IN-HOME NURSING

ASSESSMENTS

Our comprehensive in-home nursing assessments are completed to assess all parameters of health, identify unmet needs and establish a care plan for chronic disease management.

  • Comprehensive Assessment

    - Medication management and education regarding same (may include collaboration with prescribing practitioner to address any concerns)

    - Assessment of medical history/diagnoses and current medical concerns/symptomology

    - Assessment of family and social supports

    - Assessment of home environment and accessibility

    - Assessment of knowledge base around current health conditions and treatment plans for same

  • Identification of nursing priorities

    - Physical needs (nutrition, physical activity, assistance with ADL’s and iADL’s, medication, sleep hygiene, assistive devices, substance use, etc)

    - Social needs (social supports + relationships, connection, risk of isolation, etc)

    - Intellectual needs (education, gaps in understanding of medical needs, cognitive impairments, etc)

    - Psychological needs (mental health supports, stress management techniques, spiritual practices, etc)

  • Individualized care plan

    - Review of medications, interaction checks and collaboration with prescribing physician/practitioners if necessary

    - Education around health condition specific to the individual and medication management for same

    - Implementation of health promotion techniques via client-led SMART goals

    - Referral to other health care practitioners as appropriate (psychology, psychiatry, occupational therapy, physiotherapy, dietician, and other allied health providers)

    - Coordination of services to increase home accessibility

    - Social prescribing

  • Evaluation

    - Comprehensive intake questionnaire with various standardized screens/assessment tools that can be repeated to monitor change

    - Clear documentation of nursing care plan, goal setting and interventions to meet those goals

    - Measurement of objective and subjective outcomes via documentation practices

    - Length of treatment program determined on an ongoing basis via evaluation measures and progress of client towards health goals

Please note that the type of services provided and the length of care plan are determined on an individual basis based on client’s severity of medical condition, unmet needs and many other factors.