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.