form xxxx july 2014 class / dbmd nursing assessment · 2014. 11. 24. · how do you know if the...
TRANSCRIPT
Form XXXX July 2014
CLASS / DBMD NURSING ASSESSMENT
Individual Name: ____________________________
RN: __________________________________________________________________________ Page 1 of
Assessment Date: Time: Date of Birth:
Male Female
Legal Status (does the Individual have a guardian or Legally Authorized Representative (LAR)): N/A Yes No (if yes, indicate type) Parent of a minor Court Appointed Guardian Power of Attorney Other_________________________ LAR Printed Name:_______________________________________
History Received from:
Reason for Assessment: Initial Assessment Annual Reassessment Post Hospitalization Protective Devices (DBMD only) Other (specify)___________________________
Living Arrangements: Own home, family home Assisted Living Facility 1-3 bed home 4-6 bed home Number in household: Primary Support
Provider: Home conditions: Clean Unclean
Safety: Good Fair Poor
Hygiene: Good Fair Poor
Comments:
Communication (if yes is indicated for any form of communication other than VERBAL, please explain the YES answer in the comments section below) Verbal Yes No Limited verbal Yes No Non-verbal Yes No Gestures Yes No Communication symbols Yes No Facial expressions Yes No Eye movements Yes No
Paralinguistic (sounds) Yes No Touch Yes No Body language Yes No Acting out Yes No Head banging Yes No Other behaviors (describe) Yes No Numeric scale Yes No
Comments:
Immunizations: Is the individual up to date on all immunizations? N/A Yes No (if marked, indicate which immunizations are needed): Has the individual ever received blood/blood products? Yes No
Adverse Reactions:
Comments:
Texas Department of Aging & Form XXXX Disability Services October 2014
CLASS / DBMD NURSING ASSESSMENT Individual’s Name: _______________________________ Date: ______________________
RN: _____________________________________________________ Page 2 of 9
Allergies (drug, food, & environmental):
Current Medical & Mental Health Diagnoses: Dates diagnosed:
Previous Medical, Surgical & Mental Health History:
Dates:
Airborne Communicable Disease: Has the individual received testing in the past year to verify individual TB status? Yes(if marked, fill in information below) No N/A PPD Date: Result: mm OR Chest X-Ray Date: Result: Does the individual have any active reportable communicable diseases? Yes No If yes, specify: VITAL SIGNS: B/P: Pulse: Resp: Temperature:
Height: ft. in. Weight: lbs.
Blood Sugar:
Pain: Yes No Intensity (0-10 scale): Acceptable Level (0-10): Location of the pain: What relieves the pain: How do you know if the individual is in pain?
Texas Department of Aging & Form XXXX Disability Services October 2014
CLASS / DBMD NURSING ASSESSMENT Individual’s Name: _______________________________ Date: ______________________
RN: _____________________________________________________ Page 3 of 9
Neurological:
Alert & oriented to: Person Place Time
Memory Deficits: Yes No (if yes, please indicate what type of deficits): _________________________
____________________________________________________________________________________________
Pupil Reaction: Right Left Eyes Open: Right Left
Motor Movement:
Right Arm: Left Arm: Right Leg: Left Leg:
Paralysis: Yes No (If yes, location): _____________________ Syncope: Yes No
Vertigo: Yes No Tremors: Yes No
Seizures: Yes No (If yes, describe type, duration, & last seizure): _______________________________
Sensation: Intact Diminished/Absent (if marked, explain):__________________________________________
Sleep aids (other than prescription medicine): Yes No (if yes, please list):____________________________
Comments:
Eyes, Ears, Nose, & Throat:
Eyes/Vision:
Clear Red Right impaired vision Left impaired vision Adaptive aid
Ears:
Normal Ringing Right impaired hearing Left impaired hearing Adaptive aid
Nose/Smell: WNL
Smell: Intact Not intact Nose bleeds (if marked, how many/wk):___________ Frequent sinus congestion
Frequent sinus infections
Oral:
WNL Difficulty chewing Mouth pain Halitosis Dentures Edentulous Involuntary tongue movement
Throat:
WNL Throat pain Difficulty swallowing Tonsil enlargement History of choking
Thyroid enlargement
Swallow study: Yes No Date: _____________ Results: __________________________________
Comments:
Texas Department of Aging & Form XXXX Disability Services October 2014
CLASS / DBMD NURSING ASSESSMENT Individual’s Name: _______________________________ Date: ______________________
RN: _____________________________________________________ Page 4 of 9
Respiratory: Respirations: Regular Unlabored Irregular Labored
Breath sounds: Right ( Clear Rales Ronchi Wheezing Stridor) Left ( Clear Rales Ronc
Stridor) Shortness of breath: Yes No (if yes, indicate triggers): _____________________________
Respiratory treatments: None Oxygen Aerosol/Nebulizer CPAP/BIPAP Suctioning
Trach size____________
Comments:
Cardiovascular: History: N/A
Edema: Yes No Pitting: Yes No (if yes, indicate the following): 1+ 2+ 3+ 4+
Location of edema: __________________________________________________
Comments:
Gastrointestinal: Diet: Regular No added salt Diabetic/No concentrated sweets Mechanical soft Pu Other ______________ Supplements _____________________ Number of meals/day________________
Number of snacks/day________________________
Is there evidence of or a risk for malnutrition or dehydration? Yes No (if yes, explain) ________________
_________________________________________________________________________________________
Is any nutritional/fluid monitoring necessary? Yes No (if yes, describe type/frequency below)
Are assistive devices needed? Yes No (if yes, explain below)
Does the individual have a feeding tube (G-tube, Mic-key button, PEG tube, GJ tube, etc.)? Yes No (if yes,
please indicate the type of device used): _____________________________________________________________
Is there any leakage noted? Yes No (if yes, document in the comments if there is a skin barrier in place)
Mucous membranes: Moist Dry Skin turgor: Good Fair Poor
Nausea: Yes N
Bowel Sounds: Normoactive Hyperact
Last Bowel movement: _______________________ Ostomies: Yes N
(mark all that apply):
Incontinent Flatus Belching Laxatives Constipation Diarrhea (frequency): _________________
Comments:
Texas Department of Aging & Form XXXX Disability Services October 2014
CLASS / DBMD NURSING ASSESSMENT Individual’s Name: _______________________________ Date: ______________________
RN: _____________________________________________________ Page 5 of 9
Genitourinary: Bladder (mark all that apply): Normal Dribbling Incontinent Frequency Burning Nocturia Hematuria Stones Stoma Difficulty starting stream Retention Distension Catheter (if marked): type:______________ size:________________ last changed: ___________________ Dialysis (if marked): shunt bruit:___________ thrill:_____________ frequency:______________________ Comments: Skin: (Please ensure that you fill out Addendum A: Braden Scale for Predicting Sore Risk) Intact: Yes No (if no, a detailed assessment of the skin must be completed using Addendum B: Skin Assessment Tool) Normal Red Rash Irritation Abrasion Pink Cyanotic Pale Mottled Warm Cool Dry Diaphoretic Other (if marked explain in the comments section) Any skin conditions requiring treatment or monitoring? Yes No (if yes, describe condition & treatment) Comments: Functional Abilities: Activities of Daily Living (mark Independent, Needs Assistance, or Dependent for each activity listed). (If marked “Needs Assistance” or “Dependent” on administering own medications, you must refer to Addendum C: Medication Administration Delegation. If there are any additional activities that are marked as “Needs Assistance” or “Dependent”, you must refer to Addendum E: Delegation of Tasks &Addendum F: Verification of Competency/Delegation of Tasks).
