Border Comprehensive Interdiciplinary Assessment Dysuria by mikeholy


									Comprehensive Interdisciplinary Patient Assessment
Patient Name/Label: _________________________________________                                        Admission Date:________________________

Section 1                                                      Demographics
Section 1A – To be Completed by the Social Worker
Date of Birth: ____________________           Gender:                Male       Female        Transgender/Transsexual
Marital Status:  Single       Married         Widow       Divorced   Separated      Unknown
Race/Ethnicity:  American Indian/Alaska Native       Asian _____________     Black /African American  Hispanic/Latino origin
                 Native Hawaiian or Pacific Islander       White     Unknown
Nephrologist :________________________________________ Vascular Surgeon:_____________________________ Unknown
Family Physician:______________________________ Unknown General Surgeon:_____________________________                                             Unknown
Mental Health Provider: _____________________________ Unknown Dentist:_____________________________________                                       Unknown
Date of First Dialysis: ________________________ (located on 2728)  Date of first Treatment at facility:_____________________
Actual Weight____________kg                   Actual Height______________cm

Section 1B – To be Completed by the Registered Nurse
Patient's condition is currently:
   Initial Completion Date:___________           Monthly/Unstable Date:____________             90 Days Date:_____________
   Annual/Stable Date:__________

Patient is unstable if he/she has any of the following:
    ”Frequent Hospitalization” more than three hospitalizations in one month or “Extended Hospitalization” longer than 8 days / new substantial
change in condition resulting in significant changes in medical or functional status (Stroke, additional co-morbid diagnoses, amputations requiring rehab.)
    ”Poor nutritional status” include failure to thrive symptoms, with loss of body weight and low serum albumin
    ”Unmanaged anemia” would include continued lab findings of Hgb/Hct which are out of range 10-12 g/dL, >13.0 g/dL.
Ferritin >100 mg/mL <500 mg/mL., Transferrin saturation <20%
    ”Significant change in psychosocial needs” May include instability in one’s own or immediate family member’s employment, physical or
emotional abuse, deterioration in mental or functional status, housing instability, death or major illness in the family, and loss of emotional support
    ”Inadequate dialysis” Include findings of Kt/V or URR which do not meet minimum expectations. Kt/V ≥ 1.2 or URR ≥ 65%
    New substantial change in condition that is a recurrent serious complication while undergoing dialysis
( severe hypotension, seizures, dysrhythmia, blood access issues resulting in freq. interventions/changes to dialysis orders to achieve adequate dialysis )
    Refer to plan of care                     Per judgment of the team                          Per request of the patient

Section 1C - To be Completed by the Registered Nurse
Current HD Orders:        Refer to Facility MD order sheet
Hemodialysis:        N/A     Dialysate: K:_________Ca++_________Bicarb________Na:________Temp________EDW:__________
Adequacy meeting target:: Yes             No, Explain________________________________________ Refer to plan of care
Adverse Intradialytic Symptoms:           Cramping    Hypertension  Dizziness  Hypotension   Nausea     Cardiovascular complication

SECTION 2                                                          NEPHROLOGY

SECTION 2A - To be Completed by the Nephrologist - Co-morbidities :                       Refer to History and Physical
   Congestive heart failure         Atherosclerotic heart disease ASHD                Diabetes, insulin dependent          Diabetes, on oral medications
   History of Hypertension          Cerebrovascular disease, CVA , TIA                Diabetic retinopathy                 Peripheral vascular disease
   Other cardiac disease            Chronic obstructive pulmonary disease             Alcohol dependence                   Amputation
   Toxic nephropathy                 Malignant neoplasm, Cancer                       Drug dependence                      Tobacco use (Current smoker)

Normal         Review of Systems       Section 2B        NEPHROLOGY MEDICAL ASSESSMENT
                    Access             AVF      AVG       Central Venous Catheter/Permanent Catheter Location:_____________________

Rev. 12-1-08                                             Page 1 of 15
Comprehensive Interdisciplinary Patient Assessment
Patient Name/Label: _________________________________________
                   General             fatigue     weight loss fever           night sweats       weight gain        sleep loss
                    Skin               pruritis    rash lesion          pain      dry       ecchymoses         petechiae
                    Eyes               discharge      pain       diplopia       conjunctivitis       nystagmus         sclera      glaucoma
                    Ears                hearing deficit     pain      tinnitus      vertigo      otitis media
                    Nose               discharge       epistaxis     rhinorrhea
                   Mouth               sore throat sores          bleeding gum
                    Neck               JVD      thyroid     masses trachea midline             pain       decreased mobility
                                    Apical Pulse:      Regular       Irregular       S3       S4        Friction     Murmurs
                                       chest pain      diaphoresis        PVD        orthopnea          palpitations      dep. edema
                                       SOB       cough       productive        rales       rhonchi        wheeze       hemoptysis
                                       decreased breath sounds           TB exposure          skin test results
                                       pancreatitis indigestion belching diarrhea gallstones poor appetite flatulence
                                       constipation heartburn ulcer disease hematochezia indigestion
                      GU               dysuria      hematuria urgency             frequency        incontinence        nocturia     back/groin pain
                                       arthralgia     myalgia       cramps       arthritis      deformities       redness       limited motion
                                       ulcers      tenderness        varicosities       edema          clubbing      back pain       gout
                Hematological          anemia       ecchymosis        thrombocytopenia          bleeding disorder Sickle Cell             Heparin Allergy
                  Immune               HIV/AIDS       Rheumatoid Arthritis Systemic Lupus Erythematosus Cytomegalovirus Scleroderma
                                      heat/cold intolerance thyroid disease excessive thirst hypoglycemia hyperglycemia
                                      excessive appetite
                                      seizure     syncope       paralysis      parenthesis    tremor    memory problems cranial nerves
                                      reflexes      motor      sensory
                                      anxiety     depression       anhedonia       substance abuse      mood swings    suicide attempts
                    Psych             Bipolar          Alzheimer’s disease          Schizophrenia
                                       Current treatment or therapy        No      Yes, ____________________
                    Cancer            lung      multiple myeloma        colon       hematological      melanoma      renal      skin
                                      breast     gynecological         prostate
                    Breast            masses        pain     discharge
                                    FEMALE dysfunctional bleeding             menopause
                                    MALE impotence          testicular pain      poor libido    hernia



