Obesity Risk Assessment Form

Page 1

of Max Body Width Known Mobility

Obesity Risk Assessment Form 1 Date ProspectivecompletedResident Name_________________________________ Proposed Room placement

Body Size Information

Site Needs:

WeightHeight BMI (CDC BMI Calculator) Max Body Width

MDS ADL’s:

Independent or Limited Assistance: Resident highly involved in the activity; may receive physical help guiding movement of limbs, other non weight bearing assistance 3 or more times or combination of non-weight bearing help with more help provided only 1 or 2 times during period (for a total of 3 or more episodes of physical help).

Extensive or Total Assistance: Resident received at least help in the activity 3 or more times including weight bearing support or full performance by another during part (but not all) of last 3 days

Activity Independent or Limited Assistance Extensive or Total Assistance Notes Bed Mobility ☐ ☐ Transfer ☐ ☐ Walk in Room ☐ ☐ Walk Corridorin ☐ ☐ Locomotion on Unit ☐ ☐ Dressing ☐ ☐ Toilet Use ☐ ☐ PersonalHygiene ☐ ☐

Definitions:

Obesity Risk Assessment Form 2

Pressure Ulcer No / Yes

PICC Line/IV Line No / Yes No / Yes

☐ ☐

No

Hip/Knee/ShoulderReplacement ☐ ☐

Incontinence ☐ ☐

☐ ☐

Obesity Risk Assessment Form 3

Obesity

☐ ☐

BiPAP/CPAP No / Yes No / Yes

☐ ☐

☐ ☐

☐ ☐

Any Fall No / Yes No / Yes

☐ ☐

Heart Failure ☐ No / Yes

Bladder No / Yes

Skin Infection No / Yes

Severe Lymphedema or Edema No / Yes

History in Last Year Yes Will TreatmentCompromiseObesityRoutinePlan Adaptation Plan

Bowel Incontinence No / Yes

Tracheotomy ☐ ☐

Key Medical History:

Deep Vein Thrombosis / Pulmonary Embolism ☐ No / Yes

☐ ☐

☐ ☐

Urinary Tract Infection No / Yes

Supplemental Oxygen ☐ ☐

Wounds needing therapy No / Yes

Gown Size L / XL / XXL

Equipment Needs: (see Obesity Equipment Decision Guide)

Bedside Recliner Width (inch) 19 / 22 / 25 / 32

Mattress Type

Wheelchair Size (inch) 28 / 34 / 48

Walker Size (inch) 25 / 36 / 42

Hoyer Lift Needed No / Yes Max Capacity:

Commode Size (inch) 26 / 36 / 46

Equipment Type Common size options

Foam / Low Air Loss / Alternating Pressure

Hoyer Sling Size M (to 210) / L (to 350) / XL ( to 500) / XXL

Bed Width (inch) 36 / 39 / 42 / 48 / 54 / 60

Bed Length (inch) 75 / 80 / 84

Sock Size L / XL / XXL

Undergarment Size L / XL / XXL

Obesity Risk Assessment Form 4

Does bariatric bed fit in available room ☐ Yes / No

Does your preferred transportation / ambulance company provide services for a resident this size?

Will wide wheelchair fit for toilet transfers Yes / No

☐ ☐

☐ ☐

Does bariatric chair fit in available room Yes / No

Obesity Risk Assessment Form 5

Does bariatric commode fit in available room Yes / No

Will toilet and grab bars be rated to body weight Yes / No

☐ ☐

Room Needs:

Therapy Needs:

☐ ☐

What PT / OT / Rehab services are needed?

Transportation Needs:

☐ ☐

Will wide wheelchair fit for transfer Yes / No

Yes No Is a more suitable room available

Obesity Risk Assessment Form

How practical is emergency evacuation of this resident from the available room?

Discharge Planning:

How accessible is the resident’s home to necessary bariatric size equipment (wheelchair, bed, etc.)?

Evacuation Planning:

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Obesity Risk Assessment Form by mageewomens - Issuu