ACTIVITY Independent Needs Assistance
Dependent RECOMMENDATIONS COMMENTS
Feeding Administering own meds
Ambulating Transfer Bed Transfer Toilet Transfer Tub Grooming Oral Hygiene Dressing Bathing Food Preparation
Manage Attendants
Manage Medication
Manage Finance
Access ER Services
Texas Department of Aging & Form XXXX Disability Services October 2014
CLASS / DBMD NURSING ASSESSMENT Individual’s Name: _______________________________ Date: ______________________
RN: _____________________________________________________ Page 6 of 9
Psychosocial: KEY: N = Never O = Occasional R = Regular C = Continuous N O R C Comments Receptive/Expressive
Aphasia
Wanders
Depressed
Anxious
Agitated
Disturbed Sleep (describe)
Resists Care
Disruptive Behavior
Impaired Judgment
Unsafe Behaviors
Hallucinations
Delusions
Aggression
Dangerous to Self or Others
(if response is anything other than never, explain)
Does the individual smoke?
(if response is anything other than never, explain)
Does anyone in the environment smoke?
(if response is anything other than never, explain)
Does the individual drink alcohol?
(if response is anything other than never, explain)
Does the individual use recreational drugs?
(if response is anything other than never, explain)
Texas Department of Aging & Form XXXX Disability Services October 2014
CLASS / DBMD NURSING ASSESSMENT Individual’s Name: _______________________________ Date: ______________________
RN: _____________________________________________________ Page 7 of 9
Safety / Restrictive Interventions:
Safety:
Is there an accessible emergency exit? Yes No
Can the individual access the emergency exit? Yes No (if no, explain) ___________________________
Is there a safety plan? Yes No (if no, explain) ___________________________
_____________________________________________________________________________________________
Protective Devices (PD)- DBMD only:
Does the individual have a medical condition that would indicate the need for the use of a protective device?
Yes No (if yes, you must fill out Addendum D: Protective Devices)
Restraint Risks- DBMD only:
Are there any risks associated with the use of restraints for this individual? Yes No (if yes, mark which risk
applies & provide details below) Age Height Weight Physical/Medical condition
Emotional condition (including history of abuse &/or trauma) Ability to communicate
Other: ______________________
Associated risks:_______________________________________________________________________________
Limitations based on risks: _______________________________________________________________________
Comments:
Texas Department of Aging & Form XXXX Disability Services October 2014
CLASS / DBMD NURSING ASSESSMENT Individual’s Name: _______________________________ Date: ______________________
RN: _____________________________________________________ Page 8 of 9
Level of Participation/Responsibility in Health Care Management (Must complete Option A, B, or C.) Option A: To be completed by the Individual:
I have participated in & accept responsibilities for decisions about the overall management of my health care [Texas
Administrative Code, Title 22, Part 11, Chapter 225, §225.1(a)(2)], can make all of my own decisions, am able to direct
my own health care.
_____________________________ ____________________________________ ____________________
Printed Name Signature Date
Option B: (If selected, ensure completion of Addendum C: Medication Administration Delegation & Addendum E: Delegation of Tasks) To be completed by the Individual:
I have participated in but do not accept responsibility for decisions about the overall management of my health
care. [§225.1(a)(2)]
_____________________________ ____________________________________ ____________________
Printed Name Signature Date
Option C: The individual uses the Consumer Directed Services option & elects to take responsibility for some nursing tasks as allowed under Texas Government Code §531.051 (e). _____________________________ ____________________________________ ____________________
Printed Name Signature Date
Texas Department of Aging & Form XXXX Disability Services October 2014
CLASS / DBMD NURSING ASSESSMENT Individual’s Name: _______________________________ Date: ______________________
RN: _____________________________________________________ Page 9 of 9
MEDICATIONS & TREATMENTS:
(You may attach signed prescriber’s orders as an alternative to completing this page.)
ALLERGIES (list all): _______________________________________________________________ List all medications & treatments, including PRN, OTC, herbal, & dietary supplements.
Medication/Treatment Name Dose Route Frequency Reason for giving
Related monitoring & testing (if any)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Have there been any recent changes in the medications? Yes No (if yes, please explain): _____________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________
Comments: ___________________________________________________________________________________ _____________________________________________________________________________________________
Texas Department of Aging and Form XXXX Disability Services August 2014
CLASS / DBMD NURSING ASSESSMENT ADDENDUMS
Individual’s Name:_______________________________ Date:______________
Addendum A: Braden Scale for Predicting Pressure Sore
Risk
Texas Department of Aging and Form XXXX Disability Services August 2014
CLASS / DBMD NURSING ASSESSMENT ADDENDUMS Individual Name:_______________________________
Addendum A: Braden Scale for Predicting Pressure Sore Risk Date of Assessment:
SENSORY PERCEPTION Ability to respond meaningfully to pressure related discomfort
1. Completely Limited Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation
OR limited ability to feel pain over most of body.
2. Very Limited Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness
OR has a sensory impairment which limits the ability to feel pain or discomfort over ½ of the body.
3. Slightly Limited Responds to verbal commands, but cannot always communicate discomfort or the need to be turned
OR Has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.
4. No Impairment Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.
MOISTURE Degree to which skin is exposed to moisture
1. Constantly Moist Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned
2. Very Moist Skin is often, but not always moist. Linen must be changed at least once a shift.
3. Occasionally Moist Skin is occasionally moist, requiring an extra linen change approximately once a day.
4. Rarely Moist Skin is usually dry, linen only requires changing at routine intervals
ACTIVITY Degree of physical activity
1. Bedfast Confined to bed
2. Chairfast Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair.
3. Walks Occasionally Walks occasionally during the day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.
4. Walks Frequently Walks outside room at least twice a day and inside room at least once every two hours during waking hours.