SECTION 3                                                           NURSING HISTORY

SECTION 3-1 To be Completed by the Registered Nurse
ESRD (2728) Primary Diagnosis: ______________________

Patient’s current knowledge base of kidney failure:
   Excellent             Good              Needs Reinforcement                        Basic knowledge         Dependent on others
Did the patient initiate dialysis at your facility within the last 12 months?    Yes       No
Has the patient received information about Home Hemodialysis/PD within the first 30 days of treatment            Yes       No       Pt. doesn’t recall
Has the patient been dialyzing at your facility for more that 12 months?         Yes       No
Has the patient received information about Home Hemodialysis/PD within the last 12 months               Yes      No         Pt. doesn’t recall
Rev. 12-01-08                                                          Page 2 of 15
Comprehensive Interdisciplinary Patient Assessment
Patient Name/Label: _________________________________________
Does the patient want to pursue home dialysis?          Yes          No, Why;       Unsuitable home situation     Medical Contraindications
   Satisfied with in-center Hemodialysis              No suitable care partner            Psychological Contraindications       Declines
   Undecided Why____________________________________________________________________________________________________
   Other ___________________________________________________________________________________________________________
What was the cause of your Kidney Disease? _____________________________________________________                            Unknown
Has patient received transplant therapy for renal failure?          No       Yes, When____________________________________________________

General Health Status:        Good        Fair       Poor
Current Vital Signs: Height _________ Weight _________                   Well nourished       Obese       Thin
B/P Standing __________        Unable to stand           B/P Sitting ________           Apical Pulse __________ Heart Rhythm:      Regular     ]Irregular
Resp: ________        Cough       SOB              Temp: ____________

Blood Pressure Control (K/DOQI C-Level Goal: <140/80 post dialysis sitting)
Average/Typical _________________                Stable Blood Pressure / No action
History of Frequent Intradialytic:  Hypertension ____________            Hypotension _______________
Action:       Refer to plan of care   Monitor Monthly            Education regarding anti-hypertensive therapy compliance
              Adjust EDW weight as needed           Adjust blood pressure medication

Frequent Hospitalizations:           No           Yes, Action:       Educate patient / family regarding ESRD & complications
   Refer for permanent access placement or revision               Reinforce prescribed treatment/medications/fluid/diet      Refer to plan of care

SECTION 3                                                     NURSING HISTORY

SECTION 3-5 To be Completed by the Registered Nurse
Access Status: Current Access:      AVF Type: Simple Fistula Transposed vein            AVG Type:                       Poly     Other_________
Average Arterial Pressure:____________ Average Venous Pressure:______________ Cannulation Method:                       Rotation    Button Hole
Physical description of access:        Straight  Curved     Loop     Tortuous  Aneurysms
Direction of Flow:___________________________
   CVC – Location:________Date Placed:______________ Average Arterial Pressure:_________ Average Venous Pressure:____________
   Maturing permanent access Works well Difficult cannulation Intermittent flow issues High Ven. Pressures Low Art. Pressures

Med prep for needle insertion:       No          Yes-Type        Lidocaine cream        Lidocaine patch    Emla cream
  Emla patch       Other_________________ Venous mapping done prior to placement: No               Yes  Unknown
Does patient assist with self-care (cannulation / setting up machine): Not permitted in facility Yes   No

Anticoagulation:      N/A Heparin bolus dose:_____________ Maintenance dose:_____________ Other:___________________________
Rev. 12-01-08                                                            Page 3 of 15
Comprehensive Interdisciplinary Patient Assessment
Patient Name/Label: _________________________________________

Access Surveillance Method: Physical Findings:           Persistent swelling        Collateral veins     prolonged bleeding     Altered bruit / thrill
    Intra-access flow – Method_________________      Static pressure – Method______________ Duplex ultrasound      Recirculation
Interventions Required: No       Yes     Angioplasty           Date:____________________ Where____________________________
    Surgical Revision Date:______________ Where___________        Procedures Declotting Date:______________Where______________

Central Venous Catheter: Type of CVC: Quinton        Other:__________ Temporary Catheter: Quinton    Other:__________
Catheter Dysfunction: Manipulation or replacement – Date:__________________________Where:___________________________________
Thrombolytic agent:   Cathflo Activase     Other:______________ Frequency:_______________      Reversed Lines

SECTION 3-10             Hemodialysis Access History of infection:             No      Yes
   Staph aureus       Staph aureus methicillin resistant (MRSA)        Staph epi         Staph epi methicillin resistant   E-Coli      Pseudomonas
   Enterococcus       Enterococcus vancomycin resistant (VRE)            Fungus          Other_____________________________________________
Treatment:      Vancomycin        Cefazolin      Gentamycin         Rocephin          Other_______________________________________

SECTION 3-11          Access Action:       Refer to surgeon for permanent access placement              Patient/Family education on access care
   Not a candidate for permanent access placement Refer to Indications for Hemodialysis Catheter Use below     Patient preference
   All sites exhausted    Limiting co-morbid conditions  Refer to surgeon for follow up    Routine monitoring of access

