TABLE OF CONTENTS. Page TAB 1. Overview of Resident Assessment Process 6. RAP REVIEW or Working the RAP Steps 10

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1 TABLE OF CONTENTS Page TAB 1 Overview of Resident Assessment Process 6 RAP REVIEW or Working the RAP Steps 10 Working the RAPS & Documentation Systems 2 TAB 2 RAP Key 31 RAP Training Guidelines and care planning 3 RAP One...Delirium 3 RAP Two...Cognitive Loss/Dementia 38 RAP Three...Visual Function 42 RAP Four...Communication 4 RAP Five...ADL Functional and Rehabilitation Potential 48 RAP Six...Urinary Incontinence and Indwelling Catheter 1 RAP Seven...Psychosocial Well-Being 7 RAP Eight...Mood State 60 RAP Nine...Behavior Problems 64 RAP Ten...Activities 68 RAP Eleven...Falls 71 RAP Twelve...Nutritional Status 79 RAP Thirteen...Feeding Tubes 83 RAP Fourteen...Dehydration/Fluid Maintenance 8 RAP Fifteen...Dental Care 88 RAP Sixteen...Pressure Ulcers 90 RAP Seventeen...Psychotropic Drug Use 9 RAP Eighteen...Physical Restraints 103

2 TABLE OF CONTENTS (Continued) TAB 3 Page ATTACHMENTS a. MDS Forms 111 b. Initial Integrated Nursing Assessment tool 140 c. RAP Review Form for narrative system (progress note example) 142 d. Assessment/RAP Review Forms (Discipline Specific) Nursing Assessment and Rap Review Addendum Nursing Assessment/RAP Review 18 (When Nurse is responsible for all RAPs including:) 3. Nursing Quarterly Assessments Models Social Services Assessment and RAP Review 163. Quarterly Social Services Assessment Activity Assessment and RAP Review Activities Quarterly Review Nutritional Assessment and Rap Review Nutritional Quarterly Assessment 170

3 QUARTERLY RISK TOOL Bowel and Bladder Initial Assessment Bladder Control Bowel Control Can walk to BR or transfer to toilet. Can manage clothes, wipe, urinal Mental Status Continent or has indwelling catheter Continent more than 4xweek or colostomy Alone with reasonable speed Alert and oriented Continent at least 3xday Continent 3-4xweek Alone but slow Forgetful but can follow prompts Continent 1-2xday Continent 1-2xweek Needs assist from one person Confused, needs verbal and physical prompts and assistance Never Continent Never Continent Dependent or needs assist from 2 persons or more Very confused, combative, refuses to cooperate, depressed SCORE Mentally aware of toileting needs Yes, always Usually Sometimes Never Condition of skin, genitals, perineal and buttock Predisposing Dis.(DM, CVA, Prostatic Dis, UTIs, Neurogenic Bladder, retention, Terminal) Medications (diuretics, narcotics, sedatives/hypnotics, antidepressants/antianxiety, antispasmodics, antihistamines, Calcium channel blockers, antiparkinson s, antipsychotics, neuromuscular) No redness Some redness Stage 1-2 pressure Ulcer Absent Minor Moderate Severe None Yes, taking one or the meds listed Yes, taking two Stage 3-4 Pressure Ulcer Yes, taking three or more TOTAL Potential B&B Retraining: 18-24:Retraining potential, 10-17: Potential for Habit/Prompted/Scheduled Toileting, 0-9: Poor candidate Routine Toileting Decline/change noted, Further assessment indicated: Yes / No BRADEN SCALE Risk assessment tool for skin breakdown SCORE FALL PRONE EVALUATION POINTS Sensory Perception ure 1. Completely 1. Constantly Poor Activity 1. Bedfast 2. Chairfast Mobility Nutrition 1. Completely Immobile 1. Very Poor 2. Probably inadequate 3. Slightly 3. Occasionally 3. Walks Occasionally 3. Slightly Impaired 4. No Impairment 4. Rarely 4. Walks Frequently 4. No Limitations 3. Adequate 4. Excellent Confused & disoriented, senile Hallucinating or becomes confused at night History of falls 1 Limitations: a. Unsteady on feet b. Poor eye sight c. Poor Hearing d. Drugs or alcohol e. Post Operative condition/sedation f. Language barrier g. Attitude (resistive, belligerent, combative, fearful) 1 Friction & Shear 1. Problem 2. Potential problem 3. No Apparent Problem 4. No Problem TOTAL POINTS: Instructions: If points total 1 or more, patient should Results: 1 18 = At Risk TOTAL be identified FALL PRONE = Moderate risk SCORE: Fall Risk Program initiated/in place: Y/N = High Risk ( ) 9 = Very High Risk Changed in risk factors? Yes / No < 14 initiate skin care; prevention and treatment guidelines Describe risk factors: Change in risk factors? Yes / No Signature: Date: Resident RM# MR# Physician Page 1 of 1