MOBILITY Ability to change and control body position
1. Completely Immobile Does not make even slight changes in body or extremity position without assistance
2. Very Limited Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.
3. Slightly Limited Makes frequent though slight changes in body or extremity position independently
4. No Limitation Makes major and frequent changes in position without assistance
NUTRITION Usual food intake pattern
1. Very Poor Never eats a complete meal. Rarely eats more than 1/3 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement
OR is NPO and/or maintained on clear liquids or IVs for more than 5 days.
2. Probably Inadequate Rarely eats a complete meal and generally eats only about ½ of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement
OR receives less than optimum amount of liquid diet or tube feeding.
3. Adequate Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) per day. Occasionally will refuse a meal, but will usually take a supplement when offered
OR is on a tube feeding or TPN regimen which probably meets most of nutritional needs.
4. Excellent Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.
FRICTION & SHEAR 1. Problem Requires moderate to maximum assistance in moving. Complete lifting without a sliding against sheets is impossible. Frequent slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures, or agitation leads to almost constant friction
2. Potential Problem Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.
3. No Apparent Problem Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair.
Recommendations:
Total Score:
© Copyright Barbara Braden and Nancy Bergstrom, 1988 All rights reserved
Texas Department of Aging and Form XXXX Disability Services August 2014
CLASS / DBMD NURSING ASSESSMENT ADDENDUMS
Individual’s Name:_______________________________ Date:______________
Page 1 of 15
Addendum B: Skin Assessment
Texas Department of Aging and Form XXXX Disability Services August 2014
CLASS / DBMD NURSING ASSESSMENT ADDENDUMS
Individual’s Name:_______________________________ Date:______________
Page 2 of 15
When assessing the wound, be sure to
Location: Anatomic site. Circle, identify right (R) or left (L) and use “X” to mark site on body diagrams:
_____Sacrum & Coccyx _____Lateral ankle _____Ischial tuberosity _____Trochanter _____Medial ankle _____Heel _____Other (describe)
Shape: Overall wound pattern; assess by observing perimeter and depth.
Circle the appropriate description:
_____Irregular _____Linear or elongated _____Square/rectangle _____Round/oval _____Bowl/boat _____Butterfly Measurement: indicate the measurement in cm. ___________length (cm) __________width (cm) ___________depth (cm)
Texas Department of Aging and Form XXXX Disability Services August 2014
CLASS / DBMD NURSING ASSESSMENT ADDENDUMS
Individual’s Name:_______________________________ Date:______________
Page 3 of 15
Exudate (indicate the appropriate finding with a check mark) Quantity Finding
Scant Small Moderate Large Copious
Type/Color Yellow Tan Purulent Sanguineous Serosanguinous Serous Green Gray
Odor Present Absent Foul Musty
Wound Bed (indicate the appropriate finding with a check mark) Color Finding
Red Pink White Gray Tan Brown Black
Tissue Bloody Pale Sloughing Necrotic Eschar Granular Weeping Healthy
Pain Finding Yes No
Texas Department of Aging and Form XXXX Disability Services August 2014
CLASS / DBMD NURSING ASSESSMENT ADDENDUMS
Individual’s Name:_______________________________ Date:______________
Page 4 of 15
Value 1 (Low) – 10 (High)
Wound Margins (indicate the appropriate finding with a check mark) Finding Finding Edematous Clean Calloused Intact Macerated Jagged
Surrounding Tissue (indicate the appropriate finding with a check mark) Finding Finding Pink Cool White Blanched Red Shiny Pale Edematous Warm Recommendations: ______________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Texas Department of Aging and Form XXXX Disability Services August 2014
CLASS / DBMD NURSING ASSESSMENT ADDENDUMS
Individual’s Name:_______________________________ Date:______________
Page 5 of 15
Addendum C: Medication Administration Delegation
Texas Department of Aging and Form XXXX Disability Services August 2014
CLASS / DBMD NURSING ASSESSMENT ADDENDUMS
Individual’s Name:_______________________________ Date:______________
Page 6 of 15
MEDICATIONS: Safe Administration of Medications: Level of Participation/Responsibility for Medication Administration (Must complete Option A, B, C or D.) Option A: To be completed by the Individual/LAR:
I will participate in and accept responsibility for self-directing the administration of my medications
[Texas Administrative Code, Title 22, Part 11, Chapter 225, §225.1(a)(3).
____________________________ ________________________________ ____________________
Printed Name Signature Date
Option B: To be completed by the Individual/LAR:
I will participate in but do not accept responsibility for self-directing the administration of my
medications. [§225.1(a)(2)]. I direct administration of my medication to a unlicensed person (s) to
ensure that medications are received safely.
Name of Individual: _______________________________________________________________ Relationship to Individual: _________________________________________________________ _____________________________ __________________________ ____________________
Printed Name Signature Date
Option C: The individual directs the RN to delegate medication administration to unlicensed personnel to ensure safe medication administration. _____________________________ __________________________ ____________________
Printed Name Signature Date
Option D: The individual uses the CDS option & elects to take responsibility for some nursing tasks as
Texas Department of Aging and Form XXXX Disability Services August 2014
CLASS / DBMD NURSING ASSESSMENT ADDENDUMS
Individual’s Name:_______________________________ Date:______________
Page 7 of 15
allowed under Texas Government Code §531.051 (e). _____________________________ __________________________ ____________________
Printed Name Signature Date
Skip this box if you are not the Delegating Nurse
Has a 3-way mark (orders, medications, and Medication Administration Record) been conducted for all of
the individual’s medications & treatments, including Over The Counter and PRNs? Yes if no,
explain below)
Were any discrepancies identified? Yes No (if yes, explain below)
Are medications stored appropriately? Yes No (if no, explain below)
Has the caregiver been instructed on monitoring for drug therapy effectiveness, side effects, and drug
reactions, including how and when to report problems that may occur? Yes
Have arrangements been made to obtain ordered labs? Yes No (explain b
Is the resident taking any high risk drugs? Yes No (if yes, explain below)
For all high risk medications (such as hypoglycemics, anticoagulants, etc.), has the caregiver received
instructions on special precautions, including how & when to report problems that may occur?
No (explain below) N/A
Is the environment safe for the individual? Yes No (explain below)
(Adequate lighting, open traffic areas, non-skid rugs, appropriate furniture, & assistive devices.)
