A Comprehensive Nursing Assessment (CNA) is a detailed evaluation of an individual’s medical, physical, and behavioral health needs conducted by a licensed nurse. This assessment helps develop a personalized care plan to ensure individuals receive the appropriate medical support and interventions.
Key Components of a Comprehensive Nursing Assessment in IDD Care
- Medical History & Current Health Status
- Chronic conditions (e.g., epilepsy, diabetes, hypertension)
- Medication history and current prescriptions
- Allergies and past medical treatments
- Physical Health Assessment
- Vital signs (blood pressure, heart rate, temperature, etc.)
- Mobility and functional abilities
- Skin integrity (pressure ulcers, wounds, infections)
- Nutrition and hydration needs
- Behavioral & Mental Health Evaluation
- Cognitive functioning and developmental milestones
- Behavioral challenges, triggers, and interventions
- Mental health conditions (e.g., anxiety, depression, autism spectrum disorders)
- Medication Review & Management
- Current medications and potential side effects
- PRN (as-needed) medication usage
- Adherence to prescribed treatments
- Activities of Daily Living (ADLs) & Support Needs
- Eating, dressing, bathing, toileting, and mobility
- Assistive devices and accommodations required
- Risk Assessments & Emergency Planning
- Fall risk evaluation
- Seizure management
- Emergency response protocols
- Individualized Health Care Plan (IHCP) Development
- Nursing interventions tailored to the individual’s needs
- Coordination with caregivers, physicians, and therapists
- Monitoring schedules for follow-up assessments
Why a Comprehensive Nursing Assessment Matters for IDD Providers
– Ensures person-centered care tailored to the individual’s health needs.
– Helps agencies comply with Medicaid and state regulations.
– Supports risk management by identifying potential health concerns early.
– Improves coordination between nurses, caregivers, and support teams.