INITIAL ASSESSMENT – NURSING

Patient Name _____________________________ Election Date ___________________ Assessment Date _________________

MR# ____________________________________ Date of Birth ___________________ Age ____________________________

Vital Signs
T ________ Pulse (Resting) ________ Resp ________ BP __________ Weight: ________ MAC__________

Pain Assessment
Intensity: none = 0 1 2 3 4 5 6 7 8 9 10 = most intense Acceptable level: ________ /10
Frequency: occasionally y constantly
Location: ___________________________________________________________________________________________________
Description of pain: ___________________________________________________________________________________________
Nonverbal signs of pain: _______________________________________________________________________________________
Associated symptoms: _________________________________________________________________________________________
C i i i  Yes  No

Immediate Care & Support Needs: Document patient rating from ESAS assessment
_____ Pain/Comfort Describe ____________________________________________________________________________
_____ Fatigue Describe ____________________________________________________________________________
_____ Nausea Describe ____________________________________________________________________________
_____ Depression Describe ____________________________________________________________________________
_____ Anxiety Describe ____________________________________________________________________________

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_____ Drowsiness Describe ____________________________________________________________________________
_____ Appetite Describe ____________________________________________________________________________
_____ Shortness of breath Describe ____________________________________________________________________________
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_____ Well-being Describe ____________________________________________________________________________
_____ Other Describe ____________________________________________________________________________

Patient’s Primary Concern/Goals

___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
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Caregiver’s Primary Concern/Goals
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
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___________________________________________________________________________________________________________

Evaluation of Physical, Psychosocial, Emotional and Spiritual Status/Immediate Care Needs

___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

Interventions and Teaching

___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

Need for Comprehensive Assessment

 Nursing  Social work  Spiritual care  Physician  Bereavement
 Dietitian  Physical Therapy  Occupational Therapy  Speech Therapy

Patient /Caregiver refuses the following services and assessments: _____________________________________________________

RN Signature ______ Date

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 COMPREHENSIVE ASSESSMENT – NURSING

Patient Name ___________________________ MR# ______________ Election Date __________ Assessment Date __________

Date of Birth _________________ Age __________ Hospice Dx ________________________ Is death imminent?  Yes  No
Level of Care:  RHC  CC  INPT  Respite Location:  Home  Nsg Hm  ALF  Hospital  Bd/care
Admission: Precipitating factors Patient/family subjective complaint(s) ___________________________________________________
In last year (include date, if known):
 Hospitalized ________  Pneumonia ________  Aspiration pneumonia ________  UTI ________
 Recurrent fever after atb ________  Stage 3–4 decubitus ________  ER visit ________  Hip fx ________
 Septicemia ________  Pyelonephritis ________  Unexplained syncope ________  Cardiac arrest/resuscitation_______

Alteration in Comfort Problem:  Yes  No

Pain as Bad as You
No Pain Mild Pain Moderate Pain Severe Pain Very Severe Pain
Can Imagine
Circle the one number that best fits the patient’s pain at its worst in past week.
0 1 2 3 4 5 6 7 8 9 10
Circle the one number that best describes the patient’s pain right now.
0 1 2 3 4 5 6 7 8 9 10
Circle the one number that best describes the level of pain acceptable to the patient.
0 1 2 3 4 5 6 7 8 9 10
Patient response:  Number scale (0–10) pain rating used  Wong-Baker Faces pain rating used
ESAS pain assessment: ________ Pt/family goal: __________ Intervention change needed:  Yes  No
Comment: ___________________________________________________________________________________________________

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What kinds hi g k h p i ’ p i b ( x p h , , ) _____________________________________
__________________________________________________________________________________________________________
Wh ki hi g k h p i ’ p i w (PL x p w lking, standing, lifting)? __________________________________
___________________________________________________________________________________________________________
What treatments or meds is the patient receiving for pain?________________________________________ Effective:  Yes  No
Barriers to pain management ___________________________________________________________________________________
Describe the pain:
 Aching  Throbbing  Shooting  Stabbing  Gnawing  Sharp  Tender  Numb
 Burning  Exhausting  Tiring  Penetrating  Nagging  Miserable  Unbearable
Nonverbal signs of pain/discomfort:
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 Grimacing  Moaning  Guarded  Frowning  Restless  Increased BP  Increased pulse
 Poor appetite  Perspiring  Crying  Agitation  Rigid posture  Jaws clenched  Legs drawn up
SA

On the diagram, shade in the areas where the patient feels pain. Put an X on the area that hurts the most.

