O
Orientation
• Does the person have a “cognitive” diagnosis? • Is the person oriented to • Person? • Place? • Time? • Situation? •
How does this affect their current health situation and self‐care abilities? • Are there special needs that the person might require? • Include the Patient Cognitive Assessment Scale score
M
Medication
• What medications is the patient taking? • Why? • Does the person know what medications they are taking and why? • Do they require education? •
Are there special instructions or nursing implications that the nurse should note about current medications, monitoring for side effects, needed assessments, allergies/reaction, use of PRN medications?
How does the person take their medications •
•
Whole, Crushed, via Tube, with water, with applesauce/pudding)
• What is the person’s code status? • Are there conditions? • Does the person have other advance directives? • Who is their primary emergency contact? • Would patient have special needs during an emergency?
E
Emergency
G
Gai t
• Does the person have medical diagnoses that are associated with their mobility? • Describe the person have the ability to walk and transfer. • Is their gait steady? • Do they require assistive devices to ambulate or transfer? • Do they require staff assistance? • How many? • For what? • Is the person at risk for falling? • Why? • What is Hendrich Scale score? • What does this indicate? • Are there any mobility issues (balance, gait, ROM, strength, endurance, etc.) that affect ADL self‐care? • What do they prevent the patient from doing? • What assistance do they need with ADLs? • Is the person currently working with PT/OT to improve mobility? • How often?
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