Comments: ________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Delegating Nurse Signature: _____________________________________Date: ____________
Print Name and Title: _______________________________________________
Texas Department of Aging and Form XXXX Disability Services August 2014
CLASS / DBMD NURSING ASSESSMENT ADDENDUMS
Individual’s Name:_______________________________ Date:______________
Page 8 of 15
Addendum D: Protective Devices (DBMD Only)
Texas Department of Aging and Form XXXX Disability Services August 2014
CLASS / DBMD NURSING ASSESSMENT ADDENDUMS
Individual’s Name:_______________________________ Date:______________
Page 9 of 15
What is the medical condition that necessitates a protective device (PD)?
______________________________________________________________________________
What type of PD is being used? ____________________________________________________
______________________________________________________________________________
Under which circumstances will the PD be used for the individual (where, when, etc.)?
_____________________________________________________________________________
How is the PD to be used? _____________________________________________________
______________________________________________________________________________
Are there any contraindications to the use of the PD? Yes No (if yes,
explain):______________________________________________________________________
How and when should the use of a PD be documented for this individual?
______________________________________________________________________________
How should the use of the PD be monitored? (based on manufacturers recommendations,
specific to the individual, and based on nursing judgment)
______________________________________________________________________________
When and whom must the program staff notify of the use of the PD: (mark all that apply)?
RN Physician
Other: ____________________________________
First time PD is used Change in status Weekly Monthly Quarterly
Biannually Annually Other: ____________________________________
Texas Department of Aging and Form XXXX Disability Services August 2014
CLASS / DBMD NURSING ASSESSMENT ADDENDUMS
Individual’s Name:_______________________________ Date:______________
Page 10 of 15
Annual/Periodic Evaluation of Effects of PD on Health and Welfare
Is there a current need for continued use of the PD? Yes No (if yes, explain): __________
______________________________________________________________________________
______________________________________________________________________________
Is the device contributing to the overall health and well-being of the individual? Yes No (if
no, explain): ___________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Texas Department of Aging and Form XXXX Disability Services August 2014
CLASS / DBMD NURSING ASSESSMENT ADDENDUMS
Individual’s Name:_______________________________ Date:______________
Page 11 of 15
Protective Device Usage Log (DBMD only) Date Device Used Need indicated Status of Device Use
(mark all that apply) Location of
device Signature
In place upon arrival Initiated at (time)___________ Discontinued at (time)____________ Improperly placed (if marked, explain): _____________________ Not in proper working order (broken, missing parts, torn, etc.) Continued past shift
In place upon arrival Initiated at ___________ Discontinued at ____________ Improperly placed (if marked, explain): _____________________ Not in proper working order (broken, missing parts, torn, etc.) Continued past shift
In place upon arrival Initiated at ___________ Discontinued at ____________ Improperly placed (if marked, explain): _____________________ Not in proper working order (broken, missing parts, torn, etc.) Continued past shift
In place upon arrival Initiated at ___________ Discontinued at ____________ Improperly placed (if marked, explain): _____________________ Not in proper working order (broken, missing parts, torn, etc.) Continued past shift
Texas Department of Aging and Form XXXX Disability Services August 2014
CLASS / DBMD NURSING ASSESSMENT ADDENDUMS
Individual’s Name:_______________________________ Date:______________
Page 12 of 15
Addendum E: Delegation of Tasks
Texas Department of Aging and Form XXXX Disability Services August 2014
CLASS / DBMD NURSING ASSESSMENT ADDENDUMS
Individual’s Name:_______________________________ Date:______________
Page 13 of 15
-If a task falls under 22 TAC §225.10, you (the RN) must indicate delegation of the task to the Unlicensed Assistive Personnel. -Any task that is delegated or competency verified, documentation of training/education must be indicated on Appendix E.
Delegation of Tasks
Employee Signature Task Competency or
Delegation (mark one)
Date: (verified competent
or delegated)
Delegated by (RN’s Signature)
Competency Verified Delegated
Competency Verified Delegated
Competency Verified Delegated
Competency Verified Delegated
Competency Verified Delegated
Competency Verified Delegated
Competency Verified Delegated
Texas Department of Aging and Form XXXX Disability Services August 2014
CLASS / DBMD NURSING ASSESSMENT ADDENDUMS
Individual’s Name:_______________________________ Date:______________
Page 14 of 15
Addendum F: Verification of Competency/Delegation of Tasks
Texas Department of Aging and Form XXXX Disability Services August 2014
CLASS / DBMD NURSING ASSESSMENT ADDENDUMS
Individual’s Name:_______________________________ Date:______________
Page 15 of 15
Task Description of Teachings RN Method of Verification of Competency/Training Verbal recall
Return demonstration Evaluation of skill performed on individual Question and answer about task
Verbal recall Return Demonstration Evaluation of skill performed on individual Question and answer about task
Verbal recall Return Demonstration Evaluation of skill performed on individual Question and answer about task
Verbal recall Return Demonstration Evaluation of skill performed on individual Question and answer about task
Verbal recall Return Demonstration Evaluation of skill performed on individual Question and answer about task
Verbal recall Return Demonstration Evaluation of skill performed on individual Question and answer about task
Verbal recall Return Demonstration Evaluation of skill performed on individual Question and answer about task
Page 1 of 17
NURSING ASSESSMENT INSTRUCTIONS
ACRONYMS/ABREVIATIONS
LAR-Legally Authorized Representative
RN-Registered Nurse
PPD-Purified Protein Derivative
MM-Millimeter
B/P-Blood Pressure
Resp.- Respirations
Wk- week
Trach-tracheostomy
FT.-Feet
IN.-Inches
LBS.-Pounds
WNL-Within Normal Limits
CPAP- Continuous Positive Airway Pressure
BIPAP- Biphasic positive airway pressure
G-TUBE- Gastrostomy Tube
MIC-KEY BUTTON-specific type of gastrostomy tube
PEG TUBE-Percutaneous endoscopic gastrostomy
GJ TUBE- gastrojejunostomy tube
RUQ-Right Upper Quadrant
RLQ-Right Lower Quadrant
LUQ-Left Upper Quadrant
LLQ-Left Lower Quadrant
ER-Emergency Response
Page 2 of 17
PRN- Pro Re Nata- Latin term meaning as the circumstance arises
OTC-Over the Counter
PURPOSE:
This form provides the guide for a comprehensive nursing assessment for individuals in the Community Living and Support Services (CLASS) and Deaf Blind with Multiple Disabilities (DBMD) waiver programs. The form is intended to provide a complete picture of the individual’s needs from a nursing perspective as well as providing integral information for the justification of CLASS and DBMD program services.
PROCEDURE:
See nursing procedures for timing and detailed information specific to each program for the nursing staff.
Prior to completion of the nursing assessment, review the entire document for the information it provides. While completing the assessment keep in mind that the Individual Program Plan (IPP), IPC, and the Habilitation Plan are often justified by the needs identified in the nursing assessment.