Alteration in Urinary Elimination/GU Status __________________________________________________ Problem:  Yes  No

Output:  Good  Moderate  Poor  Minimal Odor ________________________ Color ___________________________
Frequency:  Normal  Frequent  Infrequent  No output last 24 hrs Retention______________ Incontinent:  Yes  No
Catheter _______________________ Type ____________________ Size _____________ Date Foley changed ______________
UTI:  Frequent  Occasional  None in last yr Date of last UTI ________________ Tx ______________________________
Current Medications ____________________________________________________________________ Effective:  Yes  No
Comment: ___________________________________________________________________________________________________

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 COMPREHENSIVE ASSESSMENT – NURSING

Alteration in Bowel Elimination Problem:  Yes  No

Constipation _____________________________________________Diarrhea _____________________________________________
Incontinence:  Yes  No Frequency of incontinence_________________________ Bowel sounds _______________________
Colostomy _______________________________________ Ileostomy __________________________________________________
Usual bowel pattern _______________________________________ Last BM ___________________________________________
Current bowel regimen _____________________________________ Effective? __________________________________________
Comment: ___________________________________________________________________________________________________

Alteration in Nutrition/Hydration Dietitian referral needed:  Yes  No Problem:  Yes  No

Ht ______ Wt ______ BMI ______ MAC ______ Normal weight ______ Weight  gain  loss in last ____ months: # lbs_____
Nutrition Intake (% usual daily amt) ___________________  Anorexia Number of meals per day:  1  2  3  4  4+
Pt/family acceptance/understanding of weight loss:  Yes  No  Restricted/special diet ____________ Appetite __________
Tube Feeding:  Yes  No Type__________ Amt___________ Nausea Vomiting: Frequency _____________________
Dysphagia:  Yes  No Prevents sufficient intake to sustain life:  Yes  No Number of dysphagia event in last week: ____
ESAS nausea assessment ________ Pt/family goal ________ Intervention change needed:  Yes  No
ESAS appetite assessment ________ Pt/family goal ________ Intervention change needed:  Yes  No
Comment: ___________________________________________________________________________________________________

Alteration in Respiratory Status Problem:  Yes  No

O2 sat level on RA ______ O2 sat level on O2@ _____ O2 ________ L/min  Continuous  Intermittent  Pt removes/refuses
Breath sounds (Rt) _____________ (Lt)_______________ Quality ___________________________ Orthopnea _______________
Dyspnea: at rest:  disabling  moderate  minimal Dyspnea: on exertion:  disabling  moderate  minimal
Amount of exertion before patient becomes dyspneic:  distance amb _______  minutes talking ______  other ______________

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Cough ____________________ Sputum color _________________________ Infections ________________________________
Current Medications ________________________________________________________________ Effective:  Yes  No
ESAS SOB assessment ________ Pt/family goal _________ Intervention change needed:  Yes  No
Comment: ___________________________________________________________________________________________________
PL
Alteration in Cardiac/Circulatory Function Problem:  Yes  No
Heart sounds __________________________ Pulses ____________________________ Pulse deficit _____________________
Regular rate/volume ___________________________ Hypo/hypertension ______________________ Cyanosis _____________
Chest pain:  Yes  No Number of episodes in last week _________________ Precipitating factors ______________________
What relieves chest pain?  Nitro  Rest  Other med _____________  Other _____________________________________
Edema  RLE Degree _____ Pitting? _____  LLE Degree _____ Pitting? _____ Other location: _______________________
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 RUE Degree _____ Pitting? _____  LUE Degree _____ Pitting? _____ Degree ________ Pitting? _____
Current Medications ____________________________________________________________________ Effective:  Yes  No
Comment: ___________________________________________________________________________________________________
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Alteration in Physical Mobility Problem:  Yes  No

