(The RN Assessment Must Be Completed. the Use of This Form to Document the RN Assessment

NDP-8

RN ASSESSMENT

(The RN Assessment must be completed. The use of this form to document the RN Assessment is optional)

Consumer Name / Case #/SS#
Date / Facility Name
DOB / Gender:
( One)
Male
Female / Age / Race / Date of Admission / Time of Admission
( One)
AM PM
Transported By:
Car Van Ambulance
Other ______/ Received From: / Accompanied By: / Relationship
MEDICAL HISTORY
Name of PCP/CRNP(s):
Phone #s: / ( ) ( )
Other Physicians:
Date of Last Visit: / Location
Baseline Data / BMI / WT HT Waist Circumference
Date of Last TB Skin Test or CXR / Result
Vital Signs / T _____ P ______R ______BP ______Arm:
R L
Pregnant? / Yes No □ N/A / Last Menstrual Period □ N/A
Breast Discharge
□ Yes □ No / Changes in Libido □ Yes □ No
Comments:
Erectile/Ejaculatory Problems / □ Yes □ No □ N/A
Comments:
Allergies / None
Medication(s)
Food(s)
Other
Pain / None
Location(s)
Frequency / Daily Daily/Intermittent Constant Other
Intensity / Mild Distressing Severe Unbearable
Pain on Admission / No Yes (If yes explain)
Special Treatments/Procedures/ Equipment (List all including purpose): / None
Past Surgeries/Implants (list all including year and location): / None
Past Psychiatric/Medical Hospitalizations (List all including year/location/reason): / None
FAMILY / RELATIONSHIPS / None
Marital Status / Children / Parents / Siblings / Significant Others
Married
Single
Divorced
Other / Yes
Number: ____
No / Mother
Alive
Deceased
Father
Alive
Deceased / None
Yes
Number _____
# Alive _____
# Deceased _____ / Legal Guardian
Yes No
Name ______
Friend(s)
Yes No
Other
RELIGIOUS/SPIRITUAL/CULTURAL
Religious Affiliation
Attend Church? / Yes No
Cultural/Ethnic Practices That Impact Care/Teaching (List)
CURRENT STATUS
PHYSICAL LIMITATIONS
Site / Degree
Paralysis/paresis
Contracture(s)
Congenital Anomalies
Prosthesis
Other
Functional Ability
AMBULATION / WEIGHT BEARING / TRANSFERS / SUPPORTIVE DEVICES
Independent
1 Person Assist
2 Person Assist
With Device (name)
______
WC only
WC Propels Self / Full Weight
Partial Weight
Non-Weight Bearing / Independent
1 Person Assist
2 Person Assist
Total Dependence / Elastic Hose
Hand Rolls
Sheepskin
Other (list)
______
______
______
General Skin Condition: (Check all that apply)
SITE / SITE
Dry / Oily
Edematous / Cyanotic
Pale / Warm
Moist / Cold
Reddened / Jaundiced
Ashen / Other
Hearing / R / L / Vision / R / L / Speech
Adequate / Adequate / Clear
Poor / Poor / Aphasic
Deaf / Blind / Dysphasic
Hearing Aid / Glasses/Contacts / Language:
Oral / Eating/Nutrition / Sleep / Bathing/
Grooming / Indep / Assist / Dep
Own Teeth
(Note condition)
DENTURES
Partial
Upper
Lower
Fit
Yes No / Independent
Needs Assist
Dysphasic (reason)
______/ Usual Bedtime
______
Usual Arising Time
______
Nap
Yes No / Tub
Shower
Bed Bath
Oral Hygiene
Shave
Adaptive Equipment
(type) / Shampoo
Grooming
Diet (Consistency) / Dressing
Bowel and Bladder Evaluation
Bowel Continent
Other: / Bladder Continent
Other: / Frequent Constipation
Y / N / Y / N / Y / N
How managed? / How managed? / How managed?
Psychosocial Functioning
Oriented / YN / Person Place Time
Situation Facility
General Appearance / Dressed/groomed appropriately for age/sex/situation
Disheveled Pale Emaciated Sad Happy
Level of Consciousness/
Behavior / Alert Responsive Hyperactive
Lethargic CombativeJoyful
ExpressionlessTics/Tremors Pacing
Cooperative Hostile Calm
Rigid/Tense Compulsive
Other(explain)
Speech / Talkative Forced Pressured/Excessive Nonverbal Slurred Impediment
Loud Illogical Monosyllabic
Other(explain)
Affect/Mood / Appropriate Depressed Elated
Anxious Guarded Flat
AngryCooperative Uncooperative
Friendly
Other(explain)
Thoughts / Normal Guarded Flighty
Wandering Disorganized Paranoid
Illusions Delusional Hallucinations
Homicidal Suicidal
Other(explain)
Memory / Remote Memory (past) Delayed Recall (repeat after 5 minutes)
Recent Memory Attention Level (ability to concentrate)
Insight / Good Fair Poor
(What is causing your problem? What causes you to be here today?)
Judgment / Good Fair Poor
(What would you do if you ran out of meds?)
Personal Habits / Smokes Cigarettes/Cigar/Pipe
Yes / No
Frequency / Drinks Alcohol
Yes / No
Frequency / Illegal Drug Use
Yes / No
Frequency
Have you received assistance to stop smoking?
Yes / No
If yes, when/where? / Have you received treatment for alcohol?
Yes / No
If yes, when/where? / Have you received treatment for drug misuse/abuse?
Yes / No
If yes, when/where?
Family Support / Good Fair
Poor / Family
Relationship / Good Fair
Poor
CURRENT MEDICATIONS
NAME / DOS / FREQ / DIRECTIONS FOR USE / REASON
AIMS COMPLETED? □ Yes □ No □ N/A (File in clinical record)

ATTACH ADDITIONAL SHEET IF NEEDED

LPN SIGNATURE
DATE

PHYSICAL ASSESSMENT TO BE REVIEWED/COMPLETED BY RN

COMMENTS:

NURSING PLAN OF CARE TO BE COMPLETED BY RN ONLY

List all problems identified

1
2
3
4
5
6
7
Personal History/Family History of Diabetes (If yes, circle correct one): □ Yes □ No
If yes, Blood Sugar Result Today ______□ Fasting □ Random
Personal History/Family History of Heart Disease (If yes, circle correct one) □ Yes □ No
Personal History/Family History of High Cholesterol (If yes, circle correct one) □ Yes □ No
If yes, date and result of last Cholesterol Level ______Result ______Date □ Unknown

ATTACH ADDITIONAL SHEET IF NEEDED

Based on the problems listed above and the level of nursing/medical care required, the following nursing interventions will be implemented directly or via delegation

Skilled Nursing □ 24 hours □ Intermittent (state frequency) ______
MAS Nurse Supervision of MAC Worker
Lab (state frequency)______Date Due
Reassessment/Evaluation ______(state frequency) Date Due
Referral to service not provided by agency (List appointments made below)
Assessment of ability to self medicate (NDP 5)To be filed in clinical record
Other (Explain)

NURSES NOTES

Person is eligible for MAC services, delegated by a MAS RN/LPN

This client is able to self-medicate:YESNO (Circle One)

______

RN SIGNATURE
DATE