nursing visit assessment report adult id# … visit assessment report ... site care: n/a sterile ......

NURSING VISIT ASSESSMENT REPORT –ADULT

Form#: CLIN-048A Effective Date: 7/1/12 Approved By: VP of Clinical Operations Revised Date: 12/6/13 Karen B. Spano, RPh

Patient Name: ____________________________________ID# ___________ DOB: _________ Date: ________________

Vital Signs: B/P ________Temp ______Pulse _____ Resp _______Weight _______ LBM ________ Allergies:________________________________

Reason for Visit (check all that apply): □Assessment □Teach □Line insertion □Dressing Change □Blood Draw □Medication Administration

□ Other: ___________________________________________________________________ □ Scheduled □ Unscheduled □ Discharge

Patient/Caregiver Status: □ Cooperative □Difficulty coping □Able □ Willing □Available □No change

Neurological: □Alert □Oriented □Disoriented □Confused □Lethargic □ Forgetful □Tremors □Seizures PERLA □YES □ NO MEMORY: □Good □Fair □Poor

□Other: _______________________________________ Mobility: ________________________ Have you fallen since last visit? □YES □ NO

Cardiac: Rhythm: □Regular □Irregular □Strong □Weak □Palpitations □Angina □Chest pain

□Edema Location: ________________ Type of Edema: □Non-Pitting □Pitting □1+ □ 2+ □ 3+ □ 4+ size: (R) ____________ (L) ________________

EENT: □ WNL □Sore Throat □Nasal Congestion □ Cough Sputum: ___________ □Blurred Vision □Other: _________________________________________

Respiratory: □Clear □Wheezing □Diminished □Crackles □Dyspena □At rest □With Exertion Oxygen Use:__________ liters for __________ hrs/day

Gastrointestinal: □WNL □Nausea □Vomiting □Diarrhea □Constipation □Dysphagia □Bleeding Gums □Oral lesions □Stomatitis

Bowel Sounds: □Normal □Hyperactive □Hypoactive Abdomen: □Soft □Firm □Ostomy Site □WNL □Other ___________ Output: □WNL □Other_______

Genitourinary: □Normal □Incontinent □Retention □Nocturia □Burning □Pain □Frequency □Odor □Urgency □Polyuria □Anuria

Urine: □Clear □Cloudy □Yellow □Amber □Rusty □Hematuria Frequency per day: _________ # of wet diapers per day: ________________ Catheter: Type: _______________________ Size_________________________ Balloon ____________________________ Change Date: ________________ Nutrition: Change in nutritional status? □Yes □No Diet type: _________________________ Loss/gain weight _______ lbs in ____days Eats ______meals per day

Appetite: □Good □Fair □Poor Fluid Intake: □2 liters/day □Less than 2 Liters/day Feeding Tube _______Ounces/day Site: □WNL □Other: ___________________

Endocrine: □ No problems □Fatigue □Lethargic □Generalized weakness □Low endurance □Diaphoresis □Polydipsia □Frequent Infections

□Blood sugar ____________dl/l □Fasting □Random

Integumentary: □ Warm dry □Intact □ Incision □ Sutures/Staples Color: □WNL □Pale □Jaundice □Flushed □Cyanosis □Rash

Wound/Decub: Location______________ Size/Depth_______________ Stage □ I □ II □ III □ IV Drainage (color, odor, amount) ______________________

Musculoskeletal: □Moves all extremities within normal limits □Abnormalities:_____________________________ Joints: □ WNL □Pain □Swelling □Stiffness

Falls/Loss balance □ YES □ NO If yes, give specifics___________________________________________________________________________

Pain: □None □ Pain Location_____________________ Description_________________________________ Intensity Scale (0-10) ___________

Frequency: □Sporadic □ Constant □With Activity Pain Medication (dose and frequency) __________________________Effective: □Yes □No

Access: □ N/A Access Type: __________________________________________ Gauge/Size: ___________________ Lumens: □ 1 □ 2 □ 3

Site Assessment: □Patent and intact □Infiltrated □Phlebitis □Inflammation □Drainage □Pain □Red □Swollen

Site Care: □N/A □Sterile/Aseptic Technique □Standard Precautions Followed □Gauze □Transparent □Antimicrobial disc □Locking device

Date Last Changed: __________ Changed/Added: □Injection Cap □Extension tubing Site rotations: □N/A □#_______attempts /rotated to: ______________

Port: □N/A □Changed Needle □Access □De-access Insertion of: □N/A □P.I.V. □P.I.C.C./Midline □Obtained consent

Brand: ____________________ Lot#: ___________________ Exp: __________ Site: ___________ Size: _________ Length: __________

Placement of tip: ________________ Arm Circumference: ________ Removed: □P.I.V. □P.I.C.C./Midline from_____________ length__________

Labs: □N/A □Drawn for: _______________________________________________________□Drawn from: ___________________________

Delivered to: □HHLA □Lab Corp □ □Other: ______________________________ Confirmation/Pick-up #________________________

Medication Administration: □ Reviewed side effects of medications supplied by the company □Yes □No

Instructed:□ Patient □ Caregiver Action: □ Introduced □ Continued Verified:□ Verbal □ Demo Patient/Caregiver level of Understanding: □ Partial □ Complete

Medications administered by: □Patient □Caregiver □Nurse □Other (name/relationship): __________________________________________

Patient /caregiver independent with therapy: □N/A □Yes □No □Follow-up teaching provided ______________________________________

Patient is: □Compliant □Non-compliant with therapy Reason for non-compliance: _________________________________________________

NURSING VISIT ASSESSMENT REPORT –ADULT

Form#: CLIN-048A Effective Date: 7/1/12 Approved By: VP of Clinical Operations Revised Date: 12/6/13 Karen B. Spano, RPh

Medication Admistration Continued:

Time: ________ Medication/Diluent/Volume: _________________________________ Dose: __________ Route: _______ Frequency: ___________

Time: ________ Medication/Diluent/Volume: _________________________________ Dose: __________ Route: _______ Frequency: ___________

Time: ________ Medication/Diluent/Volume: _________________________________ Dose: __________ Route: _______ Frequency: ___________

Time: ________ Medication/Diluent/Volume: _________________________________ Dose: __________ Route: _______ Frequency: ___________

Pump: _________________Method of Administration: ___________________________ Infusion Volume: _________________Infusion Rate: _______________

Infusion Time: ____________________ Taper Up: _________________ Taper Down_____________________

□ REFER TO IVIG FLOW SHEET

Flush: □________ml NS □________ml D5W □Pre □Post Heparin __________units/ml _________ml □Post

Patient’s Response to Therapy: □ Improved □ No Change □ Worsening Patient/Caregiver Able/Willing to Provide Tx:□ Yes □ No*

Skilled Nurse Required to Administer Tx: □ Yes □ No Patient/Caregiver Response to Care: □ Good □ Fair* □ Poor* Patient/Caregiver Needs Met: □ Yes □ No*

*See Comments

Comments: _______________________________________________________________________________________________________________________________________

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Ongoing Therapy Progress Towards Goals: □ Good □ Fair □ Poor _______________________________________________________________________________________________________________________________________

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Medication Profile Change: □ Yes □No If yes: □ See Attached Medication Profile □ list here:_____________________________________________________

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Reviewed POT and Orders Current: □Yes □No, physician to be contacted

Next Physician Visit: _______________________ Last Physician Visit: _________________________ Next Nursing Visit: __________________________

Discharge Plan: _____________________________________ Resolution of Symptoms: □N/A □ Yes discharge instructions given □No

Date: _____________ Time Start: _______________________ Time Finished ___________________________________ Total Time: __________________________

Patient signature: __________________________________________________ Patient Name (print): ___________________________________________________

Nurses Signature: __________________________________________________ Nurses Name (print): ___________________________________________________

Reviewed By: ________________________________________Date: __________________________________________