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NURSING HEALTH AND SAFETY ASSESSMENTSection I: Identifying InformationName: FORMTEXT ?????Age: FORMTEXT ?????DOB: (mm/dd/yyyy) FORMTEXT ????? Male FORMCHECKBOX Female FORMCHECKBOX Address: FORMTEXT ?????City FORMTEXT ?????State FORMTEXT ?????Zip Code FORMTEXT ?????Name of Evaluator: FORMTEXT ?????Date of Report: (mm/dd/yyyy): FORMTEXT ?????Purpose of Evaluation: FORMCHECKBOX Annual FORMCHECKBOX Change in Status FORMCHECKBOX InitialLiving Situation: FORMCHECKBOX ICF FORMCHECKBOX Waiver Race: FORMCHECKBOX African American FORMCHECKBOX Asian FORMCHECKBOX Hispanic FORMCHECKBOX White FORMCHECKBOX Native American FORMCHECKBOX Other (specify) FORMTEXT ?????7. Current Medical Information:Current DiagnosesDate Diagnosed(mm/dd/yyyy) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????8. Communication: FORMCHECKBOX Verbal FORMCHECKBOX Sign FORMCHECKBOX Assistive Technology FORMCHECKBOX Nonverbal (Comments: FORMTEXT ?????)9. Activities of Daily Living Self Care Ability: (Please score each area with the following scale)0=Independent; 1=Assistive Device; 2=Assistance from Others; 3=Assistance from device; 4=Totally DependentEating/Drinking: FORMTEXT ?????Transferring: FORMTEXT ?????Bathing/al Hygiene: FORMTEXT ?????Ambulation: FORMTEXT ?????Dressing: FORMTEXT ?????Bed Mobility: FORMTEXT ?????Toileting: FORMTEXT ????? FORMTEXT ?????Comment: FORMTEXT ?????10. Adaptive equipment: FORMCHECKBOX None FORMCHECKBOX (If yes, list all) FORMTEXT ?????11. Medical equipment: (include glucose monitoring, enteral feeding, respiratory supplies, medical alert device, etc.) FORMCHECKBOX NoneIndicate type and frequency of use: FORMTEXT ?????12. History of Falls: FORMCHECKBOX No FORMCHECKBOX Yes (specify frequency & follow-up) FORMTEXT ?????Risk Assessment for Falls Completed: Yes FORMCHECKBOX No FORMCHECKBOX Section II: Brief Health History13. Hospitalizations, ER visits, and Illnesses during the past year: (Dates and Reasons) FORMTEXT ?????Significant Family History Information obtained from health record FORMCHECKBOX Yes Date: FORMTEXT ????? FORMCHECKBOX No Information obtained from family member: FORMCHECKBOX Yes Date: FORMTEXT ????? FORMCHECKBOX No If Yes, give name: FORMTEXT ?????Relationship to person FORMTEXT ?????14. Family History of Cardiac Problems/Hypertension FORMTEXT ?????15. Family History of Diabetes FORMTEXT ?????16. Family History of Seizure FORMTEXT ?????17. Family History of Cancer FORMTEXT ?????18. Family History of Known Genetic Disorders FORMTEXT ?????19. Other Family History FORMTEXT ?????Section III: Health Data20. Allergies: FORMCHECKBOX Food FORMCHECKBOX Environmental FORMCHECKBOX Medication Reaction FORMCHECKBOX No known allergy If any reaction, identify antigen & clinical reaction: FORMTEXT ????? EpiPen: Yes FORMCHECKBOX No FORMCHECKBOX 21. Person’s Health ConcernsPerson’s Perspective: FORMTEXT ?????Family Member’s perspective (give name/relationship): FORMTEXT ?????22. Seizure Disorder: Type FORMTEXT ????? Frequency FORMTEXT ????? Not Applicable FORMTEXT ?????Summary of seizure data: FORMTEXT ?????23. Current MedicationsDateStartedMedicationDosageTimesRouteReason FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????24. Describe best approach for administering medication including: whether tablet should be crushed, given with liquids or food, or liquid form of medication should be