Comprehensive Interdisciplinary Patient Assessment

Date: (Patient ID Label here) Patient Appt: Pt. unable to Attend / Reason: ______

Annual NP month 1 NP month 3 Unstable Pt request If unstable: Hosp Marked Deterioration Poor Alb/Hgb/ Kt/V Psychosocial Other ______

MEDICAL OVERVIEW (On initial, attach current H&P) Date of 1st Dialysis: Date 1st at Center: Initial Diagnosis of Renal Failure (from 2728): Co-morbid conditions: Current modality for RRT: In-center Hemo Home hemo CAPD/CCPD Informed of dialysis options: ICHD PD HHD - if not, why______

LOC: A/O Confused Cooperative Involved in care Note: Knowledge of cause of renal disease Yes No Unsure General knowledge of ESRD: Excellent Good Needs reinforcement Dependent on others New events: Fall/Injury Surgery Other: Fall Risk- 4 or more considered fall risk: > 3 Co morbid Diagnosis Polypharmacy Prior falls in last 3 mon. Incontinent Visual Environmental Pain Cognitive

Other Providers: PCP: ______Endocrine: ______Cardiologist: ______GI: ______Neuro:______Other______DIALYSIS PRESCRIPTION REVIEW Dialysis Rx: x wk hrs Dialyzer ______Reuse Current Dry Wt. Achieving DW Average Wt Gains:______Heparin: Bolus Sustain Other Anticoag. None Bath: ______K+ Ca++ ______HCO3 Na+ Mod ______

BFR ordered ______Able to obtain Poor BFR Access: Type ______Date placed: ______Surgeon:______Surg/Intervention: Date : Last ABF AP/VPs <100 Cannulation: Rotation Buttonhole Lidocaine Other analgesic______N/A Notes on access: New-Expert only Straight Tortuous Aneurysms Access Problems: None Decr Kt/V Ext. Bleed Infection Other

Comments:______

Catheter Date: Type______Functions well Poor BFR Exit site infections: Plan for AVF/AVG:

Interdisciplinary Team Note: Continue Same Rx Changes to Rx/Plan

______

Nurse Completing form______IDT Nurse: ______Date: Kidney Center of Thousand Oaks NURSING Comprehensive Interdisciplinary Patient Assessment ASSESSMENT

Lab Review: Adequacy: Kt/V URR

Anemia: Hct / Hgb / Infection Recent Transfusion Stool OB Retic Ct. Ferritin TSat

Aranesp mcg EPO units Prev adj date Incr Decr Venofer Prev adj date Carnitor gm for Anemia HypoTN

Bone: Ca++ Phos PTH Notes: Calcijex Zemplar Hectorol mcg Sensipar

Infection: Cultures done Blood Wound Urine If positive, organism: Antibiotics:

Additional Lab Concerns: ______Clinical Parameters:

Fluid Status: Intradialytic weight gains kg Excess BVM refill Yes No Notes:

Edema Rales SOB Insomnia O2 during HD O2 at home Dehydration

BP: In acceptable range (KDOQI =140/90 pre dialysis) HTN BP Meds held prior to Tx Note: Hypotension Pre During Post Tx Note: Adverse ID Symptoms: Cramps Dizzy Nausea Hypoxemia Cardiac S/S Frequent Hospitalizations: No Yes Patient/family education re complications

Medication Review Changes (attach updated medication list) Pharmacy:______Barriers to taking meds: None Financial Transportation Dislike Side effects Allergies: None Yes ______

Complaints of Pain None Yes Where: How often: Character of pain: Scale 1-10 Medications:

Infectious Disease SGOT SGPT HbSab Other

Vaccines All Current Due: PPD Flu Pneumo Hepatitis B series Refuses:

GI: N/V Diarrhea Constip. Poor appetite Abd discomfort

GU: Residual urine > 1cup/d < 1cup/d Pain on urination

Skin: No concerns Ulcerations Ecchymosis Cuts/skin tear Other Diabetic foot checks: NA

Interdisciplinary Team Note: Continue Same Rx Changes to Rx/Plan

Nurse Completing form______IDT Nurse: ______Date: