Maryland



COMPREHENSIVE NURSING ASSESSMENTTo be completed: 1) At the time of admission prior to the delegation of any nursing tasks, 2) Within 48 hours of a significant change in the resident’s physical or mental status, 3) Within 48 hours of return from a hospitalization or 15 day or greater stay in any skilled facility, & 4) When a new RN assumes the DN/CM roleResident Name: FORMTEXT ????? DOB: FORMTEXT mm- FORMTEXT dd- FORMTEXT yyyy Date Completed: FORMTEXT mm- FORMTEXT dd- FORMTEXT yyyy 45-day Nursing Review Due: FORMTEXT mm- FORMTEXT dd- FORMTEXT yyyy ALLERGIES: FORMTEXT ?????DIAGNOSES: FORMTEXT ?????VITAL SIGNSBP FORMTEXT ???/ FORMTEXT ???P FORMTEXT ???R FORMTEXT ??T FORMTEXT ??????°FHT FORMTEXT ? ft FORMTEXT ?? inWT FORMTEXT ??? lbsASSESSMENT – Explain ALL answers that are not within normal limitsCOMMENTSNUTRITIONDiet: FORMCHECKBOX Regular FORMCHECKBOX NAS FORMCHECKBOX NCS FORMCHECKBOX Mechanical Soft FORMCHECKBOX PureedRecent weight change: FORMCHECKBOX No FORMCHECKBOX Yes Supplements: FORMCHECKBOX No FORMCHECKBOX YesConditions affecting eating, chewing, or swallowing: FORMCHECKBOX No FORMCHECKBOX YesMonitoring required at mealtimes: FORMCHECKBOX No FORMCHECKBOX YesFluids. Monitoring: FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX Increased FORMCHECKBOX RestrictedMucous membranes: FORMCHECKBOX Moist FORMCHECKBOX DrySkin turgor: FORMCHECKBOX Good FORMCHECKBOX Fair FORMCHECKBOX Poor FORMTEXT ?????ELIMINATIONBladder Incontinence: FORMCHECKBOX None FORMCHECKBOX Occasional (less than daily) FORMCHECKBOX Daily Bowel Incontinence: FORMCHECKBOX None FORMCHECKBOX Occasional (less than daily) FORMCHECKBOX DailyIncontinence management techniques: FORMCHECKBOX No FORMCHECKBOX Yes Bowel sounds present: FORMCHECKBOX Yes FORMCHECKBOX NoConstipation: FORMCHECKBOX No FORMCHECKBOX YesOstomies: FORMCHECKBOX No FORMCHECKBOX Yes FORMTEXT ?????SENSORYVision: FORMCHECKBOX Normal FORMCHECKBOX Impaired Corrective device: FORMTEXT ?????Hearing: FORMCHECKBOX Normal FORMCHECKBOX Impaired Hearing aid: FORMCHECKBOX No FORMCHECKBOX Yes FORMTEXT ?????Resident: FORMTEXT ????? Date Completed: FORMTEXT mm- FORMTEXT dd- FORMTEXT yyyy MUSCULOSKELETALMobility: FORMCHECKBOX Normal FORMCHECKBOX Impaired Assistive Devices: FORMCHECKBOX No FORMCHECKBOX Yes ROM: FORMCHECKBOX Full FORMCHECKBOX LimitedMotor Development: FORMCHECKBOX Head Control FORMCHECKBOX Sits FORMCHECKBOX Walks FORMCHECKBOX Hemiparesis FORMCHECKBOX TremorsADLs: (S=self; A=assist; T=total) Eating: FORMTEXT ? Bathing: FORMTEXT ? Dressing: FORMTEXT ? FORMTEXT ?????SKIN FORMCHECKBOX Normal FORMCHECKBOX Pale FORMCHECKBOX Red FORMCHECKBOX Rash FORMCHECKBOX Irritation FORMCHECKBOX Abrasion FORMCHECKBOX OtherSkin Intact: FORMCHECKBOX Yes FORMCHECKBOX No (if no, a wound assessment must be completed)Special Care or Monitoring: FORMCHECKBOX No FORMCHECKBOX Yes FORMTEXT ?????NEUROSensation: FORMCHECKBOX Intact FORMCHECKBOX Diminished/Absent Pain: FORMCHECKBOX None FORMCHECKBOX Less Than Daily FORMCHECKBOX Daily If there is pain indicate the site, cause, & treatment. Verbal Response: FORMCHECKBOX A/O x FORMTEXT ????? FORMCHECKBOX Confused FORMCHECKBOX Inappropriate FORMCHECKBOX Incomprehensible FORMCHECKBOX No Response Aphasia: FORMCHECKBOX None FORMCHECKBOX Expressive FORMCHECKBOX ReceptiveMemory Deficits: FORMCHECKBOX No FORMCHECKBOX Yes Impaired Decision-making: FORMCHECKBOX No FORMCHECKBOX Yes Sleep Aids: FORMCHECKBOX No FORMCHECKBOX Yes Sleep Pattern: FORMTEXT ?????Seizures: FORMCHECKBOX No FORMCHECKBOX Yes FORMTEXT ?????CIRCULATIONHistory: FORMCHECKBOX N/A FORMCHECKBOX Arrhythmia FORMCHECKBOX Hypertension FORMCHECKBOX HypotensionPulse: FORMCHECKBOX Regular FORMCHECKBOX IrregularSkin: FORMCHECKBOX Pink FORMCHECKBOX Cyanotic FORMCHECKBOX Pale FORMCHECKBOX Mottled FORMCHECKBOX Warm FORMCHECKBOX Cool FORMCHECKBOX Dry FORMCHECKBOX DiaphoreticEdema: FORMCHECKBOX No FORMCHECKBOX Yes Pitting: FORMCHECKBOX No FORMCHECKBOX Yes FORMTEXT ?????RESPIRATIONRespirations: FORMCHECKBOX Regular FORMCHECKBOX Unlabored FORMCHECKBOX Irregular FORMCHECKBOX LaboredBreath Sounds: Right ( FORMCHECKBOX Clear FORMCHECKBOX Rales) Left ( FORMCHECKBOX Clear FORMCHECKBOX Rales)Shortness of Breath: FORMCHECKBOX No FORMCHECKBOX Yes (indicate triggers) Respiratory Treatments: FORMCHECKBOX None FORMCHECKBOX Oxygen FORMCHECKBOX Aerosol/Nebulizer FORMCHECKBOX CPAP/BIPAP FORMTEXT ?????DENTAL FORMCHECKBOX Own Teeth FORMCHECKBOX DenturesDental Hygiene: FORMCHECKBOX Good FORMCHECKBOX Fair FORMCHECKBOX Poor FORMTEXT ?????Resident: FORMTEXT ????? Date Completed: FORMTEXT mm- FORMTEXT dd- FORMTEXT yyyy PSYCHOSOCIALSelf Injurious Behavior: FORMCHECKBOX No FORMCHECKBOX YesAggressive Behavior: FORMCHECKBOX No FORMCHECKBOX Yes Frequency of disruptive behavior: FORMTEXT ????? Behavior: FORMCHECKBOX Calm FORMCHECKBOX Lethargic FORMCHECKBOX Angry FORMCHECKBOX Resists Care FORMCHECKBOX OtherAnswers Questions: FORMCHECKBOX Readily FORMCHECKBOX Slowly FORMCHECKBOX InappropriatelyDelusions and/or Hallucinations: FORMCHECKBOX No FORMCHECKBOX Yes FORMTEXT ?????MEDICATIONS & TREATMENTSHas a 3-way check (orders, medications, and MAR) been conducted for all of the resident’s medications and treatments, including OTCs and PRNs? FORMCHECKBOX Yes FORMCHECKBOX NoWere any discrepancies identified? FORMCHECKBOX No FORMCHECKBOX YesAre medications stored appropriately? FORMCHECKBOX Yes FORMCHECKBOX NoHas the caregiver been instructed on monitoring the effectiveness of drug therapy, drug reactions, side effects, and how and when to report problems that may occur? FORMCHECKBOX Yes FORMCHECKBOX No (explain)Are vital signs required due to a medication or diagnosis? FORMCHECKBOX No FORMCHECKBOX Yes (specify)Is lab monitoring required related to a medication or diagnosis (hypoglycemic, anticoagulant, psychotropic, seizure, etc)? FORMCHECKBOX No FORMCHECKBOX Yes (specify)Have arrangements been made to obtain these labs? FORMCHECKBOX Yes FORMCHECKBOX No (explain) FORMTEXT ?????HIGH RISK MEDICATIONSIs the resident taking any high risk drugs? FORMCHECKBOX No FORMCHECKBOX Yes (specify) Has the caregiver received instruction on special precautions for all high risk medications (such as hypoglycemic, anticoagulants, etc) and how and when to report problems that may occur? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMTEXT ?????SAFETY NEEDSIs the environment safe for the resident? FORMCHECKBOX Yes FORMCHECKBOX No(Adequate lighting, open traffic areas, non-skid rugs, appropriate furniture & assistive devices.) FORMTEXT ?????REVIEW OF RAT (RESIDENT ASSESSMENT TOOL) FORMTEXT ?????COMMENTS FORMTEXT ?????RN’s Signature: ______________________________________________Date Completed: FORMTEXT mm- FORMTEXT dd- FORMTEXT yyyy Print Name: FORMTEXT ?????Information Source: FORMTEXT ????? ................
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