Table 1 Structured nursing assessment template for neurosurgical disease patients
Assessment category | Explanation |
|---|---|
1. General Information | Gender, age, caregivers, medical insurance status. |
2. Chief Complaint | The primary health issue or discomfort symptoms described by the patient during consultation. |
3. Current Diagnosis | Recent medical diagnosis. |
4. Past Health History | Medical history, allergy history, infectious disease history, family history, etc. |
5. Current Health Status | Includes the following four aspects: |
(1) Current Treatment | Surgical treatment, pharmacological treatment, other treatments (e.g., physical therapy, radiotherapy, chemotherapy, etc.). |
(2) Physical Status Assessment | Consciousness, pupil reaction, neurological function assessment (language, movement, sensation, cough ability, swallowing function, vision, visual fields, epilepsy, delirium, etc.), positive signs (temperature, pulse, respiration, blood pressure, oxygen saturation, etc.), skin, tubes, diet, bowel and bladder function, sleep, activity, and symptoms from other systems, etc. |
(3) Positive Laboratory and Diagnostic Results | Laboratory test results, other diagnostic findings. |
(4) Relevant Scale Scores | Morse Fall Risk Score, Braden Pressure Injury Risk Score, Barthel Index for Activities of Daily Living, Caprini Thrombosis Risk Score, Numerical Rating Scale for Pain, etc. |
6. Current Psychological Status | Psychological manifestations and characteristics of the patient and family members when coping with the disease burden. |