WHEN TO PREPARE:
• Enrollment in the CLASS/DBMD Program –
For CLASS, the nursing assessment should be completed and submitted to the Department of Aging and Disability Services (DADS) in conjunction with the Adaptive Behavior Level (ABL) Assessment and Form 8578 Intellectual Disability/Related Condition Assessment (ID/RC).
For DBMD, the nursing assessment can be completed separate from the ABL Assessment and the ID/RC, but all three documents are submitted with the rest of the Enrollment Packet.
• Reassessment –
For CLASS, the nursing assessment must be completed in conjunction with the ABL Assessment and the ID/RC on an annual basis.
For DBMD, the nursing assessment can be completed separate from the ABL Assessment and the ID/RC, but all three documents are submitted with the rest of the Renewal Packet.
Page 3 of 17
• Post-Hospitalization –
For CLASS, a nursing assessment must be completed within 48 hours of discharge unless a physician specifies in writing that no changes to the Individual Plan of Care (IPC) are required.
Individual Name- Provide the Individual’s name as it appears on the IPC form, at the top of each page of the nursing assessment. This is important in case the pages were to be separated inadvertently.
RN- Print the name of the Registered Nurse who completed the assessment at the bottom of each page.
Assessment Date/Time- Document the date and time that the nursing assessment was conducted in the space provided and at the top of each subsequent page.
Date of Birth- Document the Individual’s Date of Birth
Mark the appropriate box to indicate the individual’s sex: male or female.
Legal Status- Mark the appropriate box to indicate if the individual has a legally authorized representative (LAR): yes, no, or not applicable (N/A). If yes, indicate the type of legally authorized representative:
• N/A- the individual is over 18 and is their own guardian. • Parent of a minor- the individual is under 18 and their parents have legal authority over
their decisions. • Court Appointed Guardian- the individual is an adult, but there is another adult who has
legal guardianship over that individual’s decisions. • Power of Attorney- the individual is an adult, but another adult has power of attorney
over some or all of the individual’s decisions. Indicate what type(s) of Power of Attorney the person has.
• Other- describe the type of legally authorized representative the individual has.
If the individual is not their own guardian, print the name of the LAR. Ensure any person making decisions and signing on behalf of the individual has documentation verifying their legal ability to do so.
History Received from- Document the primary informant for this nursing assessment.
Page 4 of 17
Reason for Assessment- Indicate the reason for conducting this assessment by marking the appropriate box: initial assessment, annual reassessment, post hospitalization, protective devices (DBMD only), or other (specify in the space provided).
Living Arrangements –Program staff cannot dictate specific levels of home repair, maintenance, or cleanliness, unless it potentially qualifies as abuse or neglect. Information regarding the reporting of those issues is included. Examples: Case Management staff can offer to assist an individual in finding safer housing; home modifications can be planned to meet access needs; additional attendant care can be provided to assist with cleanliness in areas that the individual uses; attendant care can be supplied to meet health and safety supervision needs.
Mark the appropriate box to indicate if the individual lives in their own home/family home or an assisted living facility. If assisted living facility is marked, indicate if the individual lives in a 1-3 bed home or a 4-6 bed home.
Number in Household- Fill in the box with the number of people living in the individual’s household.
Primary Support Provider- Document the primary support person for the individual. This could be a paid staff or a natural support.
Home Conditions- Mark the appropriate box to indicate if the home is clean or unclean.
Safety- Mark the appropriate box to indicate if the individual’s living arrangement is safe on a scale of good, fair, or poor.
Hygiene- Mark the appropriate box to indicate if the hygiene of the individual’s living arrangement is good, fair, or poor.
Comments- Provide any other related comments to the individual’s living arrangements.
Communication – Communication needs must be facilitated and addressed if assistance is needed.
Mark the appropriate box to indicate how the individual communicates. Mark all that apply.
Comments- Provide any other related comments to the individual’s communication.
Immunizations – Program staff can work with the family to assure that the individual receives appropriate medical care. For this program and this document, program staff only collects the information regarding an individual’s immunization status but make no judgment on the decision to vaccinate or not vaccinate.
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Mark the appropriate box to indicate if the individual is up to date on all immunizations: yes, no, or N/A. Immunization status should be based off the recommended yearly schedule available through the Centers for Disease Control and Prevention (CDC).
Mark the appropriate box to indicate if the individual has ever received blood/blood products: yes or no.
Adverse reactions- Fill in the box with information regarding any adverse reactions the individual has had to either immunizations or the receipt of blood or blood products.
Comments- Provide any other related comments to this area.
Allergies – Allergies should be known to the attendant care staff to avoid exposure to potential allergens. Allergies to medications should be noted in the individual’s information sheet in case of emergency hospitalization.
Document any known allergies the individual has, including drug, food, and environmental. If none are known, indicate that in the box as well.
Current Medical and Mental Health Diagnoses/Dates Diagnosed: Document the individual’s medical and mental health diagnoses (as identified by a professional with the authority to diagnose) along with the dates of the diagnoses.
Previous Medical, Surgical, and Mental Health History/ Dates: Medical and surgical history identifies potential problems in the provision of care, e.g. Harrington Rod surgery means that the back cannot be bent where the rods were placed. The attendant care staff should be made aware of the limitation of movement.
Document the individual’s medical, surgical, and mental health history including information such as medical treatments, surgeries, hospitalizations, mental health treatments, and the dates of each occurrence.
Airborne Communicable Disease- Document if the individual has been tested for Tuberculosis (TB), the type of test used (Purified Protein Derivative (PPD) skin test or Chest X-Ray) and provide the date of the test as well as the results, OR, mark not applicable.
Mark the appropriate box to indicate if the individual has any active reportable communicable disease: yes or no. If yes, please specify the type of communicable disease in the space provided.
Vital Signs- Provide in the corresponding blank the individuals Blood Pressure (B/P); Pulse; Respiratory Rate; Temperature; Height in feet and inches; Weight in pounds (lbs); and Blood Sugar level.
Pain- Mark the appropriate box to indicate if the individual is in pain: yes or no.
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If yes, document in the space provided the current intensity of the pain on a scale from 0-10 and document the acceptable level of pain for that individual on a scale of 0-10.
Document in the space provided the location of the pain; what relieves the pain; and how you know the individual is in pain.
Neurological- Special needs for supervision or assistance are identified in this segment.
Mark the appropriate box to indicate if the individual is alert and oriented to: person, place, and time. Mark all that apply.
Mark the appropriate box to indicate if the individual has memory deficits: yes or no. If yes, indicate the type of deficits in the space provided.