used. (Include person’s usual response to taking medications) FORMTEXT ?????25. Medication regimen (indicate one): FORMCHECKBOX no changes over the past quarter FORMCHECKBOX changes over the past quarterDescribe changes: FORMTEXT ?????26. Medication concerns: FORMTEXT ?????27. Is a self-administration program utilized for any of the above listed medications? FORMCHECKBOX Yes FORMCHECKBOX No If Yes, summarize the data sheet: FORMTEXT ?????28. Date of most recent self-administration assessment: (mm/dd/yyyy): FORMTEXT ?????29. SexualityIs the person sexually active (including masturbation)? FORMCHECKBOX Yes FORMCHECKBOX NoDoes the person have multiple sex partners? FORMCHECKBOX Yes FORMCHECKBOX NoComments: FORMTEXT ?????List any Sexually Transmitted Diseases (STDs)/method of contraception currently used: FORMTEXT ?????Need for sex education programs: FORMCHECKBOX Yes FORMCHECKBOX No Education Referral: FORMTEXT ????? Date of Referral (mm/dd/yyyy) FORMTEXT ?????30. History of abuse: FORMCHECKBOX Yes FORMCHECKBOX No If yes, mark at that apply: FORMCHECKBOX Physical FORMCHECKBOX Economical FORMCHECKBOX Sexual FORMCHECKBOX Emotional & VerbalComments: FORMTEXT ?????Section IV: Review of Health Systems31. Vital Signs: B/P: FORMTEXT ????? (Sitting, Lying & Standing) T: FORMTEXT ????? P: FORMTEXT ????? R: FORMTEXT ????? SPO2% (if applicable): FORMTEXT ?????Date of last annual medical review with primary care practitioner: FORMTEXT ?????/ FORMTEXT ?????/ FORMTEXT ????? Physical Exam findings32. SKIN FORMCHECKBOX clear, healthy skin FORMCHECKBOX clear, healthy scalp FORMCHECKBOX no problems or deviations assessed FORMCHECKBOX lesions FORMCHECKBOX rashes FORMCHECKBOX bruises FORMCHECKBOX wound FORMCHECKBOX drainage FORMCHECKBOX itching FORMCHECKBOX skin color variation FORMCHECKBOX cyanosis FORMCHECKBOX pallor FORMCHECKBOX jaundice FORMCHECKBOX erythema FORMCHECKBOX dry, rough texture FORMCHECKBOX scaling/xerosis FORMCHECKBOX poor turgor FORMCHECKBOX edema FORMCHECKBOX unusual hair distribution FORMTEXT ????? FORMCHECKBOX hair loss FORMCHECKBOX reduced hair on extremities FORMCHECKBOX hirsutism FORMCHECKBOX hair characteristics FORMCHECKBOX normal FORMCHECKBOX oily FORMCHECKBOX dry FORMCHECKBOX coarse FORMCHECKBOX infestation/lice/bed bugs FORMCHECKBOX Braden Scale: Date FORMTEXT ?????Results FORMCHECKBOX Severe Risk: (Total score 9) FORMCHECKBOX High Risk: (Total score 10-12) FORMCHECKBOX Moderate Risk: (Total score 13-14) FORMCHECKBOX Mild Risk: (Total score 15-18)Comments: FORMTEXT ?????STOMA FORMCHECKBOX Not Applicable FORMCHECKBOX clean, dry FORMCHECKBOX redness FORMCHECKBOX discolored FORMCHECKBOX drainage FORMCHECKBOX swelling FORMCHECKBOX prolapseComments: FORMTEXT ?????FINGERNAILS & TOENAILS FORMCHECKBOX color, shape, cleanliness good FORMCHECKBOX no problems or deviations assessed FORMCHECKBOX irregularities in surface: FORMTEXT ????? FORMCHECKBOX inflammation around nails: FORMTEXT ????? FORMCHECKBOX fungal problem: FORMTEXT ?????Comments: FORMTEXT ?????33. HEAD & NECK FORMCHECKBOX No problems or deviations assessedHead motion: _______________________________________________________________________ (describe) FORMCHECKBOX asymmetric head position: ___________________________________________________________(describe) FORMCHECKBOX shrugs shoulders FORMCHECKBOX unable to support head midline & erect FORMCHECKBOX periorbital edema FORMCHECKBOX lymph node