Zumbro House, Inc

ZUMBRO HOUSE, INC.

RN EVALUATION-INITIAL ASSESSMENT

Resident Name: ______Record #:______

Vitals:Assistive Devices Used (check all that apply):

Temperature:______ Glasses Electric Cart/scooter

Pulse: ______ Hearing Aid Walker

Respiration: ______ Dentures Oxygen

Blood Pressure:______ Cane Assistive Dressing

Height:______ Wheelchair Devices

Weight:______ Other:______

Recent gain?______Recent loss?______

Allergies: Latex Y N Other:______

Diagnosis:

Primary Active:______

Secondary Active:______

Vaccination Status:

Pneumonia vaccination received  Yes NoDate:______

Flu vaccination received Yes NoDate:______

TB Status, if known: ______

Special diet: ______

Sensory Losses and Communication Problems:

Vision: Glaucoma Cataracts Macular DegenerationComments:______

Hearing: ______

Smell:______

Communication Problems: ______

ADLs

Inde-pendent

Needs minor assist

Needs super-vision/ oversight

Needs assistance

Totally dependent

Comments

Dressing

Toileting

Bathing

Hair Care

Oral Hygiene

Shaving

Eating

Transferring

Mobility

Self-Preservation

IADLs

Inde-pendent

Needs minor assist

Needs super-vision/ oversight

Needs assistance

Totally dependent

Comments

Telephone

Finances

Shopping

Laundry

Housekeeping

Food Preparation

Appointments

Transportation

Skin Integrity:

 Rash Pale Open Sores

 Itching Moist Cellulitis

 Cool Flushed

 Other:______

Endocrine:

 Thyroid

 Diabetes Treatment:______

Assistance needed with blood glucose monitoring?______

 Hyperglycemia

 Hypoglycemia

 Other:______

Neurological:

 Stroke Paralysis Dizziness

 Parkinson’s TIA’s Seizures

 Headaches

 Other:______

Gastrointestinal:

 Heartburn Gastric reflux Nausea/Vomiting

 Constipation Diarrhea Bowel Incontinence

 Other:______

Cardiovascular/Circulatory:

 Heart Disease Treatment:______

 High Blood Pressure  Chest Pain Heart Attack

 Pacemaker Edema—Location:______

 Other:______

Genitourinary:

 Urinary incontinence – Partial_____ Total______

How managed:______

Respiratory:

 Shortness of Breath  Cough  Bronchitis

 Pneumonia Emphysema Smoker/History of Smoking

 Asthma (Treatment:______)

 Other:______

Musculosketal:

 Fractures Arthritis Osteoporosis

 Joint Replacement

 Pain Location:______

Cause:______

Intensity:______

Relieved by:______

 Other:______

Psychological/Cognitive:

 Alert

 Oriented to: Person______Place______Time______

 Forgetful Confused Wanders

 Sad/Depressed  Anxiety Memory Loss

 Paranoid  Impaired Decision-making

 Mental illness or cognitive impairment diagnosis______

 Behavior issues (verbal or physical aggression)

 Other:______

Other Issues or Problems:

Falls:

 Afraid of falling Has fallen in past year___ # of falls in past year

 Sleep patterns Frequent Hospitalizations

 Cancer:______

Treatment:______

 Alcohol/controlled substance use How often/how much:______

 Other:______

______

Family Support: ______

______

Resident Strengths: ______

______

Other Observations/Notes:

Over-the-Counter, Herbal and Prescribed Medications (if possible, do a “brown bag” assessment):

Medication / Dose / Frequency / Route / Prescriber / Reason Used / Pharmacy

RN Evaluation/Initial Assessment Completed within 5 days of admission by:

______

(RN Signature and Title) (Date)

______

(RN Name Printed)