Form 8584 | Universal Rehabilitation Services

Comprehensive Nursing Assessment

To be performed by a Registered Nurse

Name of Individual

Date of Birth

Today's Date

1. Review

Review of Health Care Team

Health Care Practitioners

Primary Care

Date Last Seen

Comments

Psychiatrist

Date Last Seen

Comments

Neurologist

Date Last Seen

Comments

Dentist

Date Last Seen

Comments

Optometrist

Date Last Seen

Comments

Natural Supports

Client Responsible Adult (CRA)

Relationship

Telephone No.

Guardian

Relationship

Telephone No.

Health History: Psychiatric and Medical Diagnosis

Axis 1

Axis 2

Axis 3

Axis 4

History of Major

Individual:

Date

Review of Current Medications

Include OTCs, vitamins and herbs.

Medication

Dose

Freq.

Route

Purpose/Rationale

Side Effects/Labs

Allergies:

2. Current Status

Current medical and psychiatric history

What is of primary concern/greatest expressed needs of the individual, legally authorized representative (LAR) or client's responsible adull (CRA) from their own perspective?

Vital Signs

Blood Pressure

Pulse Rate

Pulse Rhythm

Respirations Rate

Respirations Rhythm

Temperature

Pain level

Blood Sugar

Weight

Height

Comments

Labs

Briefly review ordered labs, dates and abnormal values within the past year.

Fall Risk Assessment

Has a fall risk assessment been completed?

Yes (attached). Fall risk due to

Briefly review ordered labs, dates and abnormal values within the past year.

3 . Review of Systems

4. Additional Health Status Information

Immunizations: Date last received

DPT

TOPV

HIB

MMR

TDS

FLU SHOT

Comments

Nutritional Assessment

How nutrition is received:

Orally

Via jejunostomy tube

Via gastrotomy tube if residual

Other

Liquid consistency

Therapeutic diet

Food texture

Reason/date/ordered by

nvdkjv

Yes

Recent weight change.

Recent changes in appetite/medication

Satisfied with current weight

Food use as a coping mechanism.

Assistive devices with eating

Use of medications that can cause difficulty swallowing (e.g., Abilify, other psychoactives)

Knowledge of four basic food groups

Access to healthy/appropriate diet

Dietary deficiencies

Adequate fluid intake

Nutritional supplements..

Interactions with medications and food.

Lbs

Gain

Loss Over

Desired weight range:

Number of meals/snacks per day:

Comments

Sleep Pattems

Activity Level/Exercise

Substance Use/Abuse

Home Life

Work/School/Day Activity

Social Life

Spiritual Life

Coping Skills

Mental Status

Challenging Behaviors

Are medications used to control any behaviors?

Yes

Currently has a formal Behavior Plan?

Yes

Use the following scales below for frequency and severity:

For frequency: 1 less than once per month: 2 = 1 to 3 x month, 31 to 6 x week: 4=1 to 10 x day; and 51 or more x hour.

For severity: 1 mild: 2 moderate: 3 severe; and 4 = critical.

Category / Option

Frequency

Severity

Last Exhibited

Hurtful to self

Hurtful to others

Destructive to property

Pica

Resists care

Socially offensive/Disruptive Behavior

Sexually inappropriate behavior

At risk behavior, such as:

Wandering

Elopement

Sexually aggressive behavior

History of suicide attempt

Other serious behavior

Communication.

5. Implementation Assessment

Health care and Decision Making Capacity

The preceding review of functional capabilities, physical and cognitive status, and limitations indicate this individual's highest level of ability to make health care decisions.

Probably can make higher level decisions (such as whether to undergo or withdraw life sustaining treatments that require understanding the nature, probable consequences, burdens and risks of proposed treatment).

Probably can make limited decisions that require simple understanding, able to direct own health care, including delegated tasks.

Probably can express agreement with decisions proposed by someone else.

Cannot effectively participate in any kind of health care decision making.

Knowledge: Describe key health understandings/demonstrations

Comments

Participants in Comprehensive Assessment (Must complete section A, B or C; and RN section)

Option A: In this situation, the individual does not have a guardian/LAR and is able to make decisions regarding health care.