SECTION 3-12      Indications for Hemodialysis Catheter Use:
   New patient awaiting placement of fistula/graft. (Scheduled date for permanent access placement _____/_____/_____)
   New patient awaiting maturation/healing of fistula or graft. (Date access placed _____/_____/_____)
    Established patient with failed fistula/graft  new fistula/graft planned. (Scheduled date for access placement_____/_____/_____)
    Established patient with failed fistula/graft  awaiting maturation/healing of new access. (Date access placed_____/_____/_____)
    Unable to tolerate increased cardiac output induced by a fistula/graft due to cardiac condition or congestive heart failure
    Severe peripheral vascular disease precludes fistula/graft placement
    All possible graft/fistula access sites exhausted and unable to do peritoneal dialysis
    Awaiting a living donor transplant. (If an extended pre-transplant waiting period is anticipated, placement of a permanent access should be considered)
    Peritoneal dialysis patient requiring a short-term course of Hemodialysis therapy. Date of planned return to peritoneal dialysis ____/____/____)
    Severe vasculitis precludes graft/fistula placement or use until (if) condition improves
    Dermatologic condition involving extremities precludes graft/fistula placement or use (i.e.scleroderma, calciphylaxis, etc.)
    Patient refusing permanent access
    Refuses use of arm access
    Other: Illegal patients – has no coverage_____________________________________

Transplant Status: Patient’s Age________              Every patient has the right to a transplant evaluation.
Patient offered Transplant Options: No             Yes, When___________________________________________________________________
Co morbid conditions: If the patient has any one of the following conditions, it constitutes an absolute contra-indication to transplant
   Vasculopathy               CAD that cannot be repaired by surgery                 Active infections i.e. TB, Hepatitis B (Hep C are transplanted)
   Uncontrolled HIV           Active autoimmune diseases i.e. Lupus                 Nursing Home Patients with no chance of improvement
   Current drug abuse         Current Malignancy                                     Other _________________________________
Patient is not a transplant candidate
   Patient refuses, not interested              Medically unsuitable           Has religious beliefs         Financially unable
Patient with a history of the following should be referred to transplant Center.
   Hepatitis C             Chronic infections            Cirrhosis       Vascular problems            HX of malignancy 2-5 years ago
Patient has been referred to a transplant center for an evaluation.          No      Yes
Referred by: Nephrologist          Patient self-referral      Social worker     Nurse      Other: _____________________

Rev. 12-01-08                                                        Page 4 of 15
Comprehensive Interdisciplinary Patient Assessment
Patient Name/Label: _________________________________________
Specify how patient was referred: Written Communication  Phone call   Other:______________________________________
Patient sent to:_________________________________________________________________for Transplant evaluation
Has patient ever received a transplant?      No   Yes, When___________________________________________________
  Living related donor   Living non-related donor  Cadaver donor   Evaluation in progress

Med Allergies:    NKA       Medications: ____________________________________________________________________________________
Food Allergies:    N/A      Eggs     Peanuts        Chickens        Shell Fish       Iodine

SECTION 3-15 To be Completed by the Registered Nurse
Current Medication / Therapy List
Medication Review (Goal: Medication taken as prescribed)       Medication Compliance                Yes   No
Do you have problems related to the medications you take? No   Yes, Explain_____________________________________________
Do you have another physician prescribing medications? No    Yes, Name:_________________________________________________
Pharmacy name:____________________________________phone:______________________________                             Unknown
Action:     Patient/family education provided on medication schedule, purpose and side effects

EPO_______________units/IV/SQ   2Xweek    3X week     N/A Hectorol____________mcg/IV or PO TIW       N/A
Rocaltrol ________mcg PO TIW   N/A                           Venofer____________mcg/IV    X 10 Tx   Q week     Q Month
Phosphorous Binders Phoslo_______________  Renvela____________    Fosrenol_________________     Tums________________
See Medication Record

Vaccinations: Hepatitis B Antibody      Negative         Positive
Hepatitis B                   Series in process:   1st___2nd___3rd___               Needs Vaccine          Not a candidate or refuses
Pneumovax                    Current Date Given:                                    Needs Vaccine          Not a candidate or refuses
Influenza                    Current Date Given:                                    Needs Vaccine          Not a candidate or refuses
TB                           Current Date Given:                                    Needs Mantoux          Not a candidate or refuses

SECTION 3-17 To be Completed by the Registered Nurse                  NURSING PHYSICAL ASSESSMENT

Mental Health             No Problems         Anxious             Agitated       Apprehensive              Restless
                          Cooperative         Demanding           Depressed      Difficulty Understanding  Happy
                          Willing to Learn    Withdrawn           Dementia       Mood Disturbances         Calm

Physical status: Able to perform: All usual activities All except most strenuous activities Only ADLS
  Severe Physical Limitations     Ambulatory           Steady              Unsteady         Cane             Walker
  Partial Wt. Bearing             Non Wt. Bearing      Slide Board         Splint / brace   Wheelchair       Hoyer lift

Musculoskeletal:         No Problems                  Osteoarthritis                 Osteoporosis
  Hip Replacement: ______________________             Right   Left                   Knee Replacement ______________________        Right   Left

Rev. 12-01-08                                                        Page 5 of 15
Comprehensive Interdisciplinary Patient Assessment
Patient Name/Label: _________________________________________
Amputation:        Right      BKA    AKA and/or           Left        BKA     AKA

Eyes:                 No Problems    Glasses       Dry                      Pain          Glaucoma         Cataracts
                      Blurring       Spots         Recent Vision Changes    Itching       Inflammation     Exudates

Ears:                            No Problems           Tinnitus             Vertigo                 Pain
   Hearing Aid Right     Left    Hearing impairment    Frequent infections  Earache                 Drainage

Speech :      No Problems      Foreign Langange______ Difficulty understanding Difficulty expressing   Hoarseness
Explanation: _______________________________________________________________________________________________________

Mouth :         No Problems         Difficulty chewing           Dentures
 Explanation: ________________________________________________________________________________________________________

Neurological:          No Problems       Orientated to time, place, person Neuropathy              Parkinson’s Disease
  Confusion            Weakness          TIA (Transient Ischemic Attacks)  Paralysis               Restless Leg Syndrome
  Lethargies           CVA (stroke)      Peripheral neuropathy             Parkinson’s Disease     Cerebrovascular disease
Explanation: _______________________________________________________________________________________________________

Respiratory:                 No Problems             SOB                 SOB on exertion             Hemoptysis
Lung sounds Clear Rales/Rhonchi        Wheezes       Frequent Colds      Allergic Rhinitis           Asthma
   COPD                      Sleep Apnea             Tuberculosis        Productive Cough            Non-productive Cough
Explanation: _______________________________________________________________________________________________________

Cardiovascular:      No Problems     Hypertension   Hypotension     Chest Pain Numbness      Tingling     Dizziness/syncope
  Cyanosis             Calf Tenderness      Edema – Location _________________ Non-pitting Pitting ___+1 ___+2 ___+3 ____+4
Pedal pulses:   Present     Not present Explanation:______________________________________________________________________

Skin: Problems    Dry   Moist    Pale   Rash    Lesions   Scars   Hematoma     Broken areas  Jaundice

Gastrointestinal         No Problems     GI Bleed          Indigestion      Anorexia     Peptic Ulcer Disease     Nausea
   Vomiting              Indigestion     Pain               Hiccups         Dysphagia    Gastroparesis
   GERD (Gastroesophageal reflux)         Feeling of Fullness (PD Patients)              GI Disease Specific ___________
Frequency of BM____________ Constipation    Diarrhea      Ostomy Explanation:_____________________________________________

Urinary:           No Problems         Residual urine Amount/Day__________                Color________       Frequency _________     Anuria
   Urgency           Foamy               Hematuria         Dysuria                          Frequent Infections                  Prostate issues

SECTION 3-18 To be Completed by the Registered Nurse                        NURSING PHYSICAL ASSESSMENT

Reproductive: MALE    N/A     No Problems    Date of Testicular exam____________ Unknown Explanation: __________
Reproductive: FEMALE N/A No Problem       Date of Menses________ Unknown         Date of last pap smear________ Unknown
   Date of Mammogram____________ Unknown Explanation: ____________________________________________________________

Infection:          No Problems            MRSA          VRE      Active (current) Explanation: ____________________________________________
   Chronic Hep B           Chronic Hep C      Active (current) Explanation: _________________________________________________________

Surgical Procedures :         No Problems                Transplant              Transplant Nephrectomy            CABG
[ ] Other__________________________________________________________________________________________________________
Rev. 12-01-08                                                           Page 6 of 15
Comprehensive Interdisciplinary Patient Assessment
Patient Name/Label: _________________________________________

Endocrine:       No Problems        Diabetes Mellitus Type I:   Insulin-controlled                  Insulin Pump        oral meds
                                     Diabetes Mellitus Type II: Diet-controlled                    Insulin-controlled  Insulin Pump
     Hyperthyroid         Hypothyroid     Secondary Hyperparathyroidism                            Parathyroidectomy Date:______________________
Explanation: __________________________________________________________________________________________________________

Diabetes Self-Management               N/A Diet: Refer to Dietitian assessment Regular physician checkups:                     No     Yes, Who?      ____________
Foot Checks:         No       Yes, How often _________By who____________ Dental Brushing:                         0      1    2     3+    Flossing:      Yes      No
Blood Glucose monitoring Device :________________________________Usual Blood glucose:______________

SECTION 3-19 To be Completed by the Registered Nurse                              PAIN ASSESSMENT

Pain Assessment Rate the pain by circling the number                                          Right       Front       Left               Left     Back         Right
 Number that best describes your pain on the AVERAGE?
 I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I
 0        1      2        3        4     5     6        7       8         9      10
Number that best describes your pain at its LEAST in the past week?
 I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I
 0        1      2        3        4     5     6        7       8         9      10
Number that best describes your pain at its WORST in the past week?
 I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I
 0        1      2        3        4     5     6        7       8         9      10
What kinds of things make your pain feel better? (Heat, Meds, rest)
                                                                                                     On the diagram, mark an X over area of pain
                                                                                        In the last week, how much relief have pain treatment or medications
What kinds of things make your pain worse? (Walking, Standing, Lifting)                 provided? Please circle the one percentage that most show how much
_____________________________________________                                           relief you have received.
What treatments or medications are you receiving for pain?                                   I_ __ I_ _ I_ _ I_ _ I_ _ I_ _ I_ _ I_ _ I_ _ I_ _ I
_____________________________________________                                            0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
                                                                                        No                                      Complete
Refer to pain clinic:         No       Yes, _________________________                   Relief                                  Relief


SECTION 3-20 To be Completed by the Registered Nurse                            NURSING ASSESSMENT

Physical Activity: Exercise activity is equal to 30 minutes
  Inactive -1 or less exercise activities per week    Inactive light – 1 to 2 exercise activities per week                   Active- 3 to 4 activities per week

Type of Activity                Walking                       Jogging                         Dancing                   Conditioning or weight training
  Home activities (gardening, housekeeping)                   Swimming                        Bicycling                 Other:_______________________________

Physical limitations:                              All usual activities                All except most strenuous activities            Only ADLS
  Severe physical limitation                       Ambulatory                          Steady                                          Unsteady
  Cane                                             Walker                              Wheelchair                                      Slide board
  Partial wt. Bearing                              No wt. Bearing                      Splint/brace                                    Hoyer lift
Rev. 12-01-08                                                                 Page 7 of 15
Comprehensive Interdisciplinary Patient Assessment
Patient Name/Label: _________________________________________

