• Image field 301

  • PEDIATRIC INITIAL

    NURSING ASSESSMENT

  • SESSION WAS NOT INITIALIZED PROPERLY. YOU CAN NOT USE THIS FORM. MAKE SURE THIS DOCUMENT HAS BEEN OPENED DIRECTLY FROM THE SOURCE PROVIDED TO YOU.

    • Visit Information 
    • Scheduled Date*
       - -
    •  :
      Until
       :
    •  
    • Time In - Time Out 
    • Are you able to start?*
    • Why not?*
    • Visit Start Date/Time*
       - -
       :

    • Visit End Date/Time is on the last page along with signatures

    • Race:*
    •  

  • DIAGNOSIS

  • 0 - No treatment needed

    1 - Symptoms well controlled

    2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring

    3 - Symptoms poorly controlled; patient needs frequent adjustment in treatment and dose monitoring

    4 - Symptoms poorly controlled; history of re-hospitalizations

  • Additional Diagnosis?*
  • Additional Diagnosis?*
  • Additional Diagnosis?*
  • Additional Diagnosis?*
  • Additional Diagnosis?*
  • Therapies the patient receives at home:*

  • CHILDCARE ARRANGEMENTS

  • LIVING ARRANGEMENTS

  • Home Conditions:*
  • Safety:*
  • Hygiene:*

  • MEDICAL HISTORY

  • RELATIONSHIP

  • NEWBORN / INFANT SECTION

  • Is the patient a newborn or infant?
  • Umbilicus:*
  • Fontanels:*

  • Infant Motor Skills:

  • Motor Skills:*
  • Rolls over:*
  • Sits:*
  • Stands:*

  • CHILDHOOD HISTORY

  • Rows

  • VITAL SIGNS

  • Temperature Source:*

  • Pulse:*
  • Regular/Irregular?*
  • Strong/Weak?*
  • Rows
    •  

  • ALLERGIES

  • Any allergies?*
  • Seasonal?*
  • Foods?*

  • IMMUNIZATIONS

  • Is patient up to date on all immunizations?*
  • Have you ever received blood/blood products?*
  • Adverse reactions:*

  • RESPIRATORY

  • Breath Sounds:*
  • Dyspneic or Short of Breath?*
  • Cough:*

  • Oxygen Therapy:

  • Applicable?*
  • Continuous/Intermittent?*
  • How is oxygen received?*
  • Signs posted?*

  • Trach:

  • Trach?*
  • Requires Suctioning?*
  • By:*
  • Trach care (dressing, etc.):*
  • By:*

  • PAIN

  • Pain Present?*
  • Non-verbals Demonstrated:*

  • Rows
  • Rows
  • Rows
  • Image field 696
  • Does frequency of pain interfere with activities or movement?*
  • How often is breakthrough medication needed?*

  • ABILITIES

  • Rows
  • Current ability to dress upper body:*
  • Current ability to dress lower body:*
  • Current ability to wash entire body safely:*
  • Current ability in toilet or bedside commode transferring:*
  • General transferring ability:*
  • Ambulation/Locomotion ability:*
  • Does patient use a wheelchair or scooter?*
  • Type:*

  • NEUROLOGICAL

  • Tremors:*

  • Growth and Development:

  • Physical Development:*
  • Left Grip:*
  • Right Grip:*
  • Coordination/Balance:*
  • Decision Making Abilities:*

  • Mental Status:

  • Alert?*
  • Forgetful?*
  • Confused?*
  • Agitated?*
  • Depressed?*
  • Combative?*
  • Oriented/Disoriented?*
  • Comatose/Semi?*
  • Withdrawn?*
  • Lethargic?*
  • Anxious?*
  • HOH?*
  • Suicidal Ideations?*
  • Cooperative?*
  • Comprehension?*
  • Verbal?*
  • Legally blind?*
  • Sleep/Rest adequate?*

  • Seizures:

  • Applicable?*
  • Last Seizure:*
     - -

  • SENSORY STATUS

  • Eyes:

  • Issues:*

  • Ears:

  • Issues:*

  • Nose:

  • Issues*

  • CARDIOVASCULAR

  • Dizziness?*
  • Chest Pain?*
  • Edema?*
  • Pitting/Non-pitting?*
  • Pedal Pulses:*
  • Weak/Strong?

  • GASTROINTESTINAL/NUTRITIONAL

  • Appetite:*
  • Diet:*
  • Recent Weight Loss/Gain?*
  • Fluid Restriction:*

  • Bowel Sounds:

  • Present x4 quads:*
  • Hypo/Hyper:*

  • Last BM:

  • Date:*
     - -
  • Applicable:*

  • Bowel Incontinence Frequency:*
  • Patient have ostomy for bowel elimination (win 14 days)?*
  • Abdomen:*

  • Mouth:

  • Issues:*

  • Dentures:*

  • Throat:

  • Issues:*

  • Colostomy/Ileostomy:

  • Applicable?*

  • TUBE FEEDINGS

  • Applicable?*
  • Type of Feeding Tube:*
  • Frequency of Feeding:*

  • Tube Feedings By:*
  • Rows
  • Patient Tolerant Feeding?*

  • INTEGUMENTARY

  • Skin:

  • Skin Turgor:*
  • Issues:*
  • Drainage Amount:*

  • Consistency:*

  • Pressure Ulcers:

