HOME DIALYSIS Pre-Assessment Form

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1 Date of Assessment: Cell Phone: Work phone: CONTACT Person: Renal Diagnosis: Transplant Status: Medical History: Dialysis History: Current Medications: (attach copy of medication list if posssible) Access History (PD or Vascular): 1 of 9

2 Research demonstrates that the ability to self manage one s own care while working in partnership with the health care team results in better health outcomes and increased satisfaction with services received. The Home Dialysis (HD) Patient Assessment has been created to gain a greater insight into the current self-management practices of the potential HD patient. Results obtained will assist in the development of a self-management care plan to meet the individual s unique needs. Who should complete the assessment? A member of the health care team, ideally a training nurse, should fill in this form with the patient interested in Home Dialysis as a therapy modality. Family members may be included as identified. The assessment is not intended to be a self-administered tool. Valuable insight and understanding will be obtained from the discussion surrounding each patient s response to questions rather than from the actual score obtained using the tool. TO BE ADMINISTERED BY STAFF: Record Patient s / or Care Giver s NUMERIC RESPONSE ADDING TO CLARIFY At the side in Box, record Nurses (subjective) score this may vary from the Patient/Care Provider score (to be used for assessment comparison) When to complete the assessment? The assessment should be completed when a patient identifies an interest in Home Dialysis and prior to the commencement of training. How to complete the assessment? Each of the 26 questions should be explored using open-ended questions such as those provided. Thoughts are provided to assist the interviewer in the wording or direction of questions. Each question is to be rated using the 5 point Likert scale provided by selecting the number that most closely matches the response. Total score for all 26 questions is to be tallied and recorded in the total score box at the end of the assessment. Upon the completion of the assessment, the health care team in partnership with the patient and family should be in a position to formulate an individualized care plan to promote positive clinical outcomes. Responses provided by: 2 of 9

3 1. How would your rate your ability to understand and read English? Thoughts: What language does the patient understand and read? Do they have communication support in the home/community for language challenges? Requires translation? Other languages? 2. How would you describe your knowledge of your kidney disease? Thoughts: Does the patient demonstrate an understanding of their kidney disease? i.e. causes, symptoms, affect? Is the patient aware of the permanency of the condition? What does family/carer understand about the patient s condition? 3. How would you rate your knowledge of dialysis? Thoughts: Does the patient demonstrate an understanding of dialysis as a treatment for kidney disease? Is the patient aware of what happens if the treatment is stopped? Is the patient aware of the importance of dialysis as a daily therapy? What does family/carer understand about dialysis? What has their dialysis experience been so far? 4. Can you manage activities of daily living on your own? (i.e. dressing, (eating, ambulating) Never infrequently sometimes frequently always Thoughts: What things have become more difficult to do? How does the patient manage these? What things can the patient no longer do? Who helps the patient if required? 5. How would you rate your confidence in doing dialysis at home? Thoughts: To be answered based on their limited understanding of the therapy at this time. 3 of 9

4 6. Do you take your medications as prescribed by your doctor? Thoughts: Can the patient describe how and why to take medications? What stops the patient from taking meds as prescribed? 7. Are you able to take time off work or other obligations for health related issues? Thoughts: How flexible is the patient to make appointments to attend to their health needs? 8. Do you have reliable transportation to and from the dialysis centre? Thoughts: Will the patient be able to attend booked appointments? Will the patient be able to get to the clinic or emergency department if necessary? Who will provide transportation if required? 9. How is your memory or your ability to concentrate? Thoughts: Does the patient or family/carer demonstrate an awareness of changes in patients mental health status i.e. increased forgetfulness, trouble remembering appointments, difficulty following directions? 10. Do you actively participate in decisions regarding your health with your family/physician/health professional? Thoughts: How involved is the patient in making decisions around their health? Who helps them if necessary? 4 of 9

