PUBLIC HEALTH DIVISION
HIV Community Services
Nursing Assessment
"Confidential  this form must always be saved on a secure network
accessible only by Ryan White funded staff."
Client name:
Client #:
CM initial:
Date:
/
/
Vitals
Temp:
Height:
Pulse:
Current Weight:
Current CD4
Date
/
Respiration:
Ideal weight:
Current VL
Date
/
/
B/P:
BMI:
Lowest CD4
/
Date
/
Highest VL
Date
/
/
/
Physical appearance
Skin:
Obvious physical deformities:
Speech:
Personal hygiene:
Posture and position:
Mobility:
Hearing:
Facial expression:
Allergies
Medications:
Food:
Environmental:
Last medical visit:
Yes
Yes
Yes
No
No
No
List:
List:
List:
Provider:
Date:
HIV status
HIV positive (not AIDS)
dx date:
HIV positive (AIDS unknown) dx date:
CDC – defined AIDS
dx date:
/
/
/
HIV risk factors (check all that apply)
MSM
Heterosexual
IDU
Receipt of blood or tissue
Hemophilic coagulation disorder
Unknown or not reported/identified
Other:
/
/
/
/
/
Perinatal
Activities of daily living (self, assistance needed or dependent)
Activity
Self Asst. Dep.
Ambulation
Transfers
Toileting
Bathing
Pets/companion animal:
Yes
Comments:
Activity
Self
Dressing
Grooming
Laundry
Housekeeping
No Type:
Asst.
Page 1 of 6
Dep.
Activity
Eating
Meal prep
Shopping
Driving
Self
Asst.
Dep.
OHA 8402 (12/14)
Current complaints (*nutritional assessment required if yes)
X=
Yes
Description
X = Yes
Description
*Abdominal pain
*Changes in eating habits
*Nausea/vomiting
*Diarrhea
*Unexplained weight loss
*Difficulty swallowing
*Sores in throat or mouth
Changes in hearing
Changes in vision
Jaundice/Icterus
X = Yes
Headaches (changes in pattern)
Fever
Chills
Fatigue
Night sweats
Swollen lymph glands
Seizures/tremors
Dizziness
Changes in balance
Gum bleeding and Icterus
Description
Falls
Changes in strength
Numbness
Pain
Chest pain
Cough
Shortness of breath
Skin changes/rashes
EDEMA
Other:
Comments:
Medical history
Has client ever been diagnosed with opportunistic infections or conditions? (C=current; P=past)
C
C
C
C
C
C
C
C
P
P
P
P
P
P
P
P
ACD (AIDS Dementia complex)
Cholesterol — elevated
Coccidioidomycosis
Diabetes
Herpes zoster
Kaposi’s sarcoma
MAC (Mycobacterium Avian Complex)
Parasitic infection
C
P Bacterial pneumonia
C
C
P STDs (sexually transmitted diseases)
C
Have you had a positive test for:
HCV
When was last test (date):
Hepatitis B — last test date:
/ /
Tuberculin skin test — last test date:
C
C
C
C
C
C
C
C
HBV
/
Has client had any of the following treatments:
Hepatitis C
LTBI (latent TB)
/
P
P
P
P
P
P
P
P
Candidiasis
Chronic/recurrent sinusitis
Cryptococcal meningitis
Encephalopathy
Hepatitis A, B or C
Leukeoncephalopathy
Myopathy
PCP (Pneumocystis carinii
pneumonia)
P PML (Progressive multifocal
leukoencephalopathy)
P Thrombocytopenia
TB
C
C
C
C
C
C
C
C
P
P
P
P
P
P
P
P
Cervical cancer
CMV (Cytomegalovirus)
Cryptosporidiosis
Herpes simplex
Histoplasmosis
Lymphoma
Oral hairy leukoplakia
Toxoplasmosis
C
P Tuberculosis
C
P Other:
Anal Pap
Hepatitis C — last test date:
Anal pap — last test date:
None
TB disease (active)
Has client had any of the following immunizations:
None
Hepatitis A (HAV)
Hepatitis B (HBV)
Influenza
Tetanus/diphtheria (Td)
None
Polysaccharide pneumococcal
Tetanus/diphtheria/pertussis (Tdap)
Chemo
/
/
/
/
Infusion
Radiation
Measles/Mumps/Rubella (MMR)
Other:
Comments:
Client name:
Client#:
Page 2 of 6
CM initial:
Date:
/ /
OHA 8402 (12/14)
Liver health assessment
X = Yes
Description
History of liver problems?
Has client seen a doctor in the past
six months about liver problems?
Has client had liver function tested
in the past six months?
Liver health follow-up may include:
Referral for counseling (A&D concern)
Education about hepatitis C treatment
Liver health class
Other:
Comments
Normal
Abnormal
Don’t know
Referral to HIV care provider
Referral to dietician
Education about appropriate use of herbs, vitamins, supplements, etc.