enlargement FORMCHECKBOX thyroid enlargement FORMCHECKBOX tracheal displacementComments: FORMTEXT ?????Physical Exam findings34. NOSE & SINUSES FORMCHECKBOX No problems or deviations assessed FORMCHECKBOX nasal drainage FORMCHECKBOX inflamed FORMCHECKBOX tender FORMCHECKBOX nasal mucosa irregularities FORMTEXT ????? FORMCHECKBOX right nostril swelling FORMCHECKBOX left nostril swellingComments: FORMTEXT ?????35. MOUTH & PHARYNX FORMCHECKBOX No problems or deviations assessedInspect the following: FORMCHECKBOX inner oral mucosa FORMCHECKBOX buccal mucosa FORMCHECKBOX floor of mouth FORMCHECKBOX tongue FORMCHECKBOX hard palate FORMCHECKBOX soft palate FORMCHECKBOX altered oral mucous membrane: FORMTEXT ????? (describe) FORMCHECKBOX inflammation: FORMTEXT ????? (describe) FORMCHECKBOX hoarseness FORMCHECKBOX bruxism (grinds teeth) FORMCHECKBOX loose teeth FORMCHECKBOX missing teeth FORMCHECKBOX decay FORMCHECKBOX halitosis FORMCHECKBOX excessive salivation FORMCHECKBOX lips dry, cracked FORMCHECKBOX lip fissures FORMCHECKBOX lip bleeding FORMCHECKBOX gums inflamed FORMCHECKBOX gums bleed FORMCHECKBOX gum retraction FORMCHECKBOX thick tongue FORMCHECKBOX tongue dry, cracked FORMCHECKBOX tongue fissures FORMCHECKBOX tongue bleedsDeviations: FORMTEXT ????? (describe) FORMCHECKBOX lesions, vesicles: FORMTEXT ????? (describe) FORMCHECKBOX gag reflex absent FORMCHECKBOX gag reflex hyperactive FORMCHECKBOX poor denture fit or not using FORMCHECKBOX chewing problemComments: FORMTEXT ?????36. EYESInspected the external eye structures: FORMCHECKBOX eyebrows FORMCHECKBOX orbital area FORMCHECKBOX eyelids FORMCHECKBOX lacrimal ducts FORMCHECKBOX conjunctiva FORMCHECKBOX sclera FORMCHECKBOX corneaAbnormalities: FORMTEXT ????? (specify/describe)Visual fields/peripheral vision present: FORMCHECKBOX right FORMCHECKBOX leftEye tracking present: FORMCHECKBOX up FORMCHECKBOX down FORMCHECKBOX right FORMCHECKBOX leftBlink reflex: Right: FORMCHECKBOX present FORMCHECKBOX absent Left: FORMCHECKBOX present FORMCHECKBOX absentPupil & iris direct light response: Right: FORMCHECKBOX present FORMCHECKBOX absent Left: FORMCHECKBOX present FORMCHECKBOX absentPupil & iris consensual light response: Right: FORMCHECKBOX present FORMCHECKBOX absent Left: FORMCHECKBOX present FORMCHECKBOX absent FORMCHECKBOX Signs of diminished vision (explain): FORMTEXT ?????Comments: FORMTEXT ?????Physical Exam findings37. EARSInspect the following external ear structures: FORMCHECKBOX auricle FORMCHECKBOX lobule FORMCHECKBOX tragus FORMCHECKBOX mastoidExternal ear structure abnormalities: FORMCHECKBOX swelling FORMCHECKBOX nodules FORMCHECKBOX tenderness FORMCHECKBOX discharge FORMCHECKBOX no abnormalitiesOther abnormalities FORMTEXT ????? FORMCHECKBOX Signs of Diminished Hearing: explain: FORMTEXT ?????Comments (coordination of Care, i.e.: ENT consults, etc.): FORMTEXT ?????38. HEART & VASCULAR [ ] No problems or deviations assessedAuscultated heart sounds: FORMCHECKBOX S-1 at 5th intercostal space on left FORMCHECKBOX S-2 at 2nd intercostal space left or right side apical pulse: FORMTEXT ????? (rate & rhythm) Jugular venous distention: FORMCHECKBOX present FORMCHECKBOX absentCapillary refill: FORMCHECKBOX > 1 second FORMCHECKBOX < 2 seconds FORMCHECKBOX PMI palpable – 5th intercostal space medial to left midclavicular line FORMCHECKBOX PMI FORMCHECKBOX not palpable FORMCHECKBOX edema: FORMTEXT ????? (describe)Palpate bilaterally the following pulses: FORMCHECKBOX radial FORMCHECKBOX ulnar FORMCHECKBOX brachial FORMCHECKBOX femoral FORMCHECKBOX popliteal FORMCHECKBOX dosalis pedis FORMCHECKBOX posterior tibialList any pulse deviations: FORMTEXT ?????Comments: FORMTEXT ?????39. THORAX & LUNGS FORMCHECKBOX No problems or deviations assessedIs the person a smoker? FORMCHECKBOX Yes or FORMCHECKBOX No, if yes, how many cigarettes does the person smoke per day? FORMTEXT ?????Describe smoking patterns: FORMTEXT ?????Inspect: FORMCHECKBOX posterior thorax FORMCHECKBOX lateral thorax FORMCHECKBOX anterior thoraxList thorax deviations FORMTEXT ?????Auscultated breath sounds: FORMCHECKBOX vesicular sounds at periphery intercostal space lateral to sternum FORMCHECKBOX bronchovesicular sounds between scapulae or 1st – 2nd FORMCHECKBOX bronchial sounds over tracheaDiminished sounds: FORMTEXT ????? (describe) FORMCHECKBOX wheezes FORMCHECKBOX crackles FORMCHECKBOX rhonchi (Location(s) FORMTEXT ????? FORMCHECKBOX productive cough FORMCHECKBOX non-productive coughList breath sound deviations: FORMTEXT ?????Respiratory distress: FORMCHECKBOX nasal flaring FORMCHECKBOX use of accessory muscles FORMCHECKBOX SOB FORMCHECKBOX intercostal retractionComments: FORMTEXT ?????Physical Exam findings40. ABDOMEN FORMCHECKBOX No problems or deviations assessedBowel Sounds: FORMCHECKBOX auscultate all 4 quadrants FORMCHECKBOX hypoactive FORMCHECKBOX hyperactive FORMCHECKBOX tympanic FORMCHECKBOX absent FORMTEXT ????? (location)Abdomen: FORMCHECKBOX flat FORMCHECKBOX distended FORMCHECKBOX soft FORMCHECKBOX firm FORMCHECKBOX rounded FORMCHECKBOX obese FORMCHECKBOX asymmetry FORMCHECKBOX pain FORMCHECKBOX rebound tenderness FORMCHECKBOX gastrostomy FORMCHECKBOX jejunostomy FORMCHECKBOX ostomy FORMCHECKBOX mass: FORMTEXT ????? (location/describe)Skin: FORMTEXT ????? (texture) FORMTEXT ????? (color)Comments: FORMTEXT ?????41. NUTRITIONAL/METABOLIC PATTERN(S) Height: FORMTEXT ????? Weight: FORMTEXT ????? FORMCHECKBOX Recommended Ideal Body Weight (IBW) FORMTEXT ????? FORMCHECKBOX less than IBW FORMCHECKBOX more than IBW FORMCHECKBOX BMI FORMTEXT ????? FORMCHECKBOX Type of Diet FORMTEXT ????? Is there a mealtime protocol? FORMCHECKBOX yes or FORMCHECKBOX No Comments: FORMTEXT ?????42. GENITOURINARY & GYNECOLOGIC FORMCHECKBOX No problems or deviations Menses: FORMCHECKBOX LMP FORMTEXT ????? FORMCHECKBOX pattern of painful menses FORMCHECKBOX irregularity FORMCHECKBOX heavy flow FORMCHECKBOX assistance needed for menstrual hygiene FORMCHECKBOX self-care during menses FORMCHECKBOX Premenopausal FORMCHECKBOX menopausalComments: FORMTEXT ?????GYN Exam w/PAP: Date: FORMTEXT ?????Results: FORMTEXT ????? (As recommended by GYN/PCP)Mammogram/Sonogram:Date: FORMTEXT ?????Results: FORMTEXT ?????(As recommended by GYN/PCP)Prostate Exam:Date: FORMTEXT ?????Results: FORMTEXT ?????(As recommended by PCP)Breast Self-Exam:Date: FORMTEXT ?????Results: FORMTEXT ?????(Most recent date performed)Testicular Self-Exam:Date FORMTEXT ?????Results: FORMTEXT ?????