5 11. Is your living situation suitable to perform Home Dialysis? Thoughts: Is there adequate space for supplies? Do pets live in the home? Does the patient live alone? Is the home a single family dwelling, apartment, condo, trailer? Availability of parking? Entrance and steps (any delivery considerations)? Rent or Own? What is their water source (i.e. well, city water, lake) 12. How are you managing the stress in your life? very poorly poorly average well very well Thoughts: What stressors does the patient identify? What strategies does the patient identify to manage identified stress? Is the patient responsible for the care of others in the home? 13. Are you able to perform tasks such as picking up coins or buttoning your shirt? Thoughts: Assess patient s fine motor skills and physical ability to perform Home Hemo. 14. How is your eyesight? (with glasses if required) 15. How is your hearing? (with hearing aid if required) 5 of 9

6 The following questions relate to the patients physical health status. While it is important to understand what the patient s physical health status is, it is equally important to understand how the patient s health affects their self management ability. 16. The patient s albumin level is? <25g/L >35g/L Thoughts: Low serum albumin is linked to a higher mortality rate and risk of infection. 17. How many hospitalizations has the patient had in the past 6 months? (other than for catheter insertion) 4 or > hospitalizations Thoughts: Do reasons for hospitalization predict on-going issues or special needs? 18. a) Do you have endocrine disease? (i.e. diabetes, thyroid, adrenal) b) Does your endocrine disease allow you to be independent in your care? (Score 5 if patient does not have endocrine disease) 19. a) Do you have cardiovascular disease? (i.e. ischemic heart disease, heart failure, hypertension, myocardial infarction, coronary artery bypass, congestive heart failure, aneurysms, peripheral vascular disease) b) Does your cardiovascular disease allow you to be independent in your care? (Score 5 if patient does not have CV disease) 6 of 9

7 20. a) Do you have respiratory disease? (i.e. chronic obstructive pulmonary disease, asthma) b) Does your respiratory disease allow you to be independent in your care? (Score 5 if patient does not have respiratory disease) 21. a) Do you have neurological disorders? (i.e. stroke, MS, ALS, peripheral neuropathy, Parkinson) b) Does your neurological disorder allow you to be independent in your care? (Score 5 if patient does not have neurological disorders) 22. a) Do you have gastro intestinal or urinary problems? (i.e. constipation, diverticulitis, prolapsed uterus, hernia, bladder problems, history of abdominal surgery) b) Does your gastro intestinal or urinary problem allow you to be independent in your care? (Score 5 if patient does not have GI or GU problems) 23. a) Do you have musculoskeletal problems? (i.e. rheumatoid arthritis, osteoarthritis, back injury) b) Does your musculoskeletal problem allow you to be independent in your care? (Score 5 if does not have musculoskeletal problems) 7 of 9

8 24. a) Do you have immune system problems? (i.e.scleraderma, lupus, amyloidosis, HIV/AIDS), or an organ transplant. b) Does your immune disease or compromised immunity allow you to be independent in your care? (Score 5 if no immunity issues) 25. a) Do you have mental health problems? (i.e. dementia, depression, bipolar, schizophrenia, anxiety, alcohol or substance abuse) b) Does your history of mental health problems allow you to be independent in your care? (Score 5 if patient does not have mental health problems) 26. a) Do you have cancer? b) Does your history of cancer allow you to be independent in your care? (Score 5 if patient does not have cancer) 8 of 9

9 HIGH Ability to self manage care (>104) MODERATE Ability to self manage care (65-104) LOW Ability to self manage care (<65) PATIENT SCORE: NURSE S SCORE: (objective data) (subjective data) Care Plan Notes: Date Completed: Completed By: The Home Dialysis Interest Group (HDIG) ** was adapted from The Peritoneal Dialysis Patient Assessment has been developed by the following team members: Heather Bilan RN, Alberta Health Services, Southern Alberta Renal Program Karen Forsberg RN, Interior Health Authority, Kelowna General Hospital Janice James RN, CNeph(C), Alberta Health Services, Southern Alberta Renal Program Linda Turnbull RN, BN, CNeph(C), Baxter Corporation Heather Zadorozniak RN, BN, CNeph(C), Fraser Health Authority, Royal Columbian Hospital 2009 **HDIG: Is a collaborative group representing Home Dialysis (PD & Hemo) based in Southern Ontario 9 of 9

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