Case Manager
Please Select
CM: Lori Campbell
CM: Tiffany Morman
CM: Erin Fetterman
CM: Shanice Rodgers
CM: Amber Graham
CM: Francesco Agresta
CM: April Feague
CM: Marc Belote
CM: Ronisha Parker
CM: Saybah Tenny
CM: Izena Trujillo
AIDS Delaware Case Management Services
340B Nursing Assessment
Client Name
DOB
1. General Survey
Weakness
Fatigue
Fevers
Night Sweats
Recent Hospitalizations
Nutrition: Diet & Supplements
Nutrition: Appetite
Nutrition: Tolerance
Height
Weight
Date Weighed
/
Month
/
Day
Year
Weight Changes
Psychosocial: Living Arrangement
Psychosocial: Support System/Caregiver
Psychosocial: Emotional Status
Psychosocial: Counseling Attended
ADL Limitations
CD4 Count
Viral Load
Date of Labwork
/
Month
/
Day
Year
Lipodystrophy
Diabetes
Herpes
Flu Shot
2. Skin
Lesions
Rash
Itching
Shingles
Date of Outbreak
/
Month
/
Day
Year
Seborrheic Dermatitis (greasy plaques to face, axilla, groin)
Folliculitis (itchy rash to face, trunk, extremities)
Molluscum Contagiosum (facial blisters)
Kaposi's Sarcoma
3. Eyes
Decreased Visual Acuity
Date of Last Eye Exam
Glasses Prescribed
Care Provided
Recent Eye Infections
Floaters (can indicate CMV Retinitis)
Cotton Wool Spots (indicates Microangiopathy)
4. Mouth
Dentition
Last Dental Exam
Dysphagia
Care Provided
Candidiasis (thrush)
Herpes Simplex
Oral Hairy Leukoplakia (white/gray patches to sides of tongue)
Recurrent Aphthous Ulcers
5. Lymph Nodes
Swelling
Tenderness
Persistent Lymphadenopathy
6. Lungs/Thorax
SOB: On Exertion
SOB: At Rest
Cough: Non productive
Cough: Productive
Sputum Color
Cardiovascular Problems
7. Abdomen
Pain/Tenderness
Diarrhea
Constipation
Malabsorption with weight loss
8. Neurological System
Numbness
Tingling
Paresis/Paralysis
Headache
Memory Loss
Confusion
Cognitive Impairment
Depression
Anxiety
Neuropathy
9. Musculoskeletal System
Mobility: Independent?
Mobility: Assistance?
Falls
Pain
Joints/ROM
Contracture/Deformity
10. Substance Abuse
Tobacco
Alcohol
Drugs
Quit Dates
/
Month
/
Day
Year
DA Counseling
11. Immunizations
Singles Vaccine Received?
Yes
No
Pneumonia Vaccine Received?
Yes
No
Influenza Vaccine Received?
Yes
No
COVID Vaccine(s) Received?
Yes
No
12. Reproductive & Bowel Health
Prostate Exam
Include date, outcome, and any other relevant information
Colonoscopy
Include date, outcome, and any other relevant information
OBGYN Exam
Include date, outcome, and any other relevant information
Mammogram
Include date, outcome, and any other relevant information
13. Miscellaneous Information
Physicians
Frequency of Visits
Current Home Services
Medications (name, dosage, frequency)
What time do you take your medications?
Have you missed any doses?
How/where do you keep your medication regiments?
Do you know what the medicine you are taking is for?
Are your medications being delivered on time?
Any dietary restrictions with your medications?
Pharmacy
Are there any side effects that concern you about your medications?
Compliant with treatment goals?
Yes
No
Comments
Nurse Signature/Date
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