                                                             FALL RISK ASSESSMENT

Fall Risk Assessment Required core elements: Asses one point for each care element “yes”                                                  Yes   No
Diagnosis (3 or more co-existing) Assess for hypotension,
Prior history of falls within 3 months Fall definition, “An unintentional change in position resulting in coming to rest on the ground.
Incontinence Inability to make it to the bathroom or commode in timely manner. Includes frequency, urgency, and /or nocturia.
Visual impairment Includes macular degeneration, diabetic retinopathies, visual field loss, related changes, decline in visual acuity,
accommodation, glare tolerance, depth perception, and night vision or not wearing prescribed glasses or having the correct
Environmental hazards May include poor illumination, equipment tubing, inappropriate footwear, pets, hard to reach items, floor
surfaces that are uneven or cluttered, or outdoor entry and exits.
Poly Pharmacy (4 or more prescriptions) Drugs highly associated with fall risk include but not limited to, sedatives, anti-
depressants, tranquilizers, narcotics, antihypertensive, cardiac meds, corticosteroids, anti-anxiety drugs, anticholinergic drugs, and
hypoglycemic drugs.
Pain affecting level of function Pain often affects an individual’s desire or ability to move or pain can be a factor in depression or
compliance with safety recommendations.
Cognitive impairment Could include patients with dementia, Alzheimer’s or stroke patients or patients who are confused, use poor
judgment have decreased comprehension, impulsivity, memory deficits. Consider patients ability to adhere to the plan of care.

                                                         A score of “YES” 4 or more is considered at risk for falling             Total









SECTION 3-25 To be Completed by the Registered Nurse                  DIALYSIS ADEQUACY
Medical Management:         Adequacy of Dialysis     Goal: URR  65%, Kt/v  1.2               URR: _____ Kt/V_____
Action: Monitor monthly URR      Educate patient on his/her role in achieving adequate dialysis Evaluate Access          Schedule fistula gram
Treatment duration Δ:    Increase______       Decrease_____ Dialyzer size Δ: Increase______              Decrease_____       Refer to plan of care
Missed treatment % in the last 30 days? (Disregard treatments missed due to hospitalization/travel/or another setting: Percentage:___________

SECTION 3-26 To be Completed by the Dietitian                       ANEMIA MANAGEMENT

Anemia Management: Goal: Hgb 10-12 mg/dl, Tsat > 20% Ferritin >100 <500 Hgb : ______ Hct:______ Tsat : ______ Ferritin;_______
                           Is Hgb 10-12?    Yes     No      Is Ferritin >100 <500   Yes    No Is Tsat > 20%   Yes        No
Is there an active infection?    Yes      No Organism:_______________________________
Is co-morbid conditions affecting anemia:   Yes      No If yes, what?
Recent transfusions:         Yes      No        Predisposition to bleeding?     Yes     No

Rev. 12-01-08                                                      Page 8 of 15
Comprehensive Interdisciplinary Patient Assessment
Patient Name/Label: _________________________________________
Rapid change in Hgb       Yes        No         Occult blood tested? Yes     No If yes, date & results:_____________________________
ESA dose:_________________________________ Date of last ESA Change___________________________________________________
Iron dose:__________________________________ Date of last iron dose change: _______________________________________________
Action: Monitor Hgb and Tsat per protocol and/or Monthly             Adjust ESA per MD order/protocol Monthly
          Administer/adjust IV iron per MD Order/Protocol            Evaluate for causes of hypo response to ESA
          Current Prescribed ESA treatment:_________                  Draw Carnitor level           Refer to plan of care

SECTION 3 -27 To be Completed by the Dietitian                   BONE MANAGEMENT

Bone Management Goal: Intact PTH 150-300, Ca: 8.5-10.2, PO4: 3-5.5, Ca x PO4 product: 55               Refer to attached lab results
Lab Review: Ca : _____ cCa : ____ Ca x PO4: _______ cCa x PO4: _______ PO4:__________ Intact PTH: ______
Phosphorus:_____________________ Trends:           Usually in Goal         Usually High      Usually Low         Other_____________________
Calcium:_________________________ Trends: Usually in Goal                  Usually High      Usually Low        Other_____________________
Intact PTH:_______________________ Trends: Usually in Goal                 Usually High      Usually Low        Other_____________________
Medications: Phosphorus binder__________________________ Calcium supplement__________________________________________
    Vitamin D ___________________________________________ Diet Issues: Adherence Good                     Fair        Poor
Education: Understands diet: Yes         No Comments:___________________________________________________________________
Action: Refer to plan of care      Monitor pertinent chemistries per protocol and/or Monthly             Follow vitamin D protocol
    Educate patient on bone health               Phosphorus counseling on diet and taking binders as prescribed/adjust binder dose
    Current Prescribed Vitamin D analog:____________________________________________________________________________________

SECTION 4 To be Completed by the Dietician                      DIETITIAN ASSESSMENT

Nutritional Status; Goal: Albumin =  4.0    Albumin: ______________
Diet Order: _________________________________________ Weight Change?    Yes     No If “Yes” - % wt. change _______
Medical History:_______________________________________________________________________________________________________
Treatment: Hemodialysis _______times/week
HT_____ In/______cm WT______#/______kg IBM________±10% WT Hx ____________BMI ______Age ______Sex_______
EDW__________________________IDWG (Intradialytic Wt gain)_________ kg
Caloric Needs _______cal/kg EDW Protein Needs _____________gm/kg IBW Fluid Needs _____________ml/kg BW

