signs, including blood pressure, temperature, heart rate, and respiratory rate.
05
Conduct a head-to-toe physical assessment, documenting any abnormalities or concerns as you go.
06
Assess the patient's mental status, including orientation, cognition, and level of alertness.
07
Document the patient's pain level using a standardized pain scale.
08
Complete a nutritional assessment, including weight, diet preferences, and any dietary restrictions.
09
Evaluate the patient's mobility and ability to perform activities of daily living.
10
Document any additional assessments or screenings required by the nursing protocol.

Who needs nursing assessment protocols?

01
Nursing assessment protocols are needed by healthcare professionals, including nurses, nurse practitioners, and other medical staff who are responsible for assessing and monitoring patients' health status.
02
These protocols help ensure thorough and systematic assessment of patients, leading to accurate diagnoses, effective treatment plans, and improved patient outcomes.
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Nursing assessment protocols are standardized procedures used by nurses to collect information about a patient's health status.
Nurses are required to file nursing assessment protocols.
Nursing assessment protocols can be filled out by documenting the patient's vital signs, symptoms, medical history, and physical examination findings.
The purpose of nursing assessment protocols is to help nurses gather relevant information to develop an appropriate care plan for the patient.
Information such as patient's demographics, current health status, medications, allergies, and any significant findings during the assessment must be reported on nursing assessment protocols.
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