NDP-8 2019 RN ASSESSMENT

NDP-8 2019

RN ASSESSMENT

[The MAS RN is responsible and accountable for the completion of a

comprehensive assessment and evaluation of patients¡¯ nursing care

needs ABN 610-x-7-.06(3)]

¡õ Initial ¡õ Annual ¡õ Status Change ¡õ Other (State)__________

Case #/SS#

Person¡¯s Name

Date

Facility Name

DOB

Gender:

(? One)

Male

Female

Transported By:

Car

Van

Age

Race

Received From:

Ambulance

Date of Admission/

Readmission (circle one)

Accompanied By:

Time of Admission

(? One)

AM

Relationship

PM

Other ________________

Name of

PCP/CRNP(s):

(primary care provider)

Phone #s:

MEDICAL HISTORY

(

)

(

)

Other Physicians:

Date of Last PCP

Visit:

Baseline Data

Date of Last TB

Skin Test or CXR

Vital Signs

Pregnant?

Date of Last Physical Exam

Name of PCP performing exam

WT

HT

Waist Circumference

BMI

Result

T _____

P ______

Yes

No

¡õ N/A

Breast Discharge

¡õ Yes

¡õ No ¡õN/A

Date of Last Mammogram

Allergies

R _______

BP ___________

Last Menstrual Period

Changes in Libido

Comments:

¡õ Yes

Arm:

R

¡õ N/A

L

¡õ No

PSA Date _______ Results ________ ¡õ N/A

Erectile/Ejaculatory Problems ¡õ Yes ¡õ No ¡õN/A

Results

None

¡õ EpiPen Required

Medication(s)

Food(s)

Other

(Seasonal? Symptoms?)

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NDP-8 2019

None

Location(s)

Frequency

Pain

Intensity _____

(state # on 10 scale)

Daily

Daily/Intermittent

Constant

Other

Mild

Distressing

Severe

Unbearable

No

Yes (If yes explain)

Pain on Admission

None

Special Treatments/Procedures/

Equipment (List all including

purpose):

None

Past Surgeries/Implants (list all

including year and location):

Past Psychiatric/Medical

Hospitalizations (List all including

year/location/reason):

None

FAMILY / RELATIONSHIPS

Marital Status

Married

Single

Divorced

Other

Children

Yes

Number: ____

No

None

Parents

Mother

Father

Alive

Deceased

Siblings

None

Yes

Number _____

Alive

Deceased

# Alive _____

# Deceased _____

Significant

Others

Legal Guardian

Yes

No

Name

________________

Friend(s)

Yes

Other

No

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NDP-8 2019

RELIGIOUS/SPIRITUAL/CULTURAL

¡õ None

Religious Affiliation

Attend Church?

Yes

No

¡õ None

Cultural/Ethnic Practices That

Impact Care/Teaching (List)

CURRENT STATUS

PHYSICAL LIMITATIONS (Muscle/Skeletal System)

¡õ NONE

Site

Degree

Paralysis/paresis

Contracture(s)

Congenital Anomalies

Prosthesis

Other

FUNCTIONAL ABILITY

AMBULATION

WEIGHT BEARING

TRANSFERS

SUPPORTIVE

DEVICES

Independent

Full Weight

Independent

Elastic Hose

1 Person Assist

Partial Weight

1 Person Assist

Hand Rolls

2 Person Assist

Non-Weight Bearing

2 Person Assist

Sheepskin

Total Dependence

Other (list)

With Device (name)

_________________

_________________

WC only

_________________

WC Propels Self

_________________

GENERAL SKIN CONDITION: (Check all that apply)

SITE

SITE

Dry

Oily

Edematous

Cyanotic

Pale

Warm

Moist

Cold

Reddened

Jaundiced

Ashen

Other

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NDP-8 2019

Hearing

R

L

R

L

Speech

Adequate

Adequate

Clear

Poor

Poor

Aphasic

Deaf

Blind

Other

Hearing Aid

Glasses/Contacts

Oral

Eating/Nutrition

Own Teeth

(Note condition)

DENTURES

Partial

Full

Usual Arising

Time

Adaptive Equipment

(type)

No

___________

____________________

Diet (Consistency/limitations)

Indep

Assist

Dep

Tub

Shower

¡õ

¡õ

¡õ

¡õ

¡õ

¡õ

Bed Bath

¡õ

¡õ

¡õ

Oral Hygiene

¡õ

¡õ

¡õ

Shave

¡õ

¡õ

¡õ

__________

Dysphasic (reason)

____________________

Yes

Bathing/

Grooming

Usual

Bedtime

Needs Assist

Lower

Language:

Sleep

Independent

Upper

Fit

Vision

Nap

Shampoo

¡õ

¡õ

¡õ

Yes

No

Frequency/

Length

Grooming

¡õ

¡õ

¡õ

Dressing

¡õ

¡õ

¡õ

BOWEL AND BLADDER EVALUATION (GENTIAL/URINARY)

Other:

Bowel Continent

Y

Bladder Continent

Other:

N

Y

How managed?

Frequent Constipation

N

How managed?

Y

N

How managed?

PERSONAL/FAMILY HISTORY

?

Diabetes (Endocrine):

No

Self

Family

Today¡¯s Blood Sugar Results (if applicable) ______________

?

Cardiovascular Disease:

No

Heart Attack

?

High Cholesterol:

Self

Stroke

No

Random

Fasting

Family

Other _______________________

Self

Family

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NDP-8 2019

PSYCHOSOCIAL FUNCTIONING

Person

Place

Situation

Facility

Time

Oriented

Y

General

Appearance

Dressed/groomed appropriately for age/sex/situation

N

Disheveled

Pale

Emaciated

Sad

Happy

Level of

Consciousness/

Behavior

Alert

Lethargic

Expressionless

Cooperative

Rigid/Tense

Other (explain)

Responsive

Combative

Tics/Tremors

Hostile

Compulsive

Hyperactive

Joyful

Pacing

Calm

Speech

Talkative

Nonverbal

Loud

Other (explain)

Forced

Slurred

Illogical

Pressured/Excessive

Impediment

Monosyllabic

Appropriate

Anxious

Angry

Friendly

Other (explain)

Normal

Wandering

Illusions

Homicidal

Other (explain)

Depressed

Guarded

Cooperative

Elated

Flat

Uncooperative

Guarded

Disorganized

Delusional

Suicidal

Flighty

Paranoid

Hallucinations

Remote Memory (past)

Recent Memory

Delayed Recall (repeat after 5 minutes)

Attention Level (ability to concentrate)

Affect/Mood

Thoughts

Memory

Insight

Judgment

Personal Habits

Family Support

Good

Fair

Poor

(What is causing your problem? What causes you to be here today?)

Good

Fair

Poor

(What would you do if you ran out of meds?)

Smokes Cigarettes/Cigar/Pipe

Drinks Alcohol

Yes /

No

Yes /

No

Amt./day

Amt./day

Have you received assistance to Have you received

stop smoking?

treatment for

alcohol?

Yes /

No

If yes, when/where?

Yes /

No

If yes,

when/where?

Good

Fair

Poor

Family

Relationship

Illegal Drug Use

Yes /

No

Type/Freq

Have you received treatment for

drug misuse/abuse?

Yes /

No

If yes, when/where?

Good

Fair

Poor

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