Education about eating raw or undercooked shellfish
Brochure
Comments:
Current sexually transmitted disease history
Does the client have any of the following symptoms:
Genital ulcers, warts, blisters or other lesions
Pain/burning with urination
None
Pain with sex
Oral lesions
Pain in lower abdomen
Skin rash
Men:
Testicular or groin pain
Urethral discharge
Women:
Increased vaginal discharge
Changes in menses
Vaginal odor
Vulvar itching
Bleeding between periods
Has client been told by a health care provider that they have any of the following in the past year:
None
Chlamydia
Pelvic Inflammatory Disease (PID)
Herpes simplex
Trichomoniasis
Lymphogranuloma Verereum (LGV)
Syphillis
Gonorrhea
Human Papilloma Virus (HPV)
Has client been treated for any of the above?
Comments:
Current gynecological history
Is client currently pregnant?
Yes
No
Is client currently breastfeeding?
Type of birth control:
Last PAP:
/ /
Results:
Normal
Abnormal
Last breast exam:
/ /
Results:
Last mammogram:
/ /
Results:
Yes
No
Comments:
Client name:
Client#:
Page 3 of 6
CM initial:
Date:
/ /
OHA 8402 (12/14)
Tobacco use
Ask:
Current tobacco use?
Yes
No
If yes, type:
Assess:
On a scale of 1 to 10, how concerned are you about your tobacco use?
On a scale of 1 to 10, how ready are you to quit tobacco?
Assist:
Referral to Quitline
Referral to Nicotine Replacement Therapy (for CAREAssist only)
Referral to medical provider
Not ready to quit – follow up date: / /
how much:
Comments:
Oral health assessment
When was the last time the client saw a dentist?
/ /
Does client have dental insurance or other access to dental care?
Yes
No
Does client report practicing daily oral hygiene?
Yes
No
Does client report oral health problems?
Yes
No
Dentures need re-alignment
Episodic pain and/or sensitivity with teeth, gums or mouth
Missing days from work (or other activities) because of problems with teeth, gums or mouth
Difficulty interacting with others due to oral health problems that negatively impact self-esteem
Difficulty eating or speaking
Visual exam:
Has few teeth or missing teeth
Has dark, discolored teeth, missing teeth, bleeding red gums or decayed teeth
Has white, hairy growth or creamy bump-like patches or other oral lesions
Comments:
Client name:
Client#:
Page 4 of 6
CM initial:
Date:
/ /
OHA 8402 (12/14)
Nutritional assessment
X = Yes
Description
Comments
Access to food: is client getting enough to eat?
Does client have an appetite?
What is the quality of the food the client is eating?
Does client have abdominal pain?
Does client have difficulty swallowing?
Does client have difficulty chewing?
Has client experienced change in eating habits?
Does client have dental issues?
See oral health assessment
Visual assessment of client’s appearance (build, underweight, overweight, signs of wasting syndrome):
Nutritional summary may include:
Supplements w/regular wt. checks
Referral to RD
Referral for counseling (eating disorder, MH concern, substance abuse concern)
Nutritional incentive contract
Referral to primary HIV care provider
Other:
Comments:
Client name:
Client#:
Page 5 of 6
CM initial:
Referral for dental care
Referral to denturist
Date:
/ /
OHA 8402 (12/14)
HIV medication adherence
Current medication profile (see DHS 8417 or in CAREWARE)
Is client currently taking antiretroviral medications?
Yes
Sometimes
No
If no, why?
Not recommended
Does not want to take
Wants to/considering taking
Self
Other:
If yes/sometimes, who is responsible for ordering/picking up refills?
If yes/sometimes, are:
Medication outdated?
Yes
No
Medication prescribed by multiple providers?
Yes
Medication properly stored?
Yes
No
Medication borrowed from others?
Yes
If yes/sometimes, are medications taken on schedule every day/every time?
Yes
No
If no, number of missed doses in past month:
Number of late doses in past month:
Possible reason(s) for late or missed doses:
Medication side effects:
Dizziness
Nausea
Diarrhea
Drowsiness
Headache
Other:
Barriers:
Depression/mental health
Complex medication regime
Substance use/abuse
Number of pills
Mental status changes
Size of pills
Doubts medication effectiveness
Taste of medication
Lack of information
Eating habits (e.g., loss of appetite)
Works outside the home
Lack of regular schedule
Caregiving responsibilities
Needs assistance with ADLs
Lack of social support
Undisclosed HIV status
Difficulty getting refills
Other:
No
No
Comments:
Client name:
Client#:
Page 6 of 6
CM initial:
Date:
/ /
OHA 8402 (12/14)