DOC

INITIAL NURSING ASSESSMENT

By Edward Bailey,2014-08-12 12:35
15 views 0
INITIAL NURSING ASSESSMENT ...

    Initial Nursing Assessment

    Name of Assisted Living Facility: _______________________________________ Address: ___________________________________________________________ Telephone: _________________________ Fax: ________________________

    Name of Assisted Living Manager: ______________________________________

    Resident Name: _________________________________ Resident DOB: __/__/__

    Circle or check all that apply. Add descriptive comments as needed. Indicate N/A (not applicable or does not apply) when appropriate.

SECTION 1: ENVIRONMENTAL ASSESSMENT

Neighborhood:

    _______ Unclean/unkempt ___________ Safety Hazards ___________ Pests _______ Accessibility to grocery/drug store, health care facilities, fire, police, ambulance

COMMENTS:

    ____________________________________________________________________

    Home: General description of safety hazards, appearance, etc.: __________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Room: General description of safety hazards, appearance, etc.: __________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

SECTION 2: PHYSIOLOGICAL SYSTEMS REVIEW

BP _____ P _____ R _____ T _____ WT _____ HT _____

A. General appraisal of appearance:_________________________________________

    _______________________________________________________________________ _______________________________________________________________________

B. Assess level of consciousness/orientation: __________________________________

Source: The Baltimore County Department of Health’s Assisted Living Manual Date last legally reviewed: 10/30/07 (MLAN/ALP/AB)

C. Observe head and face (eyes, nose, lips): __________________________________

    ______ c/o headaches ______ swelling/masses ______ pain/stiffness ______ hair loss ______ parasites _____ enlarged nodes/glands ______ PERRA ______ ears pinna symmetrical/no discharge

    ______ visual disturbance ______ strabismus ______ cataracts ______ infection ______ contacts/glasses ______ glaucoma ______ ear infections ______ hearing aid ______ last audio exam

COMMENTS:

    ________________________________________________________________________

D. PROTECTION/SKIN:

    ______ color ______texture ______ skin tumor ______lesions ______ itching/priritus ______ skin breakdown/redness

COMMENTS:

    ______________________________________________________________________

E. NERVOUS SYSTEM

    ______ seizures ______ hallucinations ______ speech/language difficulties ______ gait problem _____ balance problem _____ learning disorder ______ tremor ______spasm ______ paralysis ______ memory loss

COMMENTS:

    ________________________________________________________________________

F. MUSCULOSKELETAL SYSTEM

    ______ joint swelling/red/pain _____ c/o back pain _____ twitching ______ weakness ______ difficulty with walking, bending, etc.

COMMENTS

    ________________________________________________________________________

G. RESPIRATORY SYSTEM

    ______ asthma ______ smoking _____ pneumonia/bronchitis

    ______ chronic cough breath sounds: ____ R ____ L ______a noisy breathing

COMMENTS:

    _______________________________________________________________________

Source: The Baltimore County Department of Health’s Assisted Living Manual Date last legally reviewed: 10/30/07 (MLAN/ALP/AB)

H. CARDIOVASCULAR SYSTEM

    ______ apical rate ______ edema ______ irregular pulse

COMMENTS:

    ________________________________________________________________________

I GASTROINTESTINAL SYSTEM

    ______ bowel sounds present ______ tenderness of abdomen

    ______ c/o stomach pain/burning ______ pain w/eating ______ nausea/vomiting ______ c/o stomach pain/burning ______ blood noted in stool ______ non-distended/soft in all 4 quads

COMMENTS:

    ________________________________________________________________________

J. ELIMINATION

    ______ constipation ______ diarrhea ______ incontinent of urine

    ______ incontinent of stool ______ hx. Of UTI

    ______ toileting schedule comments:

K. GYNECOLOGICAL:

    ______ regular menses ______ last period date ______ date of breast exam

COMMENTS:

    ___________________________________________________________

    L. MALE GENITAL: ____________________________________________________

COMMENT/ DESCRIPTION:

_______________________________________________________________________

    M. OTHER HEALTH PROBLEMS/CONCERNS:

    ________________________________________________________________________

Source: The Baltimore County Department of Health’s Assisted Living Manual Date last legally reviewed: 10/30/07 (MLAN/ALP/AB)

SECTION 3: CURRENT MEDICATIONS AND TREATMENT

    ____________________________________________________________________ SECTION 4: NURSING HEALTH GOALS:

    _____________________________________________________________________

    SECTION 5: ADDITIONAL RECOMMENDATIONS FOR FOLLOW-UP: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

    RESIDENT CURRENT LEVEL OF CARE: ______________________________ NEXT REVIEW DATE BY NURSE: ____________________________________

__________________________________

    PRINT NAME OF NURSE REVIEWER:

__________________________________ _________________

     SIGNATURE OF NURSE REVIEWER DATE

Source: The Baltimore County Department of Health’s Assisted Living Manual Date last legally reviewed: 10/30/07 (MLAN/ALP/AB)

Report this document

For any questions or suggestions please email
cust-service@docsford.com