Medications Changes: EPO __________        Hectorol _________   Venofer ____________     Carnitor _______________
  Phosphorus binders _______________________ Sensipar____________________       Potassium bath to ________K+
SECTION 4D       Laboratory Values: Date:__________________________ MD aware             √Carnitine Level___________
Ca++___________ URR___________ Albumin________ iPTH___________ PO4_______ BUN_______________
Glucose_________ HCT___________ HGB___________ Hgb A1C ________ K+ ________ Creatinine________ Cholesterol__________
WBC________     Tsat_______% Ferritin__________ HGBx3_________ Ca/Phos Product_____________ Triglycerides ____________
Diabetes Mellitus controlled   Yes    No      Bone Disease controlled         Yes   No    Anemia controlled   Yes    No
SECTION 4E Physical Impairments:
   Impaired vision/blind                Dentures/missing teeth                       Bed/Chair Bound            HOH
   Mouth Sores                          Difficulty w / Ambulation                    Deaf                       Dysphagia
   Unable to feed self                  Change in taste acuity                       Dry Mouth                   Decreased Cognition
GI Complaints: Constipation             Diarrhea                 Vomiting            Nausea            None noted

Clinical Observations: Muscle wasting Areas _______________________________Severity______________________________
Edema Areas__________________________________________________________________ +1              +2     +3     +4
Subcutaneous Fat Depletion: Areas_______________________________________________Severity_______________________________
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Comprehensive Interdisciplinary Patient Assessment
Patient Name/Label: _________________________________________
SECTION 4G Cultural Factors related to diet: Religious food:_____________________________________________________________
Cultural foods:______________________________________________________________________________________________________
Party responsible for purchasing and preparing food: ________________________________________________
Primary language: English         Spanish     Other:______________        Vision: Good        Impaired
Hearing: Good            Hearing Aid      Hard of hearing
Lives alone?      Yes      No, Has meals alone?       Yes       No People whom meals are shared:________________________
Frequency for dining out: _________________ Does patient receive food assistance? Yes            No If yes source:_________________
Dietary intake adequate? Yes          No          Excessive intake? Receiving nutritional supplement?      Yes      No
Gastrointestinal changes lasting > 2 wks?     Yes        No If “Yes”: Loss of appetite       Nausea       Vomiting     Diarrhea
Patient is: Well nourished OR At risk for malnourishment:          Mild     Moderate        Severe
SECTION 4H           Dietitian Action: Monitor labs, weight & weight changes, and other parameters Nutrition Education Provided
   Refer to plan of care      Counsel patient on ways to increase calorie and protein intake     Counsel on weight loss through diet/exercise
   Encourage use or increased use of nutritional supplements          Refer to MSW for financial/community resources Refer MD follow up
Labs/graphics discussed with Nursing home           Caregiver/family Patient               Educate on diet adjustment
SECTION 4I         Fluid Control (Goal: Fluid gain <= 5% of EDW)            Goal met         Goal not met
Action: Monitor weight gains q TX            Patient education on sodium/fluid/glycemic control and signs of fluid over Re-evaluate EDW
    Refer to plan of care     Other_______________________________________________________________________________________







SECTION 5                                              SOCIAL SERVICE ASSESSMENT

SECTION 5-1 To be completed by Social Worker
Advance Directives      No       Yes, Copy in chart Appointee Name:_______________________________________________________
   Do Not Resuscitate order at Facility     No    Yes         Do Not Resuscitate order in Community        No     Yes
   Court Appointed Guardian       No      Yes, Appointee Name:________________________________________________________________
   Financial Durable Power of Attorney       No     Yes, Name:________________________________________________________________
  Information given to patient/family Date Provided____________________          Patient Declines / Not Interested

Insurance Status Insurance    No     Yes
Insurance _______________________________________               Primary      Secondary     Active     Pending      Other___________________
Insurance _______________________________________               Primary      Secondary     Active     Pending      Other___________________
Insurance _______________________________________               Primary      Secondary     Active     Pending      Other___________________
Veterans Service_________________________________               Primary      Secondary     Active     Pending      Other___________________

Transportation to Dialysis        Drives Self    Public Transportation   Family assistance Friends assistance
     Taxi (self-pay)     Insurance funded transportation    Ambulance     Other____________________________________________________
Is transportation reliable to/from dialysis   Yes      No, explain________________________________________________________________

SECTION 5-4                                                                 Current Employment
Prior Employment If initial-use 6 months prior to starting dialysis            Employed Full Time     Employed Part Time      Retired
    Employed Full Time      Employed Part Time          Retired                Medical Leave of Absence     Not employed - By Choice
Rev. 12-01-08                                                    Page 10 of 15
Comprehensive Interdisciplinary Patient Assessment
Patient Name/Label: _________________________________________
   Medical Leave of Absence           Not employed - By Choice          Not Employed – Disabled   Not Employed – Looking for Work
   Not Employed – Disabled            Not Employed – Looking for Work   Normal Age retirement     Medical Retirement
  Normal Age retirement               Medical Retirement
School Status: Student     No          Yes , Where__________________________________________________________________________

Vocational Rehabilitation Status If not working          Enrolled in a Vocational rehab agency      Referred to a Vocational rehab agency
   Interested, but has not followed up        Not interested        Not eligible     Pursuing a vocational interest     Developing Self-Help Skills
Are there barriers identified preventing positive vocational outcomes?        No     Yes , Explain Barriers_________________________________

Rehabilitation Goals: What are the patient’s goals?
Vocational goals: Now_______________________________________________________________________________________________
The next 5 years:___________________________________________________________________________________________________
Personal goals: Now_________________________________________________________________________________________________
The next 5 years:___________________________________________________________________________________________________
Educational goals: Now______________________________________________________________________________________________
The next 5 years:__________________________________________________________________________________________

Living Status       House       Condo        Mobile home       Apartment       Rents House          Homeless
    Public Housing       Shelter      Long-Term care Facility (SNF)     Acute Rehabilitation Center      Assisted Living       Adult Group Home
With whom does the patient live?             Lives alone        Parents        Spouse          Child/Children         Significant other
    Significant Friend     Significant Relative     Other_______________________________________________________________________
Is the current living situation a barrier to positive treatment outcomes?       No        Yes, Describe_________________________________