Mark each box to indicate if the individual has a pupil reaction in the right and left eye.
Mark each box to indicate if the individual’s eye is open: right eye, left eye or mark both.
Mark each box to indicate if the individual has motor movement in the right arm, left arm, right leg, and left leg.
Mark the appropriate box, yes or no, to indicate if the individual has:
• Paralysis (If yes is marked, provide the location of the paralysis in the space provided) • Syncope • Vertigo • Tremors • Seizures
Mark the appropriate box to indicate the individual’s ability to experience sensation: intact, diminished/absent. If diminished/intact is marked, explain in the space provided.
Mark the appropriate box, yes or no, to indicate if the individual uses sleep aids other than prescription medicine. If yes is marked, please explain. Please note that prescription sleep aids should be noted under medications.
Comments- Provide any comments related to the questions in this section or the individual’s neurological status.
Eyes, Ears, Nose & Throat
Eyes/Vision- Mark the appropriate box to indicate the status of the individual’s eyes and vision: clear, red, right impaired vision, left impaired vision, adaptive aid. If an individual has a diagnosis, such as cortical blindness where the actual eye is not affected but the result is impaired vision, indicate the impairment here. If an individual requires an adaptive aid for their eyes or vision, mark adaptive aid.
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Ears- Mark the appropriate box to indicate the status of the individual’s ears and hearing: normal, ringing, right impaired hearing, left impaired hearing, adaptive aid. If an individual has a diagnosis which involves the individual’s brain’s auditory processing, where the actual ear is not affected but the result is hearing impairment, indicate the impairment here. If an individual requires an adaptive aid for their ears or hearing, mark adaptive aid.
Nose/Smell- Mark the appropriate box to indicate the status of the individual’s nose/smell: within normal limits (WNL), intact, not intact, nose bleeds (if marked note how many per week in the space provided), frequent sinus congestion, frequent sinus infections.
Oral- Mark the appropriate box to indicate the individual’s oral status: within normal limits (WNL), difficulty chewing, mouth pain, halitosis, dentures, edentulous, involuntary tongue movement.
Throat- Mark the appropriate box to indicate the status of the individual’s throat: within normal limits (WNL), throat pain, difficulty swallowing, tonsil enlargement, history of choking, thyroid enlargement.
Mark the appropriate box to indicate if the individual has completed a swallow study: yes or no. If yes, provide the date and the results of the study in the space provided.
Comments- Provide any comments related to the questions in this section or the individual’s eyes, ears, nose, and throat.
Respiratory – Respiratory function is a life or death issue. The nurse should also identify needs as applicable to service delivery and follow up with Nursing Needs/Delegation Activities as needed.
Mark the appropriate box to indicate the status of the individual’s respirations: regular, unlabored, irregular, labored.
Mark the appropriate box to indicate the status of the individual’s breath sounds: right side (clear, rales, ronchi, wheezing, stridor), left side (clear, rales, ronchi, wheezing, stridor).
Mark the appropriate box to indicate if the individual experiences shortness of breath: yes or no. If yes, indicate the triggers.
Mark the appropriate box to indicate if the individual receives respiratory treatments: none, oxygen, aerosol/nebulizer, Continuous Positive Airway Pressure (CPAP)/ Biphasic positive airway pressure (BIPAP), suctioning, tracheostomy (if marked, document the size in the space provided).
Comments- Provide any comments related to the questions in this section or the individual’s respiratory system.
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Cardiovascular– Mark the appropriate box to indicate the individual’s cardiovascular health history: not applicable, arrhythmia, hypertension, hypotension, dizziness.
Mark the appropriate box to indicate the status of the individual’s pulse: regular, irregular.
Mark the appropriate box to indicate if the individual has edema: yes or no.
Mark the appropriate box to indicate if the individual has pitting: yes or no (if yes, indicate the following by marking the box: +1-mild, +2-moderate,+3-deep or +4-very deep).
Document in the space provided the location of the individual’s edema.
Comments- Provide any comments related to the questions in this section or the individual’s cardiovascular health.
Gastrointestinal- This section should identify areas of need or awareness for eating/feeding. Any special needs such as tube feeding or choking problems are identified here and the nurse should follow up with Nursing Needs/Delegation Activities as needed.
Mark the appropriate box to indicate the individual’s diet requirements: regular, no added salt, diabetic/no concentrated sweets, mechanical soft, pureed.
Mark the box and fill in the space provided if there are any other considerations not listed.
Mark the box and fill in the space provided if the individual takes any supplements.
Fill in the space provided with the number of meals a day the individual consumes.
Fill in the space provided with the number of snacks a day the individual consumes.
Mark the appropriate box to indicate if there is evidence of a risk for malnutrition or dehydrations: yes or no (if yes, explain in the blank provided).
Mark the appropriate box to indicate if there is any nutritional or fluid monitoring necessary: yes or no (if yes, describe the type/frequency in the comments space below).
Mark the appropriate box to indicate if any assistive devices are needed in relation to gastrointestinal needs: yes or no (if yes, explain in the comments space below).
Mark the appropriate box to indicate if the individual has a feeding tube (G-tube, Mic-key button, PEG tube, GJ tube, etc.): yes or no (if yes indicate the type in the space provided).
Mark the appropriate box to indicate if there is any leakage noted for the feeding tube: yes or no (if yes, document in the comments section if there is a skin barrier in place).
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Mark the appropriate box to indicate the status of the individual’s mucous membranes: moist, dry skin.
Mark the appropriate box to indicate the turgor of the individual’s skin: good, fair, poor.
Mark the appropriate box to indicate if this individual is experiencing nausea: yes or no (if yes, note the onset in the space provided).
Mark the appropriate box to indicate if the individual experiences vomiting: yes or no (if yes, note the onset in the space provided).
Mark the appropriate box to indicate the individual’s current bowel sounds and the location: normoactive, hyperactive, hypoactive, right upper quadrant (RUQ), right lower quadrant (RLQ), left upper quadrant (LUQ), left lower quadrant (LLQ).
Document the individual’s last bowel movement in the space provided.
Mark the appropriate box to indicate if the individual has any ostomies: yes or no (if yes, document where in the space provided).
Mark the appropriate box to indicate gastrointestinal concerns or issues for that individual: incontinent, flatus, belching, laxatives, constipation, diarrhea. Mark all that apply.
Comments- Provide any comments related to the questions in this section or the individual’s gastrointestinal health.
Genitourinary – The nurse should identify special needs that will affect the individual’s care.
Mark the appropriate box to indicate the status of the individual’s bladder: normal dribbling, incontinent, frequency, burning, nocturia, hematuria, stones, stoma, difficulty starting stream, retention, distention. Mark all that apply.
