To be completed by registered nurse and attached to comprehensive assessment.
Shaded Box indicates that selection is not available per 22 TAC Chapter 225.Box indicates that selection is not available per 22 TAC Chapter 225 for stable and predictable conditions. (Some things may be eligible for delegation in 22 TAC Chapter 224 for Acute Conditions; however, this worksheet only addresses Chapter 225.)
Nursing Tasks: Require professional nursing judgment.. Require professional judgment and may not be performed by anyone other than a licensed nurse. Delegated Task. An authorized nursing service not requiring professional nursing judgment provided by unlicensed personnel who is taught and monitored by an RN. [§225.4(6)]. This can include ADLs and HMAs the RN has assessed to be complex in nature. See Delegation Criteria at §225.9, §225.10 for stable and predictable conditions as defined in §225.4(11).
Health Maintenance Activity (HMA): ) Exempt from Delegation. The individual has a single identified Client Responsible Adult (CRA) whose knowledge, abilities and availability qualify this allowable task as an HMA listed in §225.4(8) as eligible for exemption from delegation and is appropriate per RN judgment. Tasks must be related to stable and predictable conditions and may be performed without RN supervision if the CRA is willing and able 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. §225.4(8), §225.8.
Activity of Daily Living (ADL): - A non-complex activity that an individual may perform as part of a normal daily routine.
Self-Administration of Medications
Individual knows how to safely take each medication (what, why) dose, route and 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. §225.4(3).
Orally (Check box if medications are not self-administered.)
Via gastrostomy or jejunostomy tubes (Check box if meds are self-administered.)
Sublingually
Topically
Drops for eye, ears, nose, Spray for nose
Suppositories, rectal or vaginal (Check box if suppository is part of a bowel program.)
Oxygen administration for non-acute maintenance
Inhalation agents
From a pill reminder box (Must be able to identify each med.)
Insulin
Administration of Medications
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. §225.4(2).
Orally (Check box if medications are not self-administered.)
Via gastrostomy or jejunostomy tubes (Check box if meds are self-administered.)
Sublingually
Topically
Drops for eye, ears, nose, Spray for nose
Suppositories, rectal or vaginal
Rectal suppositories as part of a bowel program
Inhalation agents for routine maintenance and prophylaxis
Inhalation agents for other than routine maintenance
Oxygen administration for non-acute maintenance
Insulin - Refer to §225.11 for specific requirements.
From a pill reminder box Refer to $225.11 for specific requirements.
Additional Health-Related Tasks
Feeding and irrigation via gastrostomy or jejunostomy tube (not naso-gastric not Dobhoffs)
Feeding
Meal preparation
Routine trach care including instilling normal saline, routine suctioning, routine oxygen
Trach care other than routine cleaning, instilling saline, routine suctioning and routine oxygen
Stage I decubitus routine care (blanches with pressure)
Care of broken skin with low risk of infection
Non-invasive and non-sterile treatments with low risk of infection
Sterile procedures involving a wound or anatomical site that could potentially become infected
Hair/Skin care
Bathing
Bowel program limited to suppositories, enemas, manual evacuation, digital stimulation
Stoma care including but not limited to pouch changes, measuring intake and output, and skincare surrounding stoma
Bladder program including intermittent catheterization (not Foleys) and irrigation
Toileting
Dressing
Grooming
Transfer/Ambulation
Exercise
Positioning
Range of Motion
Collecting, reporting and documentation of data including:
Vital signs
Height/weight
Environmental conditions
Comments r/t plan of care
Behaviors
Reinforcement of health teachings provided by RN