TABLE 1. Summary of Sections, Categories, and Variables Included in the First Version of the Nursing Assessment Tool.
| Sections | Categories | Variablesa |
|---|---|---|
| I—Demographic information | Record number, initials of the name, date of birth, age, gender, ethical group, marital status, the number of children, educational level, occupation, family income, nationality, and origin | |
| II—Data of hospitalization | Date, time, ward, bed number, past hospitalizations, updated immunizations, history of allergies, family history, reason for hospitalization, medical diagnosis | |
| III—Lifestyle | Use of tobacco, alcohol, uncontrolled substances/drugs, self-medication, physical activity, eating habits, hydration and elimination (bladder pattern and bowel pattern), and usual medication | |
| IV—Psychobiological needs | Oxygenation | Complaints, inspection, palpation, percussion, and auscultation |
| Circulation | Blood pressure (site of measurement, patient position, arm circumference, cuff width), wrist (characteristics), heart rate (characteristics), skin color, presence of edema, peripheral perfusion, presence of venous catheters, venous infusions | |
| Thermoregulation | Body temperature, presence of sweating, tremors | |
| Mental status | Complaints, level of consciousness, visual acuity, pupils, olfactory acuity, hearing acuity, taste acuity, tactile perception | |
| Skin and mucosal integrity | Skin characteristics (color, humidity, lesions), loss of sensation, appearance of the nails, scalp | |
| Nutrition/hydration | Weight (current, usual, changes), height, body mass index, presence of feeding tube, type of diet, amount of diet, fluid intake, complaints (nausea, vomiting), examination of the mouth, lips, oral mucosa, gums, teeth | |
| Elimination | Urinary and intestinal (frequency, appearance, volume), complaints, abdominal examination (inspection, auscultation, palpation and percussion) | |
| Sleep and rest | Sleep pattern, changes in the sleep pattern | |
| Physical activity and mobility | Walking, changes in the gait pattern | |
| Hygiene | Need for bathing self-care, need for toileting self-care, need for dressing self-care | |
| Regulation | Thyroid (inspection, palpation) | |
| Shelter | Type and condition, people living with, existence of sanitation, destination after hospital discharge | |
| Sexuality | Genitals (inspection), changes and/or complaints related to sexual activity, contraceptive use | |
| V—Psychosocial needs | Safety | Presence of anxiety, fear, aggression, afflictions, self-perception of the health state |
| Communication | Type of communication, tone of voice, how communicates, changes | |
| Social interaction | Communicates with others, stands alone, participates in activities, receives visits, family relationship | |
| Leisure/recreation | Watches television, listens to the radio, performs manual labor, reads | |
| Self-esteem | Confidence, negative verbalizations, crying, anguish, poor body presentation | |
| Self-realization | How the disease affects your life, life expectancy | |
| VI—Psychospiritual needs | Religious, ethical, philosophy of life | |
| VII—Drug therapy in hospital | ||
| VIII—Supplementary examinations results |
aNot all variables are shown in this table.