4 QUARTERLY SOCIAL SERVICES ASSESSMENT (Subjective / Objective Data) Current Status / Progress towards Goals to Obtain Highest Level of Psychosocial Well- Being: Changes Influencing Psychosocial-Well Being/Mood/Behaviors Evaluation/Plan: Signature Date: Current Status / Progress towards Goals to Obtain Highest Level of Psychosocial Well- Being: Changes Influencing Psychosocial-Well Being/Mood/Behaviors Evaluation/Plan: Signature Date: Resident: Room: MR#: Physician: Page 1 of 1

5 PRELIMINARY NURSING ASSESSMENT Admit Date Admit time From Via Diagnosis Allergies: T: P: R: BP: HT: WT: 1. COGNITIVE (CIRCLE) ALERT / ORIENTED TO: PERSON PLACE TIME MEMORY PROBLEMS / ACUTE CONFUSION / LETHARGIC / SEMI COMATOSE / COMATOSE: DESCRIBE CARE PLAN Y OR N 2. MOOD AND BEHAVIOR (CIRCLE) ELOPEMENT POTENTIAL: Y or N If yes, complete full Elopement Assessment tool (Circle One) WITHDRAWN / PACING / VERBALLY ABUSIVE / CRYING / WEEPING / ANGRY / RESISTS CARE / REPETITIVE BEHAVIORS / AGITATION/ OTHER: CONDITION/DIAGNOSIS: CARE PLAN: Y OR N RECEIVING: HYPNOTIC / ANTIPSYCHOTIC / ANTIANXIETY / ANTIDEPRESSANT: LIST MEDS: If applies: BEHAVIOR MONITOR INITIATED: REFERRED TO PHARMACY: CONSENT SIGNED: SIDE EFFECT MON. STARTED: AIMS: 3. COMMUNICATION (CIRCLE) HOH / DEAF L R B HEARING AIDE L R B / OTHER: COMMUNICATES: SPEECH / GESTURES / WRITES / OTHER APHASIC CAN BE UNDERSTOOD Y OR N UNDERSTANDS Y OR N CARE PLAN: Y OR N REFER TO THERAPY: Y OR N 4. VISION (CIRCLE) ADEQUATE Y OR N GLASSES Y OR N BLIND Y OR N L R B LENS IMPLANTS L R B PROSTHESIS L R B GLAUCOMA / CATARACTS / FIELD CUT L R B CARE PLAN: Y OR N. PAIN (CIRCLE) VERBAL OR NONVERBAL EXPRESSION OF PAIN: PAIN: Yes No CARE PLAN Y OR N COMPLETE PAIN SCREEN ON ALL RESIDENTS: IF SCORE IS GREATER THAN 3, COMPLETE FULL ASSESSMENT FORM.: Pain Screen Score: Pain Scale: 1-10: RESIDENT: RM: MR# Page 1 of 4

6 PRELIMINARY NURSING ASSESSMENT 6. Bowel and Bladder Initial Assessment SCORE Bladder Control Bowel Control Can walk to BR or transfer to toilet. Can manage clothes, wipe, urinal Mental Status Continent or has indwelling catheter Continent more than 4xweek or colostomy Alone with reasonable speed Alert and oriented Continent at least 3xday Continent 3-4xweek Alone but slow Forgetful but can follow prompts Continent 1-2xday Continent 1-2xweek Needs assist from one person Confused, needs verbal and physical prompts and assistance Never Continent Never Continent Dependent or needs assist from 2 persons or more Very confused, combative, refuses to cooperate, depressed Mentally aware of toileting needs Yes, always Usually Sometimes Never Condition of skin, genitals, perineal and buttock No redness Some redness Predisposing Dis.(DM, CVA, Prostatic Dis, UTIs, Neurogenic Bladder, retention, Terminal Medications (diuretics, narcotics, sedatives/hypnotics, antidepressants/antianxiety, antispasmodics, antihistamines, Calcium channel blockers, antiparkinson s, antipsychotics, neuromuscular) Stage 1-2 pressure Ulcer Absent Minor Moderate Severe None Yes, taking one of the meds listed Yes, taking two Potential B&B Retraining: 18-24:Retraining potential, 10-17: Potential for Habit/Scheduled Toileting, 0-9: Poor candidate (CIRCLE) CATHETER/ COLOSTOMY / HX OF LAXATIVE / ENEMA / SUPPOSITORY: Stage 3-4 Pressure Ulcer Yes, taking three or more TOTAL DATE OF LAST BM HX OF CONSTIPATION / FECAL IMPACTION: USES: COMMODE/ BP/ URINAL/TOILET INITIATE VOIDING PATTERN Y OR N CARE PLAN Y OR NO CATHETER JUSTIFICATION: OTHER RISK FACTORS/OBSERVATIONS: 7. ADL (CIRCLE) BED MOBILITY: INDEP SUPERVISED ASSIST 1 2 DEPENDENT 1 2 TRAPEZE SIDE RAILS FOR BED MOBILITY TRANSFER: INDEP SUPERVISED ASSIST 1 2 DEPENDENT 1 2 AMBULATION: INDEP SUPERVISED ASSIST 1 2 DEPENDENT 1 2 ADAPTIVE DEVICE TOILETING: INDEP SUPERVISED ASSIST 1 2 DEPENDENT 1 2 DRESSING: INDEP SUPERVISED ASSIST 1 2 DEPENDENT 1 2 SET-UP ONLY ADAPTIVE DEVICE GROOMING: INDEP SUPERVISED ASSIST 1 2 DEPENDENT 1 2 SET-UP ONLY EATING: INDEP SUPERVISED ASSIST 1 2 DEPENDENT 1 2 SET-UP ONLY ADAPTIVE DEVICE CONTRACTURES: Y OR N AT RISK? Y or N JOINT (S) / SEVERITY: SPLINTS / PROTHESIS / BRACE:: REFERRAL TO THERAPY Y OR N REFERRAL TO RESTORATIVE Y OR N CARE PLAN Y OR N OTHER RISK FACTORS/OBSERVATIONS: RESIDENT: RM: MR# Page 2 of 4