Weakness AEB __________________________________________ Disability _________________________________________
Ambulation  Indep  Walker  Need assistance  Holds furn/walls ROM limitations ______________________________
Ambulation Distance ___________ (steps or feet) Decrease:  Yes  No Transfer ability:  Indep  Needs assist
 Mainly sit/lie  Mainly in bed  Totally bed bound  Unable to do most activity  Unable to do any activity
Family/facility report of  in functional ability: ____________________________ AEB_____________________________________
ESAS tiredness assessment ________ Pt/family goal ________ Intervention change needed:  Yes  No
Comment: ___________________________________________________________________________________________________

ADL Assessment HHA Needed:  Yes  No Frequency __________

I=Independent P=Partially able N=Needs assistance U=Unable to Do
Feeding Self ________ Transferring ________ Dressing ________ Bathing ________
Toileting _________ Ambulating ________ Sit Independently ________ Prepare Meals ________
Light Housekeeping ________ Personal Laundry ________
Ability of caregiver to assist with custodial needs of patient _____________________________________________________________
Comment: ___________________________________________________________________________________________________

Fall Risk Assessment Circle appropriate item and add scores Problem:  Yes  No
Hx of falls = 15 Incontinence = 5 Unable to ambulate independently = 5
Confusion = 5 Increased anxiety = 5 Decreased level of cooperation = 5
Age > 65 = 5 Cardio/pulm disease = 5 Meds for HTN or level of consciousness = 5
Impaired judgment = 5 Postural hypotension = 5 Initial admission to hospice/facility = 5
Sensory deficit = 5 Attached equip (IV, O2 tubes) = 5
Score of 15 or higher is considered high risk Patient Score: _________________ High Risk:  Yes  No
Comment:__________________________________________________________________________________________________

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 COMPREHENSIVE ASSESSMENT – NURSING

Alteration in Skin Integrity Problem:  Yes  No

Wounds/Decubiti ___________________________________ Skin color _________________________________________________
Lacerations _______________________________________ Skin turgor ________________________________________________
Contusions _______________________________________ Skin to touch ______________________________________________
Petechiae ________________________________________ Rash ____________________________________________________
Skin tears ________________________________________ Abrasions _________________________________________________
Comment: ________________________________________ ―W A ‖ i i his assessment:  Yes  No
Document stage of each pressure ulcer on diagram.

Alteration in Mental/Neurological Functioning Problem:  Yes  No

Pupils equal _____________________ Disorientation ________________________ Responsiveness _____________________
Cognition _______________________ Level of consciousness ________________ Seizures ___________________________
Syncope ________________________ Headache __________________________ Anxiety _____________________________
Depression __________________________ Memory impairment:  Long term  Short term Progressing:  Yes  No

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Vision __________________________ Hearing ____________________________ Sensory impairment __________________
Speech: 6 words or less  Yes  No One word or less  Yes  No Nonverbal  Yes  No
Dysphasia:  Yes  No Able to smile:  Yes  No Able to hold head up independently:  Yes  No
Coma:  Abnormal brain stem response: _________________  Absent verbal response  Absent withdrawal response to pain
PL
Current Medications _____________________________________________________________________ Effective:  Yes  No
ESAS drowsiness assessment: _________________ Pt/family goal: _____________ Intervention change needed:  Yes  No
ESAS anxiety assessment: ____________________ Pt/family goal: _____________ Intervention change needed:  Yes  No
ESAS depression assessment: _________________ Pt/family goal: _____________ Intervention change needed:  Yes  No
Comment: ___________________________________________________________________________________________________
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Alteration in Sleep Patterns Problem:  Yes  No
Current sleep pattern ______________________________________ Change in pattern
Sedatives used __________________________________________ Effective
Comment:
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Alteration in Endocrine System Problem:  Yes  No

Diabetes __________________________________________________ Treatment
Current Medications _________________________________________ Effective
Comment:

Vital Signs:
T _________ Pulse (Resting) __________ Resp _________ BP _________ Ascites:  Yes  No Abdominal girth ___________
Pertinent Laboratory Results (if known): _________________________________________________________________________

Alteration in Coping Problem:  Yes  No

Signs of psychosocial/emotional distress ________________________________________________________  Pt  Caregiver
Signs of spiritual distress _____________________________________________________________________  Pt  Caregiver
Signs of family discord/distress ________________________________________________________________  Pt  Caregiver
Caregiving environment is adequate to meet patient needs:  Yes  No Comment _____________________________________
Caregiver expressing anticipatory grief:  Yes  No Comment _____________________________________________________

