(The RN Assessment Must Be Completed. the Use of This Form to Document the RN Assessment

NDP-8 RN ASSESSMENT (The RN Assessment must be completed. The use of this form to document the RN Assessment is optional)

Consumer Name Case #/SS#

Date Facility Name

DOB Gender: Age Race Date of Admission Time of Admission ( One) Male ( One) Female AM PM Transported By: Received From: Accompanied By: Relationship Car Van Ambulance Other ______

MEDICAL HISTORY Name of PCP/CRNP(s):

( ) ( ) Phone #s:

Other Physicians:

Location Date of Last Visit: BMI WT HT Waist Circumference Baseline Data

Date of Last TB Result Skin Test or CXR T _____ P ______R ______BP ______Arm: Vital Signs R L Last Menstrual Period □ N/A Pregnant? Yes No □ N/A Changes in Libido □ Yes □ No Breast Discharge Comments: □ Yes □ No □ Yes □ No □ N/A Erectile/Ejaculatory Comments: Problems None Medication(s) Allergies Food(s)

1 Revised May 24, 2016 NDP-8 None Location(s)

Frequency Daily Daily/Intermittent Constant Other Pain Intensity Mild Distressing Severe Unbearable No Yes (If yes explain) Pain on Admission

Special Treatments/Procedures/ Equipment (List all including purpose):

Past Surgeries/Implants (list all including year and location):

Past Psychiatric/Medical None Hospitalizations (List all including year/location/reason):

FAMILY / RELATIONSHIPS None Significant Marital Status Children Parents Siblings Others Married Yes Mother None Legal Guardian Single Number: ____ Alive Yes No Divorced Deceased Yes Other No Name Number _____ Father ______Alive # Alive _____ Deceased Friend(s) # Deceased _____ Yes No Other

2 Revised May 24, 2016 NDP-8 RELIGIOUS/SPIRITUAL/CULTURAL Religious Affiliation

Attend Church? Yes No Cultural/Ethnic Practices That Impact Care/Teaching (List)

CURRENT STATUS PHYSICAL LIMITATIONS (Muscle/Skeletal System) Site Degree

Paralysis/paresis

Contracture(s) Congenital Anomalies

Prosthesis

FUNCTIONAL ABILITY SUPPORTIVE AMBULATION WEIGHT BEARING TRANSFERS DEVICES Independent Full Weight Independent Elastic Hose 1 Person Assist Partial Weight 1 Person Assist Hand Rolls 2 Person Assist Non-Weight Bearing 2 Person Assist Sheepskin With Device (name) Total Dependence Other (list) ______WC only ______WC Propels Self ______

GENERAL SKIN CONDITION: (Check all that apply) SITE SITE Dry Oily Edematous Cyanotic Pale Warm Moist Cold Reddened Jaundiced Ashen Other

HEAD/EAR/EYE/NOSE/THROAT Hearing R L Vision R L Speech

3 Revised May 24, 2016 NDP-8 Adequate Adequate Clear Poor Poor Aphasic Deaf Blind Dysphasic Hearing Aid Glasses/Contacts Language:

Oral Eating/Nutrition Sleep Bathing/ Indep Assist Dep Grooming Own Teeth Independent Usual Tub (Note condition) Bedtime Needs Assist Shower ______Bed Bath DENTURES Dysphasic (reason) Partial ______Oral Hygiene Usual Arising Upper Time Shave Lower ______Fit Adaptive Equipment Shampoo Yes No (type) Nap Grooming Diet (Consistency) Yes No Dressing BOWEL AND BLADDER EVALUATION (GENTIAL/URINARY) Bowel Continent Bladder Continent Frequent Constipation Other: Other: Y N Y N Y N

How managed? How managed? How managed?

PERSONAL/FAMILY HISTORY

 Diabetes (Endocrine): No Self Family

Today’s Blood Sugar Results (if applicable) ______Random Fasting

 Cardiovascular Disease: No Self Family

Heart Attack Stroke Other ______

 High Cholesterol: No Self Family

PSYCHOSOCIAL FUNCTIONING

4 Revised May 24, 2016 NDP-8

Person Place Time Oriented Y N Situation Facility

General Dressed/groomed appropriately for age/sex/situation Appearance Disheveled Pale Emaciated Sad Happy Alert Responsive Hyperactive Level of Lethargic Combative Joyful Expressionless Tics/Tremors Pacing Consciousness/ Cooperative Hostile Calm Behavior Rigid/Tense Compulsive Other (explain) Talkative Forced Pressured/Excessive Nonverbal Slurred Impediment Speech Loud Illogical Monosyllabic Other (explain) Appropriate Depressed Elated Anxious Guarded Flat Affect/Mood Angry Cooperative Uncooperative Friendly Other (explain) Normal Guarded Flighty Wandering Disorganized Paranoid Thoughts Illusions Delusional Hallucinations Homicidal Suicidal Other (explain) Remote Memory (past) Delayed Recall (repeat after 5 minutes) Memory Recent Memory Attention Level (ability to concentrate) Good Fair Poor Insight (What is causing your problem? What causes you to be here today?) Judgment Good Fair Poor (What would you do if you ran out of meds?) Personal Habits Smokes Cigarettes/Cigar/Pipe Drinks Alcohol Illegal Drug Use Yes / No Yes / No Yes / No Frequency Frequency Frequency Have you received assistance to Have you received Have you received treatment for stop smoking? treatment for drug misuse/abuse? Yes / No alcohol? Yes / No If yes, when/where? Yes / No If yes, when/where? If yes, when/where?

Good Fair Family Good Fair Family Support Poor Relationship Poor

CURRENT MEDICATIONS NAME DOSE FREQ DIRECTIONS FOR USE REASON

AIMS COMPLETED? □ Yes □ No □ N/A (File in clinical record)

ATTACH ADDITIONAL SHEET IF NEEDED LPN SIGNATURE

PHYSICAL ASSESSMENT TO BE REVIEWED/COMPLETED BY RN

COMMENTS:

REVIEW OF SYSTEMS: (Skin, HEENT, Cardio, Respiratory, Gastrointestinal, Genitourinary, musculoskeletal, Psychosocial, Nervous, Blood)

NURSING PLAN OF CARE TO BE COMPLETED BY RN ONLY

List all problems identified ATTACH ADDITIONAL SHEET IF NEEDED DATE PROBLEM GOAL/OUTCOME INTERVENTIONS EVALUATION 1/1/16 Diagnosis of Blood Sugar < 200 Delegate to MAC: 2/1/16 Example NIDDM 7 Revised May 24, 2016 NDP-8 No signs of Assist with meds; Meds taken as hyper/hypoglycemi ordered, no errors a No weight gain Check blood sugar; Blood sugar <200 Monitor for signs of No signs of hypo/hyperglycemia hypo/hyperglycemia, ; No voiced complaints Weigh monthly 165 – no change

Based on the problems listed the Level of Care Required is: (Select all that apply) Skilled Nursing Only MAS Nurse Supervision of MAC Worker 24/7 Combination of skilled nursing services and MAS Nurse Supervision of MAC Worker 24/7 Psychiatric status monitoring (state frequency) Medical/physical status monitoring (state frequency)

8 Revised May 24, 2016 NDP-8 Referral to: PCP Dentist Optometrist Other______

Based on the problems listed and the level of nursing/medical care required, the following Nursing Interventions Will Be Implemented by Nurse directly or via delegation

□ Skilled Nursing □ 24 hours □ Intermittent (state frequency) □ List all Skilled Nursing Interventions (Must be done by a licensed nurse only)

□ Assessment of ability to self-medicate completed (NDP 5) Filed in clinical record □ Reassessment/Screening ______Date Due (state frequency) □ Fall Screening □ AIMS □ ______□ ______□ ______□ Referral to service(s) not provided by the agency (List service and appointments made below) Service/Appts made:

Delegated Tasks: (Tasks that will be delegated to unlicensed persons) □ Assist with medication administration □ Monitor and Measure I & O (state frequency) □ T/P/R/BP/Wt. (state frequency) □ Assisted ambulation/mobility/transfer (instructions) □ Assisted toileting/bathing/dressing (instructions) □ Monitor skin condition (state location/ frequency) □ Choking Prevention Techniques (instructions) □ Take to Lab (state frequency)______Date Due □ Fall Precautions (instructions) □ Other tasks deledgated:

NURSES NOTES

______

9 Revised May 24, 2016 NDP-8 ______

______

RN SIGNATURE

10 Revised May 24, 2016