COMPREHENSIVE NURSING ASSESSMENT - Maryland
[Pages:3]COMPREHENSIVE NURSING ASSESSMENT
To 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 role
Resident Name: ___________________________________________________
45-day Nursing Review Due: ________________________________
ALLERGIES:
DIAGNOSES:
DOB: ______________ Date Completed: _____________
VITAL SIGNS
BP
P
R
T
?F HT
ft
in WT
lbs
NUTRITION ELIMINATION SENSORY
ASSESSMENT ? Explain ALL answers that are not within normal limits Diet: Regular NAS NCS Mechanical Soft Pureed Recent weight change: No Yes Supplements: No Yes Conditions affecting eating, chewing, or swallowing: No Yes Monitoring required at mealtimes: No Yes Fluids. Monitoring: No Yes Increased Restricted Mucous membranes: Moist Dry Skin turgor: Good Fair Poor Bladder Incontinence: None Occasional (less than daily) Daily Bowel Incontinence: None Occasional (less than daily) Daily Incontinence management techniques: No Yes Bowel sounds present: Yes No Constipation: No Yes Ostomies: No Yes
Vision: Normal Impaired Corrective device: ___________________ Hearing: Normal Impaired Hearing aid: No Yes
COMMENTS
Form Created 6/6/12
Page 1 of 3
Resident: ___________________________________ MUSCULOSKELETAL Mobility: Normal Impaired Assistive Devices: No Yes
Date Completed: _________________
ROM: Full Limited
Motor Development: Head Control Sits Walks Hemiparesis Tremors
ADLs: (S=self; A=assist; T=total) Eating: ____ Bathing: ____ Dressing: ____
SKIN
Normal Pale Red Rash Irritation Abrasion Other
Skin Intact: Yes No (if no, a wound assessment must be completed)
Special Care or Monitoring: No Yes
NEURO
Sensation: Intact Diminished/Absent
Pain: None Less Than Daily Daily
If there is pain indicate the site, cause, & treatment.
Verbal Response: A/O x _____ Confused Inappropriate
Incomprehensible No Response
Aphasia: None Expressive Receptive
Memory Deficits: No Yes
Impaired Decision-making: No Yes
Sleep Aids: No Yes
Sleep Pattern: __________________________________
Seizures: No Yes
CIRCULATION
History: N/A Arrhythmia Hypertension Hypotension
Pulse: Regular Irregular
Skin: Pink Cyanotic Pale Mottled Warm
Cool Dry Diaphoretic
Edema: No Yes Pitting: No Yes
RESPIRATION
Respirations: Regular Unlabored Irregular Labored
Breath Sounds: Right ( Clear Rales) Left ( Clear Rales)
Shortness of Breath: No Yes (indicate triggers)
Respiratory Treatments: None Oxygen Aerosol/Nebulizer CPAP/BIPAP
DENTAL
Own Teeth Dentures
Dental Hygiene: Good Fair Poor
Form Created 6/6/12
Page 2 of 3
Resident: ___________________________________
PSYCHOSOCIAL Self Injurious Behavior: No Yes
Aggressive Behavior: No Yes
Frequency of disruptive behavior: ___________________________________
Behavior: Calm Lethargic Angry Resists Care Other
Answers Questions: Readily Slowly Inappropriately
Delusions and/or Hallucinations: No Yes
MEDICATIONS Has a 3-way check (orders, medications, and MAR) been conducted for all of the & TREATMENTS resident's medications and treatments, including OTCs and PRNs? Yes No
Were any discrepancies identified? No Yes
Are medications stored appropriately? Yes No
Has 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? Yes No (explain)
Are vital signs required related to a medication or diagnosis? No Yes (specify)
Is lab monitoring required related to a medication or diagnosis (hypoglycemic, anticoagulant, psychotropic, seizure, etc)? No Yes (specify)
Have arrangements been made to obtain these labs? Yes No (explain)
HIGH RISK MEDICATIONS
SAFETY NEEDS
REVIEW OF RAT (RESIDENT
ASSESSMENT TOOL)
COMMENTS
Is the resident taking any high risk drugs? No 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? Yes No N/A Is the environment safe for the resident? Yes No
(Adequate lighting, open traffic areas, non-skid rugs, appropriate furniture & assistive devices.)
RN's Signature: __________________________________________________ Date Completed: ______________________________ Print Name: _____________________________________________________ Information Source: ____________________________
Form Created 6/6/12
Page 3 of 3
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