(Most current date performed)Was educational material or information provided? FORMCHECKBOX Yes, if yes explain in comments FORMCHECKBOX NoComments: FORMTEXT ?????THIS SECTION OF THE PHYSICAL EXAM IS REQUIRED FOR PEOPLE WHO ARE UNABLE TO SELF-EXAM GENITOURINARY & GYNECOLOGICExternal genitalia (female): FORMCHECKBOX No problems or deviations FORMCHECKBOX excoriations FORMCHECKBOX rash FORMCHECKBOX lesions FORMCHECKBOX vesicles FORMCHECKBOX inflammation FORMCHECKBOX bright red color FORMCHECKBOX bulging FORMCHECKBOX discharge FORMCHECKBOX inguinal hernia FORMCHECKBOX odor FORMCHECKBOX itchyComments: FORMTEXT ?????Breast Exam (male & female): FORMCHECKBOX No problems or deviations Deviations assessed in: FORMCHECKBOX size FORMCHECKBOX symmetry FORMCHECKBOX contour FORMCHECKBOX shape FORMCHECKBOX skin color FORMCHECKBOX texture FORMCHECKBOX venous pattern Nipple deviations: FORMCHECKBOX retraction FORMCHECKBOX discharge FORMCHECKBOX bleeding FORMCHECKBOX nodules FORMCHECKBOX edema FORMCHECKBOX ulcerations FORMCHECKBOX gynecomastiaComments: FORMTEXT ?????External genitalia (male): FORMCHECKBOX No problems or deviations FORMCHECKBOX testicular mass FORMCHECKBOX tight scrotal skin FORMCHECKBOX enlarged scrotum FORMCHECKBOX displaced meatus FORMCHECKBOX lesions/sores FORMCHECKBOX rash FORMCHECKBOX bright red color FORMCHECKBOX odor FORMCHECKBOX discharge FORMCHECKBOX inflammation FORMCHECKBOX inguinal hernia FORMCHECKBOX itchyComments: FORMTEXT ?????43. MUSCULOSKELETAL FORMCHECKBOX No problems or deviations assessed FORMCHECKBOX gait abnormalities: FORMTEXT ????? FORMCHECKBOX posture abnormalities: FORMTEXT ????? FORMCHECKBOX Impaired Weight Bearing: FORMTEXT ????? FORMCHECKBOX asymmetry: FORMTEXT ????? FORMCHECKBOX misalignment: FORMTEXT ????? FORMCHECKBOX decreased ROM: FORMTEXT ????? FORMCHECKBOX joint swelling FORMCHECKBOX stiffness FORMCHECKBOX tenderness FORMCHECKBOX Warm to touch FORMCHECKBOX contractures FORMTEXT ????? FORMCHECKBOX increased muscle tone (hypertonicity): FORMTEXT ????? FORMCHECKBOX decreased muscle tone (hypotonicity): FORMTEXT ????? FORMCHECKBOX gross motor skills impaired FORMCHECKBOX fine motor skills impairedComments: FORMTEXT ?????Physical Exam findings Neurologic System44. MENTAL & EMOTIONAL STATUS FORMCHECKBOX alert (person/place/self) FORMCHECKBOX non-verbal FORMCHECKBOX impaired level of consciousness FORMCHECKBOX able to communicate FORMCHECKBOX limited verbalization FORMCHECKBOX vocalized sounds only FORMCHECKBOX intellectual impairment FORMCHECKBOX memory impairment FORMCHECKBOX abstract reasoning impaired FORMCHECKBOX impaired association ability FORMCHECKBOX impaired judgment FORMCHECKBOX sleeps well at night FORMCHECKBOX difficulty falling asleep FORMCHECKBOX difficulty staying asleep FORMCHECKBOX difficulty with early awakening FORMCHECKBOX naps during day due to: FORMCHECKBOX age FORMCHECKBOX health status FORMCHECKBOX medications FORMCHECKBOX sleep aids used: FORMTEXT ????? FORMCHECKBOX sleep safety devices used: FORMCHECKBOX bedrails FORMCHECKBOX pillow(s) FORMCHECKBOX mat beside bed FORMCHECKBOX other: FORMTEXT ?????Comments: FORMTEXT ????? FORMCHECKBOX Dementia screening (required for people with Down syndrome 40 years and over and others with cognitive changes FORMCHECKBOX Not indicated FORMCHECKBOX Completed Date FORMTEXT ?????Comments: FORMTEXT ?????45. SENSORY FUNCTIONTouch FORMCHECKBOX intact FORMCHECKBOX impaired: FORMTEXT ????? (describe)Pain FORMCHECKBOX intact FORMCHECKBOX impaired: FORMTEXT ????? (describe)46. BEHAVIOR FORMCHECKBOX No maladaptive behaviorsMaladaptive Behaviors: FORMCHECKBOX ritualistic FORMCHECKBOX stereotypical FORMCHECKBOX PICA behavior FORMCHECKBOX mood swings FORMCHECKBOX self-injurious FORMCHECKBOX aggression towards others FORMCHECKBOX illicit drug use FORMCHECKBOX elopement FORMCHECKBOX suicidal ideations FORMCHECKBOX other behaviors (describe): FORMTEXT ????? FORMCHECKBOX Receives: FORMTEXT ????? (medication) for behavior(s) FORMCHECKBOX A behavior program is in place FORMCHECKBOX An exception to behavior medication reduction is in placeComments: FORMTEXT ????? 