ST GEORGE VISITING NURSES

ASSESSMENT TOOL NAME: DOB: Based on the DVA Assessment and Clinical Pathway

ATTACH LABEL HERE

DIAGNOSIS: ______

______

______ALLERGIES: ______

SURGICAL HISTORY: ______

______

Respiratory & Cardiovascular Assessment category

 Nil problems

 Chest Pain Palpitations  Peripheral Cyanosis Ankle Oedema

 Shortness of Breath  On exertion At rest Oxygen Therapy

Heart rate: ______ Regular Irregular  Blood Pressure______ Respirations______

Comments: ______

Sensory Assessment category

Eyes Nil problem/s

 Glaucoma  Cataracts  Macular degeneration  Glasses  Contacts  Legally blind  Other

(Specify)______

Ears Nil problem  Tinnitus Hearing loss- Left  Right Hearing aid-  Left  Right

Oral & Gastrointestinal Assessment category

 Nil problem/s

Are there any conditions or problems of the mouth identified:

Specify: ______

 Requires assistance with oral hygiene

Are any of these identified?

 Dysphagia  Appetite changes  Altered taste or smell  Weight loss  Weight gain

Does someone monitor the client’s food and fluid intake? Yes / No

Is the client requiring  Small frequent meals  Thickened fluids

Does the client require a dietician review  Yes  No Referral attended  Yes  No

Bowel habits  Normal consistency & frequency  Constipated  Diarrhoea  Faecal incontinence

Comments: ______

Skin Integrity Assessment category

 Nil problem/s

 Rash  Sensation deficit  Dry  Moist  Other (specify) ______

 Pressure ulcer (specify site & stage) ______

Pressure relieving/reduction devices in use:  Bed Chair  Other (specify) ______

 WoundIf there is a wound: Complete a wound assessment

Musculoskeletal & Neurological Assessment category

 Nil problem/s

Pain in  Muscles  Joints  Bones ______

Oedema in  Ankles  Legs  Other - ______

 Weakness Limitations in movement  Stiffness unsteady on feet  Paralysis  Tremor

 Numbness  Tingling  Other (specify) ______

Comments:______

Medication Management Assessment Category

Medications list including prescription, over the counter, medicines & topical preparations.

Name / Why taken
(client description) / How taken
(client description) / When taken
(client description) / Commencement date

Administration details / dose administration aides

 Self manages own medication Requires prompting Uses medication aid

 Carer manages client’s medications RN administered with appropriate LMO orders

 EEN administered. EN must be authorised to administer medications as per State registration requirements and must be administered with appropriate LMO orders

PolypharmacyYes / NoAction: ______

Has a home medication review been undertaken? Yes No Not required

Are there any other medication issues? ______

Name of Pharmacy: ______Tel: ______Fax: ______

Cognition / Behaviour Assessment category

 Nil problem/s

 Disoriented to  Time  Place  Person

 Memory loss Short-term  Long-term

 Confused  Yes No AMTSScore: ______Date / /

Does the client have a formal assessment/diagnosis of dementia No Yes

By  LMO/GP or  Geriatrician/Specialist

Does the client display behaviours of concern No  Yes

Describe ______

Genito-urinary Assessment Category

 Nil problem/s

 Continence assessment required

Continence assessment attended Date / / Outcomes______

 Urinary incontinence  Frequency Retention  Urgency  Nocturia

Incontinence Aids used NoYes, comment ______

 Prostate problems  Gynaecological issues IDCSPC: ______

Body Image / sensuality / sexuality Assessment category

Identify any specific body image or sensuality/ sexuality concerns (specify)

Endocrine Assessment Category

 Nil problem/s

 Fatigue Depressed mood Weight gain Weight loss  Urinary frequency

 Excessive thirst  Hyperthyroidism  Hypothyroidism  Other (specify) ______

 Diagnosis of diabetes (specify type) ______

Comments ______

Pain Assessment Category

 Nil problems/s
Where does the client rate their pain on the pain scale
0
No pain / 1 2 3
mild / 4 5
moderate / 6 7
severe / 8 9
very severe / 10
worst possible
Pain score on initial assessment______Site(s) of pain______
How long has the pain been present ______
Type of pain  Acute  Chronic  Somatic  Visceral  Incident  Neuropathic  Mixed
 Breakthrough  Procedural  Surgical  Wound  Other(specify)______
How does the client describe the pain  Aching  Stabbing  Throbbing Pressure  Gnawing
 Cramping  Sharp  Burning  Shooting  Other(specify)______
What helps to relieve the pain ______
What worsens the pain ______
Associated symptoms
 Nausea Vomiting  Sleep disturbance  Anxiety  Fear
 Client /carer distress Family support  Mental health history  Cultural issues  Religious issues
Are there any environmental factors contributing to pain (specify)______