SECTION 5-7 Social Status:
 Income                 No problems                      Maximum Assistance in place              Referral needed              Referral in process
Food                    No problems                      Maximum Assistance in place              Referral needed              Referral in process
Medication              No problems                      Maximum Assistance in place              Referral needed              Referral in process
Utilities               No problems                      Maximum Assistance in place              Referral needed              Referral in process
Housing/rental          No problems                      Maximum Assistance in place              Referral needed              Referral in process
Legal                   No problems                      Maximum Assistance in place              Referral needed              Referral in process
Immigration             No problems                      Maximum Assistance in place              Referral needed              Referral in process
Other                   No problems                      Maximum Assistance in place              Referral needed              Referral in process
Other                   No problems                      Maximum Assistance in place              Referral needed              Referral in process

SECTION 5-8 Mobility Status and Activities of Daily Living:
Ambulatory assistance:        None      Cane/crutch        Walker       Manual Wheelchair        Electric wheelchair   Limb prosthesis ____________
  Near total / Total Disability Cannot work, difficulty participating socially. Barely able to perform self-care.
  Frequent hospitalization for management of complications and physical symptoms.
   Marked Disability Substantially reduced work load and participation in social activities. Some independence in self care
   Mild/Moderate disability Performs all or most ADL’s. Moderate limitations from symptoms or lack of endurance
    Minimal /No disability Performs all or most ADL’s without limitation. Some adjustment in social activities   Refer to plan of care
Assistance required for:      Bathing       Toileting     Dressing        Medication Management         Meal Preparation      House keeping
    Laundry      Transportation       Shopping       Finances      Medical Appointments       Other:______________________________________
Is there adequate support or services in place to provide assistance?             No     Yes, Describe_________________________________
SECTION 5 -9        What is the patient’s learning preference:         Seeing       Hearing      Doing

  Tobacco    N/A   Packs per day_______Years_____
  Alcohol    N/A How often:    Daily   4 + weekly   2- 3 Weekly     2-4 Monthly    Monthly or less
  Drugs      N/A Name of Drug:__________ How often: Daily     4 + weekly    2- 3 Weekly     2-4 Monthly                       Monthly or less

Rev. 12-01-08                                                       Page 11 of 15
Comprehensive Interdisciplinary Patient Assessment
Patient Name/Label: _________________________________________
Have you ever received Drug or Alcohol treatment?        No      Yes When _________________________________________________________

Support System and Spirituality What is the patient’s relationship status?    Domestic partner       Married     Divorced       Single
    Widowed        Separated Describe family composition: ____________________________________________________________________
What is the level of involvement of family and friend on a regular basis:      Daily     Weekly    Monthly      Less frequently than monthly
How does the patient cope with life events and dialysis stress?        Keeps it to him/herself   Talk to family    Talk to friends     Pray
    Talk with a professional     Support group     Resources on the internet     Other______________________________________________
Is the patient involved in community activities, groups, social events or volunteering?        No       Yes, Describe___________________
What has the patient previously done for enjoyment or recreation? __________________________________________________________
Is (s) he able to engage in these activities now?       No       Yes
Is the patient part of a spiritual or religious community      No      Yes, Describe______________________________________________
Are there any specific cultural or spiritual practices/restrictions?    No       Yes, Describe____________________________________

Cognitive Patterns & Cognitive Skills Is there evidence of a change in cognitive status from the patient’s baseline since the last assessment?
(initial assessment, compare to reported status 6 months prior to starting dialysis treatments)       No        Yes
The patient makes decisions regarding tasks of daily life:         Independent – decisions consistent and reasonable
     Modified independence – some difficulty in new situations       Moderately impaired – decisions poor, cues/supervision required
     Severely impaired – never/rarely makes decisions
Does the patient appear to have a problem with the following? Short Term Memory                  No        Yes        Long term Memory     No        Yes
If yes, the patient was normally able to recall the following during the last 5 days:
     Current Season        Day of the Week        Staff names and faces         That ( s )he is in a dialysis facility     None of the above is recalled


                                                                                                            Behavior             Behavior present,
                                                                                       Behavior           continuously          fluctuates (comes
                                                                                      not present         present does          and goes, changes
                                                                                                          not fluctuate             in severity
Inattention – Did the patient have difficulty focusing attention (easily distracted,
out of touch, or difficulty keeping track of what was said)?
Disorganized thinking – was the patient’s thinking disorganized or incoherent
(rambling or irrelevant conversation, unclear or illogical flow of ideas, or
unpredictable switching from subject to subject)?
Altered Level of consciousness – Did the patient have altered level of
consciousness (Not related to low blood pressure)?
Psychomotor retardation – Did the patient have an unusually decreased level
of activity (sluggishness, staring into space, moving slowly)?
What sources of information were used in answering this section?
    Patient’s self-report      Medical records       Observations of dialysis staff    Social supports/family Other:_______________________
Does the patient’s behavior change during dialysis treatments?                No     Yes, describe_______________________________________

Mental Health Status – Does the patient report any past or current mental health issues, concerns or mode disturbances (feeling of
depression or anxiety?      No       Yes, describe_______________________________________________________________________
    Unknown – Reason______________________________________________________________________________________________
Is there any history of mental health diagnosis?     No      Yes, record below
                               Diagnosis                                                        Approximate Date of Diagnosis

Rev. 12-01-08                                                      Page 12 of 15
Comprehensive Interdisciplinary Patient Assessment
Patient Name/Label: _________________________________________

Has the patient participated in counseling?      No     Currently in counseling (describe)      Yes, in the past (describe)
Has the patient started counseling or a support group?    No      Yes, Describe______________________________________________
Are there signs/symptoms present for depression or anxiety problems?       No       Yes, complete signs and symptoms below

                                   SECTION 5-14                                                                 Severity Level
                             Signs and Symptoms                                              Not a
                                                                                                               Mild          Moderate       Severe
Depressed mood most of the day
Decreased interest/pleasure in most activities
A problem with appetite/weight change
Significant sleep disturbance
Psychomotor retardation or agitation
Fatigue, loss of energy
Feelings of worthlessness or guilt
Poor concentration
Suicidal ideation
Panic attacks
Irritable mood
Early awakening
This signs/symptoms list is not comprehensive and is not intended to diagnosis depression, Further assessment should be completed if
signs/symptoms are present. Somatic symptoms may be due to medical causes.