Mark the box if this individual has a catheter and document the type, size and last time it was changed in the spaces provided. If the individual does not have a catheter, leave these blank.
Mark the box if this individual has dialysis and document the shunt bruit, thrill, and frequency in the spaces provided. If the individual does not have dialysis, leave these blank.
Comments- Provide any comments related to the questions in this section or the individual’s genitourinary health.
Skin – The nurse should identify any special needs and follow up with Nursing Needs/Delegation Activities as needed.
Fill out Addendum A: Braden Scale for Predicting Sore Risk- REQUIRED FOR ALL INDIVIDUALS.
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Mark the appropriate box to indicate if the individual’s skin is intact: yes or no (if no, a detailed assessment of the skins must be completed using Addendum B: Skin Assessment Tool).
Mark the appropriate box to indicate the status of the individual’s skin: normal, red, rash, irritation, abrasion, pink, cyanotic, pale, mottled, warm, cool, dry, diaphoretic, other (if other is marked, explain in the space provided for comments within this section). Mark all that apply.
Mark the appropriate box to indicate if the individual has any skin conditions that require treatment or monitoring: yes or no (if yes, describe the condition and the treatment).
Comments- Provide any comments related to the questions in this section or the individual’s skin.
Functional Abilities- Abilities assessment identifies specific areas of need that should be addressed in the IPP and IPC.
Activities of Daily Living - Mark independent, needs assistance, or dependent for each activity listed (see the scale below). If marked “needs assistance” or “dependent on Administering own medications”, you must complete Addendum C: Medication Administration Delegation. If there are any additional activities that are marked as “needs assistance” or “dependent”, you must complete Addendum E: Delegation of Tasks and Addendum F: Verification of Competency/Delegation of Tasks. Provide any recommendations or comments regarding the individual’s ability to perform each activity of daily living in the spaces provided.
• Independent- The individual does not require any hands on assistance to complete the task. If the individual can do the task, but requires prompting or reminders, indicate that in the comments section.
• Needs assistance- The individual can complete some parts of the task but cannot complete the entire task without assistance. If the individual needs assistance, but can self-direct the task, indicate that in the comments section.
• Dependent- The individual cannot complete any part of the task independently. If the individual is dependent on others to do the task, but can self-direct it, indicate that in the comments section.
Psychosocial – Program staff cannot dictate an individual’s preferences or lifestyles. Knowledge of those lifestyles can assist the team in planning attendant care and respond to crisis situations by planning in advance.
Mark the appropriate box to indicate if the individual displays the attributes listed in the chart (aphasia, wanders, depressed, anxious, agitated, disturbed sleep (explain), resists care, disruptive behavior, impaired judgment, unsafe behaviors, hallucinations, delusions, aggression, dangerous to self or others, smoking, drinking alcohol, using recreational drugs):
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never, occasional, regular, continuous. If the answer is anything other than never for the last four attributes, explain in the space provided for comments. Provide any additional information related to each attribute in the space provided for comments as well.
Safety– The nurse should identify special safety needs. The IPP and IPC should incorporate these needs. The team must pay close attention to safety needs and have a plan to meet them.
Mark the appropriate box to indicate if there an accessible emergency exit: yes or no (if no, explain in the space provided).
Mark the appropriate box to indicate if the individual can access the emergency exit: yes or no (if no, explain in the space provided).
Mark the appropriate box to indicate if there is a safety plan in place: yes or (if no, explain in the space provided).
Protective Devices (DBMD only)- Refer to program rules for additional information regarding Protective Devices.
Mark the appropriate box to indicate if the individual has a medical condition that would indicate the need for the use of a protective device: yes or no. (If yes, you must fill out Addendum D: Protective Devices.
Restraint Risks (DBMD only)- Refer to program rules for additional information regarding Restraints.
Mark the appropriate box to indicate if there are any risks associated with the use of restraints for this individual: yes or no (if yes, mark the appropriate box below to indicate which restraint risk(s) apply to the individual).
• Age • Height • Weight • Physical/Medical condition e.g., a Harrington Rod • Emotional condition- e.g., including a history of abuse or emotional trauma • Ability to communicate- example, if an individual uses American Sign Language, you
cannot restrain their hands because it would prevent them from being able to communicate.
• Other- Document any other risks associated with restraining this individual.
Associated Risks- Describe in detail how the risk identified above is contraindicated for the use of restraints.
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Limitations based on Risks- Describe in detail the limitations to restraint use as a result of the risks indicated above.
Comments- Provide any additional comments related to Restraint Risks or the questions in this section.
Level of Participation/Responsibility in Health Care Management
Indicate the individual’s level of participation and accepted responsibility in their health care management by marking in the most appropriate box (Option A, Option B or Option C), printing their name, signing, and dating.
Option A- I have participated in and accept responsibilities for decisions about the overall management of my health care [Texas Administrative Code, Title 22, Part 11, Chapter 225, §225.1(a)(2)], can make all of my own decisions, and am able to direct my own health care.
Option B- I have participated in, but do not accept responsibility for, decisions about the overall management of my health care. [§225.1(a)(2)]
Option C- The individual uses the Consumer Directed Services option and elects to take responsibility for some nursing tasks as allowed under Texas Government Code §531.051 (e).
Medications and Treatments
Prescriber’s signed orders- Attached signed prescriber’s order as an alternative to completing this page, if desired/applicable.
Allergies- List all allergies the individual has.
Medication/Treatment Name, Dose, Route, Frequency, Reason for giving, Related monitoring and testing (if any)- Complete all areas of the chart for each medication or treatment the individual is receiving. If additional space is needed, multiple copies of this page can be printed and attached. Include medications taken as needed (PRN), over the counter (OTC), herbal or dietary supplements.
Have there been any recent changes in the medications—Document any recent changes to the individual’s medications and treatments, if applicable.
Comments- Provide any comments related to the individual’s medications and treatments in the space provided.
ADDENDUM A: BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK
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This addendum must be completed as a part of all comprehensive nursing assessments to determine if the individual has a risk for pressure sores.
Document the individual’s name at the top of the page.
Instructions- Use the Braden Scale to assess the patient’s level of risk for development of pressure ulcers. The evaluation is based on six indicators: sensory perception, moisture, activity, mobility, nutrition, and friction or shear. Scoring- The Braden Scale is a summated rating scale made up of six subscales scored from 1-3 or 4, for total scores that range from 6-23. A lower Braden Scale Score indicates a lower level of functioning and, therefore, a higher level of risk for pressure ulcer development. A score of 19 or higher, for instance, would indicate that the patient is at low risk, with no need for treatment at this time. The assessment can also be used to evaluate the course of a particular treatment.