To be completed by the Individual:

I have participated in decisions about the overall management of my health care [$5225.1(2)], can make all of my own decisions, am able to direct own health care, and

will not be directing health maintenance activities (HMAS)(§225.8(2)(D)(i)).

agree to train unlicensed personnel in the performance of HMAS.

Printed Name

Date

Signature

Option B: In this situation, the individual cannot make decisions regarding health care or has asked for assistance.

To be completed by the CRA:

have participated in decisions about the overall management of health care. (§225.1(2)]

I will be participating in decisions only, not directing care. No HMAs will be performed by unlicensed personnel.

I agree to train unlicensed personnel in the proper performance of tasks identified as HMAs, be present when the task is performed or, if not present, will have observed the unlicensed person perform the task and will be immediately accessible in person or by phone to the unlicensed personnel when the task is performed. [5225.8(2)(D) (8)(1-41)]

Printed Name

Date

Signature

Option C :In this situation, the Individual cannot make decisions regarding health care and does not have a single identified adult who is willing and able to participate in decisions about the overall management of the individual's health care. [§225.1(a)(2)]

Provider Advocate Committee (PAC) will act as CRA (form attached).

Registered Nurse (RN)

I have developed this plan and retain accountability for delegated tasks. Each unlicensed personnel's competency will be verified before allowing delegated tasks to be performed without direct nursing supervision. An RN will be immediately accessible by phone to the unlicensed personnel when the task is performed.

Printed Name

Date

Signature

Safe Administration of Medications

A comprehensive review of functional capabilities, physical and cognitive status, limitations and natural supports rate this individual's ability to take his/her own medications in a safe and appropriate manner according to the five Rights of Medication Administration (correct person, medication (what, why], dose, time, route).

RN Delegation Worksheet:tachedN/A

Self-Administration of Medication. Individual knows how to safely take each medication (what, why) dose, route, time of each medication. The individual is competent to safely self-administer medications independently or independently with ancillary aid provided to the individual in the individual's self-administered medication treatment or regimen, such as reminding an individual to take a medication at the prescribed time, opening and closing a medication container, pouring a predetermined quantity of liquid to be ingested, returning a medication to the proper storing area, and assisting in reordering medications from a pharmacy.No RN Delegation is necessary.

Administration of medication to an individual by a paid unlicensed person(s) to ensure that medications are received safely. . Administration of medications includes removal of an individual/unit dose from a previously dispensed, properly labeled container, verifying it with the medication order, giving the correct medication and the correct dose to the proper individual at the proper time by the proper route; and accurately recording the time and dose given. [TX BON $225.4(2)]. Check all that apply:

CRA can safely direct as an HMAΑ.No RN delegation is necessary. . The individual has a single identified CRA whose knowledge, abilities and availability qualifies the administration of oral medications (by mouth or through a permanently placed feeding tube) as an HMA exempt from delegation and is appropriate per RN judgment. Medications may be administered for stable and predictable conditions (not initial doses and/or for acute conditions) without RN supervision provided that the CRA is willing, able and agrees in writing to train the unlicensed person(s) in performing the task at least once to assure competence and will be immediately accessible in person or by telecommunications to the unlicensed person(s) when the task is performed. [5225.4(8), §225.8]

RN delegation necessary to ensure safe medication administration.RN can safely authorize unlicensed personnel to administer medications for stable and predictable conditions as defined in §225.4(11) not requiring nursing judgment. Competency of each unlicensed personnel, including the ability to recognize and inform the RN of client changes related to the task must be verified by RN. The six rights of delegation (the right task, the right person to whom the delegation is made, the right circumstances, the right direction and communication by the RN, the right supervision, and the right documentation) and all criteria at §225.9 must be met. CRA lacks knowledge, abilities and/or availability per §225.8 to direct as an HMA. Individual (if competent), CRA (if one exists) or Provider Advocate Committee (PAC) must approve the decision of the RN to delegate tasks in writing. See delegation criteria at §225.9, §225.10

Routes that may be delegated:

The RN has determined that delegation is not required because the parent/LAR/foster care provider can assume responsibility and accountability for the individual's health care. The RN has considered the length of time the individual has been living in the home, the relationship of the individual and foster care provider, the supports available to the foster care provider, and has determined that the foster care provider can safely assume this responsibility. The RN will serve as a resource, consultant or educator, and will intervene when necessary to ensure safe and effective care. [§225.6(a)(3)] Documentation of subsequent interventions, including when additional follow-up is needed, will be a part of the RN's nursing care plan.

