Home Nursing Assessment
Date
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Day
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Month
Year
Date
Registered Nurse Email (for purpose of completing a potentially saved but not submitted copy)
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example@example.com
Name of Client
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
ID number
Date of Birth
Medical Aid Details: name, plan, number
Type of Care Needed & Estimated Hours - Day Care, Night Care, Live-in / Days of week / Times from - to / Respite - Relief Care Dates only
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VITALS
Weight (in KG) - if no scale and not sure, pls estimate the number in KG
*
Height (in M) - if not sure, pls estimate the number in M, such as 1.65. Needs to be in M for automatic BMI calculation to work.
*
height factor
BMI
BMI Outcome
*
Below 18.5 - Underweight
18.5 - 24.9 - Normal
25 - 29.9 - Overweight
30 - 34.9 - Obesity Class 1
35 - 39.9 - Obesity Class 2
Weight
Height
Blood Pressure
Temperature
Pulse
Respiration Rate
HGT (Glucose)
Oxygen Saturation
STATS OUTCOME
Rows
In Range
Intermediate Risk
High Risk
Blood Glucose
Blood Pressure
Cholesterol
Respiration Rate
Oxygen Saturation
Heart Rate / Pulse
Temperature
Surgical / Medical History
Pain - areas and indication?
Allergies
Medications (take pictures pls): if available picture of label on dosage and frequency. Guidance for clients: medication must please be in blister packs.
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Medications: Name of medication, dosage & frequency (ONLY if anything missing from pictures). Guidance for clients: medication must please be in blister packs.
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Neuro and Psych (multiple choice) - Mental Status
Orientated
Disorientated
Depressed
Anxious
Talkative
Confused
Positive
CVA (Stroke)
Epilepsy
Dementia
Alzheimer's
Brain Tumour
Memory Long-term
Memory Short-term
Aggressive
Wanders off
Mood Swings
Neuro Abnormalities:
Cardiac Status
Hypertensive
Pace Maker
Cardiac Stent
AF (Atrial fibrillation - irregular heartbeat)
CCF (congestive cardiac failire)
Hyperlipidimea
Previous MI (myocardial infarction -heart attack)
Cardiac Abnormalities
Respiratory Status
Asthma
Current Distress
COPD ( Chronic obstructive pulmonary disease)
Smoker
On Oxygen
Respiratory Abnormalities
Muscular, Bones, Joints Status
Body weakness
Knee problems
Back problems
Hip problems
Shoulder problems
Muscular, Bones, Joints abnormalities
Genitourinary Status
Continent
Incontinent
Genitourinary Abnormalities
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Current Diet
Preferred Fluids
Status
Diabetic
Renal
Diarrhea
Constipation
Poor appetite
PEG tube
Nasogastric tube
Supplement
Gastrointestinal abnormalities
Endocrine
Diabetes Mellitus
Diabetes Mellitus Type 2
Thyroid
Senses
Rows
Normal
Impaired
Aids
Sight
Hearing
Rows
Wet
Dry
Comments
Eyes
Tongue
Skin
Intact
Impaired
Pressure Injury
Surgical Wound
General Wound
Bruising
Eczema
Skin Illnesses
Edema
Wound Information / other info about Skin
Dental Info
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History about person / career history / interesting facts to talk about
Social Status
Retired
Employed
Unemployed
Physical Family Support
Physical Family Involvement
Virtual Family Involvement (family lives in other city or country)
No Family
Additional Remarks
Sleeping Patterns - Any Changes seen? Guidance
Interest in Activities - Activities schedule
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DAILY CARE PLAN
Rows
TICK
MORE DETAILS
WHAT TIME
SKIN CARE & JOINT CARE
BATHING / CLEANING
TOILET ASSISTANCE
LIFTING / TRANSFER Techniques
TURNING (bedridden)
MOBILITY / WALKS
PASSIVE EXERCISES
DRESSING
MOUTH CARE
NAIL CARE
HAIR CARE
FEEDING / MEAL PREP INFO
LIGHT HOUSE KEEPING
MASSAGE
COMPANIONSHIP / ACTIVITIES
SHOPPING REQUIRED
Recommendation for Home Care Furniture or Mobility Aids to assist Patient in their own home?
Hospital Beds, Rails, Specific Mattresses, Walkers etc?
Any Risk Factors to consider - Patient him / herself and or Home (f.ex. staircases, loose carpets)
Date of followup assessment (client signs for quarterly assessments, please setup already if open to it. if you feel more frequent visits required, pls address with client)
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Month
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Day
Year
Date
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RATINGS
used to identify current state of patient / also required for potential medical aid claims.
BETA SCORE ASSESSMENT: 1: Patient can do nothing him/herself; 2: Patient is "trying"; 3: Patient can do 50% but needs help; 4: Patient needs occasional help; 5: Patient needs supportive help; 6: Patient can do him/herself but needs "extra time" or "assistive device"; 7: Normal
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EATING
GROOMING
BATHING
DRESSING - UPPER
DRESSING - LOWER
TOILETING
BLADDER
BOWEL
TRANSFER: Bed, Chair, Wheelchair
TRANSFER: Toilet or Chair
TRANSFER: Tub, Shower
Walk, Wheelchair
Stairs
Comprehension
Expression
Social Interaction
Problem Solving
Memory
Overall BETA Score (addition of numbers from table above)
ECOG Score
0: Fully Active, able to carry on all predecease performance without restriction
1: Restricted in physically strenuous activity but ambulatory and able to carry out work of a light and sedentary nature
2: Ambulatory and capable of all self care, but unable to carry out any work activities; up more than 50% of waking hours
3: Capable of limited self care; confined to bed or chair more than 50% of waking hours
4: Completely disabled; cannot carry on any self care; totally confined to bed or chair
KARNOFSKY SCORE
100: Normal, no complaints, no evidence of disease
90: Able to carry on normal activity; minor signs or symptoms of disease
80: Normal activity with effort, some signs of symptoms or disease
70: Cares for self, but unable to carry on normal activity or do active work
60: Requires occasional assistance but is able to care for most of personal needs
50: Requires considerable assistance and frequent medical care
40: Disabled; requires special care and assistance
30: Severely disabled; hospitalisation is indicated although depth not imminent
20: Very ill; hospitalisation and active supportive care necessary
10: Moribound
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