SECTION 5-15 Has the patient started taking a psychotropic medication?                    No       Yes, note below
                                                                                                                Not         Adverse       Not Yet
                      Medication and Dosage                                Date Started        Effective
                                                                                                             Effective      Reaction    Determined

SECTION 5-16    If Unable to interview patient specific reason: Yes No,
SECTION 5-17          Say to the patient: “Over the past two weeks, have you often been bothered                    Yes               No
Decreased interest/pleasure in most activities?____________________________________________________
Feeling of worthlessness or guilt?______________________________________________________________
Little interest or pleasure in doing things?
Feeling low, depressed, or hopeless?
Communication Status: Are there physical or cognitive barriers that affect the patient’s ability to communicate? No      Yes, Describe
                                                                                                        N/A        No           Barriers
                   Assessment of Patients Ability to Communicate in English
                                                                                                                 Limitation     Present
Able to communicate in English
Not able to communicate in English – Requires interpretation assistance at all times
Only able to communicate basic needs to staff – Uses single words or short phrases – requires
interpretation assistance for conversations and care planning
Able to communicate with staff in most situations – Able to carry on conversations with staff.
Requires occasional interpretation assistance for more complex conversations
If barrier is present: What is the patient’s primary language for communicating with facility staff?   N/A___________________________

SECTION 5-19         N/A
When interpretation assistance is required, how does the patient communicate with the care team
    Family                        Friends and/or other social supports            Professional Interpreter               Community Agency
    Facility staff (able to communicate with the patient in their primary language
    None of the above (care team unable to effectively communicate with the patient)

Rev. 12-01-08                                                      Page 13 of 15
Comprehensive Interdisciplinary Patient Assessment
Patient Name/Label: _________________________________________
Is the patient able to read printed materials?
                Language                      Yes       No     Limited                                  Details

Patient’s level of understanding & Level of Participation               Not Able           Limited                Adequate          Excellent
Chronic kidney disease
Treatment options
Dialysis vascular access options

                                                                               Very     Somewhat      Neither easy     Somewhat           Very
Patient Interview: “Over the past month, how easy or                N/A
                                                                               Easy       Easy        nor Difficult     Difficult        Difficult
difficult has it been for you to do any of the following?”
Come to each hemodialysis treatment.
Complete the full-prescribed hemodialysis treatment time.
Perform every peritoneal dialysis treatment.
Take medications as prescribed.
Follow dietary restrictions.
Follow fluid restrictions

What is the number of percentage of shortened treatments in the last 30 days? _________         N/A

Does patient appear comfortable asking staff/physician questions?       N/A        Yes       No
                                             Does not know what questions to ask                             Cannot speak
If NO, what factors limit the patient’s
                                             Does not speak English or any language staff speak              Limited Cognitive ability
comfort in asking questions?
                                             Thinks asking questions is disrespectful                        Other

SECTION 6                                                      EDUCATION

                                                                                         Staff Signature
Introduce self to patient and family or S.O.

Orientation to Unit     Waiting room, lockers, and bathroom    Family Visiting rights    Staff Signature
   Food and drink policy     Patient Schedule     Unit hours   Parking                   ___________________________

Consents         Hemodialysis     Reuse    Release of information                        Staff Signature
                 Hepatitis vaccine HIPAA Consent                                         ___________________________

Concepts of dialysis
Normal Kidney Function        Fluid retention   Chemical Balance Waste Products
Renal Failure      Signs and symptoms       Cause of this patient’s kidney failure
Artificial Kidney
Equipment and Monitors                                                                   Staff Signature
Medical Problems during Dialysis Decreased BP              N/V         Muscle cramps     ___________________________
Access Care       Infection    Clotted Access     line separation
Treatment Options        Hemodialysis Home Hemodialysis PD Transplant
Medications Dose Schedule Purpose for taking medications
                 Side Effects Heparin Consent

RN Only          Admission Data - Home Medication Sheet                                  Staff Signature
                 Problem List - Diet and fluid Management                                ___________________________

Social Service      Transportation   Finances                                            Staff Signature
Rev. 12-01-08                                                  Page 14 of 15
Comprehensive Interdisciplinary Patient Assessment
Patient Name/Label: _________________________________________
Patient Handbook given Containing:     Advance Directives Grievance procedure         ___________________________
                                       Patient Bill of Rights Standards of Conduct

Emergency Evacuation & Disconnect        Clamp and Disconnect                         Staff Signature
  Fire, Tornado, Bomb Threat, Power Failure, Unit Emergency                           ___________________________

                                                                                      Staff Signature
Emergency Phone Numbers          Dialysis Unit     Nephrologist    Hospital

Admission Lab Work completed                                                          Staff Signature
Initiate Patient Education Worksheet                                                  ___________________________

                                                                                      Interpreter Signature
Interpreter Used     Yes       No

                                                 Comprehensive Interdisciplinary Signatures:
Nephrologist                                                                                                    Date:
Nurse                                                                                                           Date:
Dietitian                                                                                                       Date:
Social Worker                                                                                                   Date:
Transplant                                                                                                      Date:
Patient                                                                                                         Date:

Rev. 12-01-08                                                     Page 15 of 15

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