Provide any recommendations as a result of the findings of the Braden Scale.
ADDENDUM B: SKIN ASSESSMENT TOOL
This addendum must be completed if any part of the skin is identified as not intact in the skin assessment.
Follow the instructions within the tool to assess wound status.
Identify the location of the wound(s) by circling the written location and indicating right (R) or left (L) in the space next to the word. Then mark on the body diagram with an “X”.
Described the shape of the wound(s) by circling the written description and indicating right (R) or left (L) in the space next to the word.
Indicate the length, width and depth of the wound in the space provided.
Evaluate each item:
• Exudate (quantity, type/color, odor) • Wound Bed (color, tissue, pain) • Wound Margins • Surrounding Tissue
Mark the descriptors that apply to the wound in the chart next to the descriptor.
Provide any recommendations as a result of the findings of the Skin Assessment Tool.
ADDENDUM C: MEDICATION ADMINISTRATION DELEGATION
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This addendum must be completed if “Needs Assistance” or “Dependent” is indicated for administering own medications in the Functional Abilities: Activities of Daily Living section of the nursing assessment.
Level of Participation/Responsibility for Medication Administration
Indicate the individual’s level of participation and accepted responsibility in their medication administration by marking in the most appropriate box (Option A, Option B, Option C, or Option D), printing their name, signing and dating.
Option A- I will participate in and accept responsibility for, self-directing the administration of my medications [Texas Administrative Code, Title 22, Part 11, Chapter 225, §225.1(a)(3).
Option B- I will participate in, but do not accept responsibility for, self-directing the administration of my medications. [§225.1(a)(2)]. I direct administration of my medication to (an) unlicensed person(s) to ensure that medications are received safely.
Option C- The individual directs the RN to delegate medication administration to unlicensed personnel to ensure safe medication administration.
Option D- The individual uses the CDS option and elects to take responsibility for some nursing tasks as allowed under Texas Government Code §531.051 (e).
If you are the delegating nurse, complete the following questions:
Mark the appropriate box to indicate if a 3-way check (orders, medications, Medication Administration Record (MAR)) has been conducted for all the individual’s medications and treatments, including OTCs and PRNs: yes or no (if no, explain in the comments section below).
Mark the appropriate box to indicate if any discrepancies were identified during the 3-way check: yes or no (if yes, explain in the comments section below).
Mark the appropriate box to indicate if the medications are stored properly: yes or no (if no, explain in the comments section below).
Mark the appropriate box to indicate if the caregiver has been instructed on monitoring for drug therapy effectiveness, side effects, and drug reactions, including how and when to report problems that may occur: yes or no. Explain if needed in the comments section below.
Mark the appropriate box to indicate if arrangements have been made to order labs: yes or no. Explain if needed in the comments section below.
Mark the appropriate box to indicate if the individual is taking any high risk drugs: yes or no (if yes, explain in the comments section below).
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Mark the appropriate box to indicate if the caregiver has received instructions on special precautions, including how and when to report problems that may occur for all high risk medications: yes, no or N/A. Explain if needed in the comments space below.
Mark the appropriate box to indicate if the environment is safe for the individual (adequate lighting, open traffic areas, non-skid rugs, appropriate furniture, assistive devices, etc.): yes or no. Explain if needed in the comments section below.
Comments- Provide any comments related to the individual’s level of participation/responsibility for medication administration in the space provided.
Delegating Nurse Signature- The nurse who is responsible for delegating medication administration must sign, date, and print their name and title in the space provided.
ADDENDUM D: PROTECTIVE DEVICES (DBMD only)
Have the RN complete the assessment regarding protective devices:
Document the medical condition that necessitates use of a protective device (PD)?
Document the type of PD is being used?
Under which circumstances will the PD be used for the individual (where, when, etc.)?
How is the PD to be used?
Mark the appropriate box to indicate if there are any contraindications to the use of the PD: yes or no (if yes, explain).
How and when should the use of a PD be documented for this individual?
How should the use of the PD be monitored? (e.g., based on manufacturers recommendations, specific to the individual, and based on nursing judgment, etc.)
Mark the appropriate box to indicate when (first time PD is used, change in status, weekly, monthly, quarterly, biannually ,annually, other (specify)) and whom (RN, physician, other (specify)) the program staff must notify of the use of the PD. Mark all that apply.
Annual Periodic Evaluation of Effects of PD on Health and Welfare
Mark the appropriate box to indicate if there is a current need for continued use of the PD: yes or no. (If yes, explain in the space provided).
Mark the appropriate box to indicate if the device is contributing to the overall health and well-being of the individual: yes or no (if no, explain in the space provided).
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Protective Device Usage Log (DBMD only)
The protective device usage log is a tool for service providers to document the use of the protective device based on the recommendations of the RN. The appropriate professional as identified by the RN should monitor the log according to the schedule identified by the RN.
Document the following information in the chart:
Date- Date the PD is used
Device used- Type of PD used
Need indicated- What is the need for the PD?
Mark the appropriate box to indicate the status of the device use: in place upon arrival, initiated (provide time), discontinued (provide time), improperly placed (if marked, explain), not in proper working order (e.g., broken, missing parts, torn, etc.), continued past shift. Mark all that apply.
Location of device- Location of the PD on the body
Signature- Sign name (and print title, if applicable).
ADDENDUM E: DELEGATION OF TASKS
This addendum must be completed for tasks which fall under 22 TAC §225.10, which will be completed by unlicensed assistive personnel or for any other tasks the RN determines must be delegated. The nurse should always comply with the delegation guidelines provided by the Board of Nursing Texas Administrative Code. This chart is a tool for proper documentation of delegated tasks training.
Document the following information in the chart:
• Signature of the employee who will be responsible for completing the task. • Task to be delegated. (Mark the box to indicate that the employee’s competency has
been verified and that the task has been delegated.) • Date that the competency has been verified and that the task has been delegated. • Signature of the RN who delegated the task.
ADDENDUM F: VERFICATION OF COMPETENCY/DELEGATION OF TASKS
This addendum must be completed for tasks which fall under 22 TAC §225.10 which will be completed by unlicensed assistive personnel or for any other tasks the RN determines must be delegated. The nurse should always comply with the delegation guidelines provided by the
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Board of Nursing Texas Administrative Code. This chart is a tool for proper documentation of delegated tasks training.
Document the following information in the chart:
• Task to be delegated. • Description of teachings regarding the delegated task. (Mark the appropriate box to
indicate the RN’s method of verifying competency/training: verbal recall, return demonstration, evaluation of skill performed on individual, question and answer about task). Mark all that apply.