7 PRELIMINARY NURSING ASSESSMENT 8. Risk assessment tool for skin breakdown SCORE 9. FALL PRONE EVALUATION POINTS Sensory Perception 1. Completely Poor 3. Slightly 4. No Impairment Confused & disoriented, senile Hallucinating or becomes confused at night 1 ure 1. Constantly Activity 1. Bedfast 2. Chairfast Mobility Nutrition 1. Completely Immobile 1. Very Poor 2. Probably inadequate 3. Occasionally 3. Walks Occasionally 3. Slightly Impaired 4. Rarely 4. Walks Frequently 4. No Limitations 3. Adequate 4. Excellent History of falls 1 Limitations: a. Unsteady on feet b. Poor eye sight c. Poor Hearing d. Drugs or alcohol e. Post Operative condition/sedation f. Language barrier g. Attitude (resistive, belligerent, combative, fearful) Friction & Shear 1. Problem 2. Potential problem 3. No Apparent Problem 4. No Problem TOTAL POINTS: Results: 1 18 = At Risk TOTAL = Moderate risk SCORE: = High Risk ( ) 9 = Very High Risk < 14 initiate skin care; prevention and treatment guidelines. OTHER RISK FACTORS: PVD/ DIABETES / MALNUTRITION / UNDERWEIGHT/CIRCULATORY/ RESISTIVE TO CARE / TERMINAL /END-STAGE DEMENTIA/ SEVERE COPD / SEPSIS / PARA/QUADPLEGIA / BOWEL INC / BODY CAST / CONTINUOUS URINARY INC / CHRONIC LIVER, HEART, HEART DIS / IMMUNOSUPPRESSION / STEROID THERAPY / RENAL DIALSYIS / RADIATION THERAPY / CHEMOTHERAPY / HOB UP DUE TO MED COND Safety: CARE PLAN SKIN RISK Y OR N Instructions: If points total 1 or more, patient should be identified FALL PRONE Fall Risk Program initiated/in place: Y/N Unsafe transfer Y/N Uses call light effectively Y/N Waits for help Y/N Alteration in safety awareness Y /N Comatose, semi, fluctuating Y/N Risk of seizure Y/N Immobile in bed Y/N Difficulty with trunk control Y/N Able to use SR for positioning Y/N Side rail: All down Full rails both up One full rail up- R or L Half rails up-r or L or both Bottom rails up- R or L or both Other: Rationale: No side rails needed Alert Resident preference Enhance Bed mobility Prevent rolling OOB Provide reminder to not rise Unassisted Side rail is restrictive Care Plan Y or N Obtained physician order for side rail: If restrictive complete full assessment: Obtained consent: RESIDENT: RM: MR# Page 3 of 4

8 PRELIMINARY NURSING ASSESSMENT 10. NUTRITION / HYDRATION / DENTAL DIET: FLUID RESTRICTIONS: CHEWING PROBLEMS: DESCRIBE SWALLOWING PROBLEMS: DESCRIBE IV: HYDRATION RISK / AWARE OR UNAWARE OF THIRST / UNABLE TO ACCESS AND DRINK FLUID DENTURES/PARTIAL: UPPER - LOWER USES / DOES NOT USE / MOUTH PAIN / BLEEDING GUMS ORAL STATUS: FEEDING TUBE / TPN : REFER TO THERAPY Y OR N 11. SYSTEMS REVIEW CARE PLAN Y OR N NEUROLOGICAL STATUS: WNL DEVIATION: SEIZURES PUPILS CARDIOVASCULAR: WNL DEVIATION: EDEMA HEART SOUNDS RESPIRATORY: WNL DEVIATION: COUGH SPUTUM LUNG SOUNDS GASTRO INTESTINAL: WNL DEVIATION: BOWEL SOUNDS ABDOMEN OTHER: TRACH SUCTIONING INJECTIONS IV MEDS O2 DIALYSIS 12: Self Administration of Meds: Resident desires to self-adm. Meds? If yes, proceed with further assess. 13. SUMMARY / PROBLEMS NURSE: DATE: SECTION: NURSE: DATE: SECTION: RESIDENT: RM: MR# Page 4 of 4