DME & Supplies

Medical Supplies and Equipment in home __________________________________________________________________________
Medical Supplies and Equipment needed __________________________________________________________________________
Patient/caregiver to demonstrate equipment use and safety? ___________________________________________________________

Infusion
Type:  Peripheral  PICC  Central Venous  Subcutaneous  Other: _______________________________________
Location: _____________________________ Date placed: _____________ Size/gauge: ________ Type/brand: ___________
Purpose:  Pain mgmt  Hydration  Antibiotics  Maintain venous access  Other: _____________________________
Pump: Type: ______________________________ Pump setting: _______________________ Verified w/ orders:  Yes  No
Comments: __________________________________________________________________________________________________

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 COMPREHENSIVE ASSESSMENT – NURSING
Medications
See Medication Profile for current medications  List of medications reviewed with patient/representative
Pt able to take medications as prescribed:  Yes  No Caregiver able to administer medications as prescribed:  Yes  No
Medications effective:  Yes  No Unwanted side effects:  Yes  No
Drug interactions:  Yes  No Need for pharmacist consultation:  Yes  No
 Reviewed facility orders & Notes  New orders found  Copy of orders/Notes obtained for hospice chart
 Provided written policy on disposal of controlled drugs to patient/family  Reviewed drug disposal policy

Eligibility Assessment  Prognosis Guideline (LCD) attached for _______________________ (dx)

Patient is eligible for hospice care as evidenced by (AEB). Document comparisons of current status with baseline assessments
(admission or recertification assessments). Reference changes with specific time period. Check all that apply.
 Progressive malnutrition: AEB ________________________________________________________________________________
  weakness: AEB __________________________________________________________________________________________
  function: AEB ____________________________________________________________________________________________
  cognitive status: AEB _____________________________________________________________________________________
  skin integrity: AEB ________________________________________________________________________________________
 Recent infections: AEB ______________________________________________________________________________________
 Changes in medications _____________________________________________________________________________________
  need for services: AEB ____________________________________________________________________________________
 Diminishing lab results: AEB _________________________________________________________________________________
  pulmonary function: AEB ___________________________________________________________________________________
  cardiac function: AEB _____________________________________________________________________________________
 Other: _______________________ AEB ______________________________________________________________________

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Plan of Care
Complications/risk factors affecting care planning ___________________________________________________________________
 The plan of care was presented to and discussed with the patient and representative
Level of understanding:  Good understanding  Partial understanding  Do not understand
PL
Level of ability to participate in care:  Good participation  Partial participation  Cannot participate  Decline

Patient/Representative Instructions
 Hospice Services  Plan of Care  How to Contact Hospice  Resuscitation Policy
 After Hours Services  Emergency Procedures  Grievance Procedure  Bill of Rights
 Use of Equipment  Infection Control  Confidentiality of Records  Advance Directives
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Teaching
Understand disease process and signs of disease progression: Patient  Yes  No Representative  Yes  No
Caregiver willing and able to receive instructions and provide care:  Yes  No Comment: ________________________________
Reviewed PoC with:  Patient  Representative  Facility staff __________________________________________________
SA

Teaching to:  Patient  Representative  Facility staff __________________________________________________

Teaching topics: ______________________________________________________________________________________________
Caregiver expresses confidence in providing care:  Yes  No Response to teaching: __________________________________
Level of understanding:  Excellent ___________________  Good ___________________  Poor ______________________

Communication/Collaboration/Referrals/Need for Comprehensive Assessment

 SW ________________________________________________  Spiritual Care ____________________________________
 Facility staff _________________________________________  Volunteer Coordinator _____________________________
 Aide _______________________________________________  Dietician ________________________________________
 Bereavement ________________________________________  Other __________________________________________
Attending Physician:
 Reported patient status  Reported on plan of care problems, interventions, goals & patient response
 Received new order(s) ______________________________________________________________________________________
Consultation results __________________________________________________________________________________________

Summary

Need for Comprehensive Assessment:

 Nursing  Social work  Spiritual care  Physician  Bereavement
 Dietitian  Physical Therapy  Occupational Therapy  Speech Therapy
Patient /Caregiver refuses the following services and assessments: _____________________________________________________

Signature/Title ____________________________________________________ Date ____________________________________

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TCG–110 © 2008 The Corridor Group, Inc.