  • At least one Unhealed Pressure Ulcer/Injury at Stage 2 or higher or designated as Unstageable?*

  • Mucus Membranes:

  • Dry/Moist?*
  • Pink/Pale?*

  • ENDOCRINE / HEMATOLOGY

  • Diabetes:*
  • Insulin utilized?*
  • On insulin since:
     - -
  • Within normal limits?*
  • FBS/Random/Post prandial:*

  • Additional Factors:*

  • GENITOURINARY

  • Catheter:

  • Applicable?*
  • Type:*
  • Date last changed:*
     - -
  • By:*

  • Urination:

  • Continent/Incontinent?*
  • Burning?*
  • Frequency?*
  • Hematuria?*
  • Retention?*
  • Urgency?*
  • Toilet Trained?*
  • Nocturia?*
  • Frequent UTIs?*
  • Diapers?*
  • Difficulty starting stream?*
  • Dribbling?*
  • Stones?*
  • Urine Color:*

  • Odor:*

  • Dialysis:

  • Applicable?*
  • Type:*

  • FALL RISK ASSESSMENT

  • Mobility:
  • Mental State:
  • Toileting:
  • History of Falls:

  • If the total score of the items above is 3 or greater, or based on clinical judgement, initiate the Fall Prevention Program in the Plan of Care.

  • Scoring Criteria:

    1. Clinical Judgement Patient diagnosis or condition warrants fall prevention program.
    2. Mobility Uses assistive devices or needs assitance for ambulance/transfer. Evidence of generalized weakness or decreased mobility in lower exremities, poor balance and dizziness.
    3. Mentation Patient is developmentally delayed or is disoriented.
    4. Elimination Has need to get to toilet frequently or urgently. Needs assistance with toileting.
    5. History of Falls related to Illness Has the patient fallen within the last year related to illness, including falls at home or a previous admission or during this admission? (refer to inpatient admission assessment).
    6. Current Medications Anticonvulsants, opiods, benzodiazepines. Also consider diuretics, antihypertensives, and analgesics, bowel preps.

     

  • Fall Prevention Program Reviewed with Family/Client:
  • Patient/cg demonstrated understanding of safety awareness?*
  • Patient/cg demonstrated understanding of fall prevention?*

  • SAFETY MEASURES

  • Safety Measures:

  • Hazards Noted?*
  • Can participant access emergency response without assistance?*
  • Is emergency response available in the house?*
  • Is smoke detector present and functioning?*
  • Environment suitable for type, amount, level of care ordered?*
  • Equipment needed/ordered:*

  • MUSCULOSKELETAL / FUNCTIONAL

  • Able to ambulate?*
  • Ability of patient to crawl (if infant)?*
  • Bed/Wheelchair Bound?*
  • Cane/Walker?*
  • Holds onto walls/furniture?*

  • Homebound Status:

  • Homebound?*
  • Needs assistance with all activities?*
  • Requires assistance to ambulate?*
  • Confusion, unable to go out of home alone?*
  • Unable to safely leave home unassisted?*
  • Severe SOB, SOB upon exertion?*
  • Dependent upon adaptive device(s)?*
  • Medication restriction?*
  • Residual weakness?*

  • Limited ROM:

  • Limited ROM:*
  • Amputation/Deformities?*
  • Paralysis/Hemiparesis?*
  • Poor coordination/balance?*
  • Weakness?*
  • Unsteady Gait?*
  • Low Endurance?*

  • MEDICATIONS

  • Medication Review:*

  • Demonstrates compliance with medications by:*
     - -
  • New/Changed Meds?*
  • Rows
  • Potential adverse effects/drug reactions/drug interactions?*
  • Significant drug side effects?*
  • Drug Therapy?*

  • INSTRUCTIONS

  • Remembers instructions from last visit?*
  • Discharge plan discussed?*
  • Universal precautions observed?*
  • Visit verification discussed/phone available?*
  • Written material given?*
  • Test/Lab results?*
  • Date patient last saw physician:*
     - -

  • INTERVENTIONS

  • Telephone call to physician?*
  • Verbal orders completed?*
  • Next nursing visit date:*
     - -

  • Rehabilitation Potential/Goals:

     

    Nursing:







  • Highest quality of ongoing care?*

  • Home Health Aide:


  • Physical Therapy:


  • Speech Therapy:



  • Occupational Therapy:


  • Medical Social Services:


  • SUPERVISORY

  • Applicable?*
  • Supervising:*
  • Rows
  • Following Care Plan?*
  • Care Plan updated?*
  • Care Plan present?*
  • Safety Plan reviewed with employee?*
  • Environmental needs met?*
  • Mental needs met?*
  • Social needs met?*
  • Physical needs met?*
  • Service change requested?*
  • Correct hand washing technique?*
  • Correct use of gloves?*
  • Correct bag technique?*
  • Proper equipment cleaning technique?*
  • Proper use of in-service training/teaching?*
  • Rows
  • Rows

  • DISCHARGE PLANS

  • Problems resolved when:*

  • Discussed with patient:*
  • Rehab potential:*

  • OVERALL COMMENTS

  • SIGNATURES

  • Visit End Date/Time*
     - -
     :
  • Is the patient able to sign?*
  • Is anyone (other than the patient) present in the home over eighteen years old?*
  • Who is present and able to sign?*

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