Mental Health Assessment Category

 Nil problem/s

 Sad  Withdrawn  Anxious  Restless  Angry  Hostile  Sleep disturbances

 PTSD  Inability to enjoy activities  Feeling of worthlessness or guilt  Suicide ideation

 Depression - Specify depression scale tool used ______Score:______

Treated by:

 LMO/GP  ACAT  Mental health services  Counsellor  Veterans’ Counselling  Other (specify)____

______

Self Care Assessment Category

ADL dependencyoutcome ______ low dependency  high dependency

Equipment used in the client’s home:

Well-being Assessment Category

Alcohol Screen (Audit-C)

How often does the veteran have a drink containing alcohol?

 Never = 0  Monthly or less = 1  2-4 times a month = 2  2-3 times a week = 3 > 4 times a week = 4

Score ______

Does the client smoke?Yes / No If yes, how many per day?

Environment Assessment Category

Has the veteran had a fall in the last 3 months  No  Yes Cause identified No  Yes

Intervention______

Falls risk assessment completed  No  Yes Date / / Outcome____________

Does the client have trouble with stairs  No  Yes

Can the client safely use their bath/shower & toilet  No  Yes Are grab rails installed No  Yes

Is the toilet inside?  No  Yes

Is the toilet easy to access (consider distance, clutter etc) No  Yes

Are there any potential hazards identified within the home (uneven paths, loose floor mats, rips in carpet, clutter, pets etc)  No  Yes

If Yes, please complete a Workplace Assessment Tool

Manual Handling Assessment Category

Is the client able to understand & follow simple instructions? / Yes / No
What assistance is required to move the client from bed to chair? / Walking frame or other / Hoist
Sling
Other / Manual Lifter / Transfers Self
What assistance is required to move the client from chair to bed? / Walking frame or other / Hoist
Sling
Other / Manual Lifter / Transfers Self
What assistance is required to sit the client up in bed? / Unaided / Overhead bar / Bed Rope / Electric device
Has there been an Occupational Therapy assessment conducted in the home? / Yes / No / Comments / actions as a result of the visit
Manual handling classification / Not able to assist Able to assist Supervise Independent

Referrals not previously recorded and require action category

 LMO/GP  Asthma educator  Chronic illness support group

 Physiotherapist  Occupational therapist  Speech pathologist

 ACAT-Date: ______ Social worker  Counsellor  Mental health service

 Diabetes support group  Fitness/ falls program  Dietician  Dentist

 Continence consultant  Pain clinic/specialist  Palliative care service/consultant

 Optometrist  Ophthalmologist  Audiologist

 Wound specialist/ consultant  Veterans’ Home Care

 Carer support services  Respite services  HACC  Non Veteran Home Care

 VietnamVeterans’ Counselling Service  Homefront Assessment

 Other (specify) ______

BLANK

Education needs not previously recorded category

 Diagnosis  Self management plan  Medication equipment and use  For family

 BSL monitoring  Signs & Symptoms of hypo/hyperglycaemia  Nutrition

 Falls risks & prevention  Mobility & ADL aids  Exercise

 Hygiene  Repositioning and pressure relieving

 Pain management  Quit Programs  Other (specify) ______

Action taken______

Is there “End of Life Directives” in place? (Not for Resuscitation Orders) Yes No

If YES, what are the directives? ………………………………………………………………...……………………………………………

Nursing Care:

DVA Classification:NL-Clinical Care NT-Personal Care Other

Staff mix and approved time frame/s:

Additional Comments:

Assessing RN Name: ______

Signature:______

Date:______

K: /Templates/2014 Red folder/Assessment Tool/ V7 10 2014 Approved Smith 10/14 Next Review 10 2017 Control Doc 82 5