[Assessment of the critical patient at admission. An indicator of quality of care]. / Valoración al ingreso del paciente crítico. Un indicador de calidad asistencial.

The type of information recorded by nurses at admission of critical patients to the Intensive Care Unit was described and the relation between the information recorded and the presence of absence of endotracheal intubation in the patient admitted was analyzed. A sample of 214 admission records of patients admitted to our unit in 1998 was studied using a data sheet based on Virginia Henderson assessment questionnaires. The presence or absence of 71 variables classified into four sections was analyzed: personal data, general data, Virginia Henderson basic needs, and other assessment data. Most data collected at admission were objective data obtained by observation and/or physical examination of the patient. These data were contained in two sections: "Virginia Henderson basic needs" (normal breathing, food and water intake, excretion, mobility, maintaining posture, conserving body temperature, skin hygiene and integrity, and avoiding danger) and "other assessment data" (medical treatment, diagnostic and therapeutic tests, and hemodynamic monitoring). Information about the patient's background in the section "general data" was obtained less frequently. Subjective data obtained from interviews was clearly limited. These data are included in the "Virginia Henderson basic needs" (sleep, rest, dressing and undressing, communicating, values and beliefs, feeling of satisfaction, absence of boredom, and intellectual stimulation).