47. Glasgow Depression Screen: Date FORMTEXT ????? FORMCHECKBOX No discrepancies noted FORMCHECKBOX Referred for assessment Date FORMTEXT ?????Instructions: To be used for measuring pain in people who have dementia and/or unable to self-reportAbbey Pain ScaleFor measurement of pain in people with dementia who cannot verbalize.How to use scale: While observing the resident, score questions 1 to 6Name of resident: ………………………………………………………………………...Name and designation of completing the scale: ………………………….Date: ….………………………………………Time: ………………………………………Latest pain relief given was…………………………..…………..….….at ………..hrs.Q1. Vocalization FORMTEXT ?????eg. whimpering, groaning, crying Absent 0 Mild 1 Moderate 2 Severe 3Q1 Q2. Facial expression FORMTEXT ?????eg: looking tense, frowning grimacing, looking frightened Absent 0 Mild 1 Moderate 2 Severe 3Q2 Q3. Change in body languageeg: fidgeting, rocking, guarding part of body, withdrawn FORMTEXT ?????Absent 0 Mild 1 Moderate 2 Severe 3Q3 Q4. Behavioral Change FORMTEXT ?????eg: increased confusion, refusing to eat, alteration in usual patternsAbsent 0 Mild 1 Moderate 2 Severe 3Q4 Q5. Physiological changeeg: temperature, pulse or blood pressure outside normal limits, FORMTEXT ?????perspiring, flushing or pallorAbsent 0 Mild 1 Moderate 2 Severe 3Q5 Q6. Physical changes FORMTEXT ?????eg: skin tears, pressure areas, arthritis, contractures, previous injuries.Absent 0 Mild 1 Moderate 2 Severe 3Q6 FORMTEXT ?????237363014478000Add scores for 1 – 6 and record here Total Pain Score 0-2No Pain FORMCHECKBOX 3-7Mild FORMCHECKBOX 8-13Moderate FORMCHECKBOX 14+Severe FORMCHECKBOX 23545808255000Now click the box that matches theTotal Pain Score23260058636000Finally, click the box which matchesAcute and Chronic FORMCHECKBOX Acute FORMCHECKBOX Chronic FORMCHECKBOX the type of painDementia Care Australia Pty LtdWebsite: Abbey, J; De Bellis, A; Piller, N; Esterman, A; Giles, L; Parker, D and Lowcay, B.Funded by the JH & JD Gunn Medical Research Foundation 1998 – 2002(This document may be reproduced with this acknowledgment retained)Comments: FORMTEXT ?????Instructions: If the person denies pain, please record no pain below. If pain is verbalized, rate the pain and provide a full description below (location, frequency, radiates, throbbing, triggers, etc.). A pain management plan will need to be designed to further address pain relief ments: FORMTEXT ?????-14466657822400000Additional Information and Date (i.e., lab work, revisions to nursing assessment, etc.): FORMTEXT ?????For information regarding specific areas of concern and expected outcomes, see the attached Health Management Care Plan. Also, note that there may be other assessments as appropriate to the nursing care of the person attached to the Nursing Assessment, i.e. Braden scale, fall risk assessment dementia screening assessment._______________________________________________________________________ (Print) RN’s Name & Title Signature and Date of Completion ................
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