The RN has determined that delegation is not required for oral, topical and metered dose inhalers.The RN has determined that the medications not being delegated to paid unlicensed personnel are for a stable or predictable condition. The RN or LVN, under the direction of an RN, has trained and determined the paid unlicensed personnel competency. [Human Resources Code, Chapter 161, Subchapter D]

Must be administered by a licensed nurse. Medications that may not be delegated are:

Nurse Supervision

For each unlicensed personnel, determine in consultation with the individual CRA, LAR or PAC the level of supervision and frequency of supervisory visits, taking into account: the stability of the individual's status; the training, experience and capability of the unlicensed personnel to whom the nursing task is delegated; the nature of the nursing task being delegated; the proximity and availability of the RN to the unlicensed person when the task will be performed and the level of participation of the individual or CRA ($225.9(a)(3)(A-E)]

Name of Unlicensed Personnel:

List all who were consulted in determining the level of nurse supervision for the above named unlicensed personnel:

Provider Advocate Committee (PAC)

Legally Authorized Representative (LAR)

Client Responsible Adult (CRA)

Individual

Other

RN follow-up to monitor competency of the above named unlicensed personnel of the following delegated task(s):

Frequency of required RN monitoring:

once additionally within the firstthen

other

Frequency of additional RN or LVN monitoring:

not applicable; no additional monitoring is needed

once additionally within the firstthen

Notes

6. Summary

Summary/Clinical Impressions

Strengths as related to healthup to date on all appointments, focused on weight management and better

Consultations recommended

Summary

Nursing Service Plan

Concerns/Nursing Diagnoses

Intervention/Strategies

Implementation Strategy Objectives

Start Date

Target Completion

Calculation of Units (if applicable)

Total Units (per strategy)

Total Nursing Units Needed

RN Specialized

LVN

LVN Specialized

Desired Outcomes/Goals

Printed Name

Date

Signature

Review of Comprehensive Nursing Assessment by RN:

Note: The nursing assessment must be reviewed at least annually to verify information remains current and decisions remain appropriate.

Date of Review:

Purpose (must check one):

review of a temporary or permanent change in the individual's physical health, support system, mental status, social functioning, ability to perform activities of daily living or health maintenance activities, or medication or treatment regimen;

review assessments, documentation and decisions made by a previous RN; or

annual review of assessments, documentation and decisions to verify information remains current and decisions remain appropriate.

Description of Review:

Action Taken by RN

Change(s) in Nursing Service Pian:

No change required

Nursing service plan revisions:

Date

Signature

Purpose (must check one):

review assessments, documentation and decisions made by a previous RN; or

annual review of assessments, documentation and decisions to verify information remains current and decisions remain appropriate.

Description of Review:

Action Taken by RN

Change(s) in Nursing Service Pian:

No change required

Nursing service plan revisions:

Date

Signature

Comprehensive Nursing Assessment

1. Review

Review of Health Care Team

Review of Current Medications

2. Current Status

Vital Signs

Labs

Fall Risk Assessment

3 . Review of Systems

Neurological

Gastrointestinal

Cardiovascular

Musculoskeletal

Integumentary

Respiratory

Genitourinary

Endocrine

4. Additional Health Status Information

Immunizations: Date last received

Nutritional Assessment

Mental Status

Cognition

Thoughts

Challenging Behaviors

Communication.

5. Implementation Assessment

Health care and Decision Making Capacity

Support Systems: Discuss the adequacy, reliability, avallability, ability to communicate effectively.

Stability and Predictability and Need to Reassess

Knowledge: Describe key health understandings/demonstrations

Participants in Comprehensive Assessment (Must complete section A, B or C; and RN section)

Safe Administration of Medications

Nurse Supervision

6. Summary

Summary/Clinical Impressions

Nursing Service Plan

Intervention/Strategies

Total Nursing Units Needed

Review of Comprehensive Nursing Assessment by RN: