Comprehensive Interdisciplinary Patient Assessment
Date:
Patient Appt: Pt. unable to Attend / Reason:
______ ______
Annual NP month 1 NP month 3 Unstable Pt request
If unstable: Hosp Marked Deterioration Poor Alb/Hgb/ Kt/V Psychosocial Other
______
MEDICAL OVERVIEW (On initial, attach current H&P) Date of 1st Dialysis: Date 1st at Center:
Initial Diagnosis of Renal Failure (from 2728):
Co-morbid conditions:
Current modality for RRT: In-center Hemo Home hemo CAPD/CCPD
Informed of dialysis options: ICHD PD HHD - if not, why______
LOC: A/O Confused Cooperative Involved in care Note:
Knowledge of cause of renal disease Yes No Unsure
General knowledge of ESRD: Excellent Good Needs reinforcement Dependent on others
New events: Fall/Injury Surgery Other:
Fall Risk- 4 or more considered fall risk: > 3 Co morbid Diagnosis Polypharmacy
Prior falls in last 3 mon. Incontinent Visual Environmental Pain Cognitive
Other Providers: PCP: ______Endocrine: ______Cardiologist: ______
GI: ______Neuro:______Other______
______
DIALYSIS PRESCRIPTION REVIEW
Dialysis Rx: x wk hrs Dialyzer ______Reuse
Current Dry Wt. Achieving DW Average Wt Gains:______
Heparin: Bolus Sustain Other Anticoag. None
Bath: ______K+ Ca++ ______HCO3 Na+ Mod ______
BFR ordered______ Able to obtain Poor BFR
Access: Type ______ Date placed: ______Surgeon:______
Surg/Intervention: Date: Last ABF AP/VPs <100
Cannulation: Rotation Buttonhole Lidocaine Other analgesic______N/A
Notes on access: New-Expert only Straight Tortuous Aneurysms
Access Problems: None Decr Kt/V Ext. Bleed Infection Other
Comments:______
Catheter Date: Type______Functions well Poor BFR
Exit site infections:
Plan for AVF/AVG:
Interdisciplinary Team Note: Continue Same Rx Changes to Rx/Plan
______
Nurse Completing form______IDT Nurse: ______Date:
Kidney Center of Thousand Oaks NURSING
Comprehensive Interdisciplinary Patient Assessment ASSESSMENT
Lab Review:
Adequacy: Kt/V URR
Anemia: Hct / Hgb/ Infection Recent Transfusion Stool OB
Retic Ct. Ferritin TSat
Aranesp mcg EPO units Prev adj date Incr Decr
Venofer Prev adj date Carnitor gm for Anemia HypoTN
Bone: Ca++PhosPTH Notes:
Calcijex Zemplar Hectorol mcg Sensipar
Infection: Cultures done Blood Wound Urine
If positive, organism: Antibiotics:
Additional Lab Concerns:
______
Clinical Parameters:
Fluid Status: Intradialytic weight gains kg Excess BVM refill Yes No Notes:
Edema Rales SOB Insomnia O2 during HD O2 at home Dehydration
BP: In acceptable range (KDOQI =140/90 pre dialysis)
HTN BP Meds held prior to Tx Note:
Hypotension Pre During Post Tx Note:
Adverse ID Symptoms: Cramps Dizzy Nausea Hypoxemia Cardiac S/S
Frequent Hospitalizations: No Yes Patient/family education re complications
Medication Review Changes (attach updated medication list) Pharmacy:______
Barriers to taking meds: None Financial Transportation Dislike Side effects
Allergies: None Yes ______
Complaints of Pain None Yes Where: How often:
Character of pain: Scale 1-10 Medications:
Infectious Disease SGOT SGPT HbSab Other
Vaccines All Current Due: PPD Flu Pneumo Hepatitis B series Refuses:
GI: N/V Diarrhea Constip. Poor appetite Abd discomfort
GU: Residual urine > 1cup/d < 1cup/d Pain on urination
Skin: No concerns Ulcerations Ecchymosis Cuts/skin tear Other
Diabetic foot checks: NA
Interdisciplinary Team Note: Continue Same Rx Changes to Rx/Plan
Nurse Completing form______IDT Nurse: ______Date: