Covid 19 Care Assessment using Purpose T

Final Version 01/10/20 Developed by SBU Health Board. Approved by All Wales Executive Nurse Directors. IP8030(k)

Please write in BLACK ink

Patient Care Assessment document in COVID 19 Surge Escalation

DOCUMENT IN COVID-19 EMERGENCY PATIENT CARE ASSESSMENT DOCUMENT This document is to be utilised when COVID 19 Gold Command places the Health Board in a Super Surge Escalation Status in line with the Health Board’s Standard Operating Procedure (COVID-19 System Surge Escalation) The Document is a compressed Patient Care Assessment to support clinical staff at times of extreme pressure. COVID 19 Gold Command will remove the document from use when the Health Board returns to Surge/Adaptive Status in line with the Health Board’s Standard Operating Procedure (COVID-19 System Surge Escalation)

Covid 19 Care Assessment using Purpose T

Final Version 01/10/20 Developed by SBU Health Board. Approved by All Wales Executive Nurse Directors.

1


1. Definitions For the purposes of this document the following definitions apply; Table 1 Surge Definitions Surge Level Definition Adaptive COVID demand is being managed through taking actions to align available

capacity. Surge COVID demand exceeds all actions taken to align capacity and requires

additional beds (surge) Super Surge COVID demand exceeds that of surge capacity and requires further additional

beds (Field Hospital)


2


PATIENT CARE ASSESSMENT DOCUMENT IN COVID-19 EMERGENCY

Date Time of Admission

Route of admission/referral Unit Hospital Registrant Comple�ng

Document Signature: Designa�on:

THIS DOCUMENT IS ONLY TO BE USED DURING COVID-19 SYSTEM SURGE ESCALATION - Adults Only

Pa�ent ID Label Preferred Name: ID Band in situ

YES/ NO

Preferred Language Cultural/ Spiritual

Preference GP Name and Address:

Tel:

Is a translator required?

YES/ NO

Allergies (including latex, food allergies):

Epi pen used? Yes No If yes, is the pen with the pa�ent? Yes No

What is the nature of the reac�on:

NEXT of KIN / SIGNIFICANT OTHERSFirst named point of

contact Next of Kin/Significant others/nearest rela�ve

Main carer

Name Rela�onship

Is this person the emergency contact?

Is this person aware of admission?

Is this person the main carer? Consent to share informa�on?

Address:

Contact Numbers:


3


ADVANCED CARE PLANHas the pa�ent made a valid and applicable advanced care plan? YES/ NO/ UNSURE

If yes what date was this made:

Is there a current Do Not A�empt Cardio Pulmonary Resuscita�on Decision in the Medical Notes?

YES/ NOIf yes what date was this made:

Specimen signature list of ALL staff wri�ng in this care record - If not based on Unit please ALSO complete sec�on below

Name of staff member Designa�on Signature Ini�als


4


OTHER STAFF ASSESSING PATIENT – Record the names of AHPs or other staff (not medical) external to Unit

Name Designa�on Department Contact no.

BACKGROUND

PRESENTING COMPLAINT A brief descrip�on of the background to the current problem that has brought the pa�ent into hospital. Include details of any relevant pre-hospital informa�on


5

Please write in BLACK ink CAPACITY TO CONSENT TO CARE AND TREATMENT MENTAL CAPACITY (for Adults aged 16 years and over)

If you have reason to doubt the patient’s mental capacity to consent to their nursing care or treatment, consider the following and record your decision making in the patients notes: Consideration Action

a) Does the patient’s clinical condition mean that you can’t delay emergency nursing care or treatment in order to undertake an assessment of capacity?

Can’t delay treatment: Essential care should be carried out under a duty of care. For other non-urgent treatment, assess capacity as soon as it becomes possible. Can delay treatment: Assess capacity.

b) When assessing capacity you need to consider whether the patient can: • Understand the information relevant to the decision? • Retain the information long enough to make the

decision? • Use and weigh the information in making the decision? • Communicate their decision in any way?

The significance of the decision to be made will affect how formal the assessment of capacity needs to be. For more significant decisions, consider a formal capacity assessment in relation to any significant care and treatment decisions. Ensure that you document your decision making.

c) If the patient does lack capacity to consent to their care or treatment, is this lack of capacity likely to be temporary?

Lack of capacity is temporary: Can the care or treatment wait until the patient regains capacity and can consent for themselves? For more significant decisions, consider a formal capacity assessment fin relation to any significant care and treatment decisions.

Lack of capacity is permanent: Treat in best interests.

SAFEGUARDING

Is there anything in this person’s presentation that gives you cause for concern?

Summary of action taken – please write details in record of care section

Does the patient have a social worker? YES / NO Name: Contacted by:

Safeguarding Report/Referral made to Local Authority and Date YES/NO


6



7


5 & 7. Personal Hygiene including Oral Care (H&CS 8 & 10) - please CIRCLE what applies and ADD addi�onal informa�on

Hygiene & Dressing Fully independent Needs assistance Dependent

Oral Hygiene Fully independent Needs assistance Dependent

6. Toilet Needs (H&CS 11) – please CIRCLE what applies ADD addi�onal informa�onUsing the toilet Fully Independent Needs assistance Dependent

In urinary reten�on

Cons�pated Diarrhoea Uses incon�nence pads Incon�nent: urinary/

faecal

Ileostomy Colostomy Urostomy Indwelling Urinary Catheter Intermi�ent self Catheterisa�on

9. Preven�ng Pressure Ulcers (H&CS 12) Use stand alone Purpose T Risk Assessment to assess risk

Use stand-alone All Wales Purpose T Risk Assessment to assess risk

Any Addi�onal Comments Overall - Record Ac�on Required Below


8


Clinical Frailty Screen*

(Consider, factors that contribute to the level of frailty e.g. mobility, nutrition, continence, presence of dementia. Consider risk of falls, food chart and referral to Multi-

disciplinary Team). Please Tick:

1. Very Fit – People who are robust, active, energetic and motivated. These people commonly exercise regularly. They are among the fittest for their age. 2. Well – People who have no active disease symptoms but are less fit than category 1. Often, they exercise or are very active occasionally e.g. seasonally. 3. Managing Well – People whose medical problems are well controlled, but are not regularly active beyond routine walking.

4. Vulnerable – While not dependent on others for daily help often symptoms limit activities. A common complaint is being “slowed up”, and/or being tired during the day. 5. Mildly Frail – These people often have more evident slowing, and need help in high order IADLs (finances, transportation, heavy housework, medications). Typically, mild frailty impairs shopping and walking outside alone, meal preparation and housework. 6. Moderately Frail – People need help with all outside activities and with keeping house. Inside, they often have problems with stairs and need help with bathing and might need minimal assistance (cuing standby) with dressing.

7. Severely Frail – Completely dependent for personal care, from whatever cause (physical or cognitive). Even so, they seem stable and not at high risk of dying (within – 6 months).

8. Very Severely Frail – Completely dependent, approaching end of life. Typically, they could not recover even from a minor illness. 9. Terminally Ill – Approaching the end of life. This category applies to people with a life expectancy <6mnths, who are not otherwise evidently frail.

Date:

Signature: Adapted from *1. Canadian Study on Health & Aging, Revised 2008. 2.K. Rockwood et al. A Global Clinical Measure of Fitness and Frailty in Elderly People. CMAJ 2005;173:489-495


9

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4.

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of F

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bell

wor

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in re

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risk

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& C

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l fa�

gue,

gen

eral

ised

ach

ing

and

disc

omfo

rt a

nd h

eada

ches

-

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win

g pa

in a

sses

smen

t adm

inis

ter r

egul

ar

anal

gesi

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d re

ass

ess

impa

ct

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sure

pa�

ent c

omfo

rt –

posi

�on,

bed

clo

thes

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e re

ason

able

adj

ustm

ents

use

ada

pted

pai

n to

ol fo

r th

ose

with

mor

e co

mpl

ex n

eeds

10.

Skin

H

igh

tem

pera

ture

and

bod

y sw

eat w

ill

impa

ct o

n sk

in a

nd in

crea

se r

isk

of p

ress

ure

dam

age

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mpl

ete

pres

sure

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er p

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ris

k as

sess

men

t and

act

on

resu

lts

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fer t

o in

pa�e

nt p

ress

ure

redi

stri

bu�o

n se

lec�

on

flow

cha

rt fo

r gu

idan

ce o

n re

leva

nt e

quip

men

t -

Ensu

re r

egul

ar c

hang

e of

pos

i�on

and

ski

n in

spec

�on

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ep h

ydra

ted

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aint

ain

pers

onal

car

e


12

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ase

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e in

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ink

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ired

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ain

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id –

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riorit

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�ons

Si

gnat

ure

Date

11.

Slee

p

Covi

d-19

may

cau

se lo

ng p

erio

ds o

f sle

ep

thro

ugh

fa�g

ue, o

r pr

even

t sl

eep

due

to

men

tal d

istr

ess

-Su

ppor

t/en

cour

age

with

flui

ds if

fa�g

ued

-En

sure

ade

quat

e re

st a

nd s

leep

-

Ensu

re in

divi

dual

und

erst

andi

ng o

f wha

t is

usua

l fo

r th

e pe

rson

-

Enco

urag

e pa

�ent

to ta

lk a

bout

fear

s/w

orrie

s

12.

Spiri

tual

Car

e Im

pact

of C

ovid

-19

expe

rien

ce m

ay g

ener

ate

spec

ific

spir

itual

requ

irem

ents

-

Enco

urag

e pa

�ent

to ta

lk a

bout

spi

ritu

al c

are

need

s

-En

cour

age

pa�e

nt to

talk

with

fam

ily/N

OK

re

spir

itual

-ca

re n

eeds

/End

of l

ife if

app

ropr

iate

-Id

en�f

y an

y sp

iritu

al n

eeds

req

uire

men

ts

-

13.

Heal

th &

W

ellb

eing

Th

e im

pact

of C

ovid

-19

may

gen

erat

e he

alth

an

d w

ell-b

eing

life

cho

ices

/cha

nges

Soci

al d

ista

ncin

g, s

elf-

isol

a�on

and

oth

er

Covi

d-19

lang

uage

mig

ht b

e di

fficu

lt fo

r pe

ople

to u

nder

stan

d an

d in

terp

ret t

o th

eir

own

lives

-En

cour

age

pa�e

nt to

dis

cuss

and

con

side

r th

e ch

oice

s an

d ch

ange

s -

Enco

urag

e pa

�ent

to li

sten

to m

usic

/rad

io e

tc. –

rela

xa�o

n (h

eadp

hone

s) if

app

ropr

iate

-

Enco

urag

e de

ep b

reat

hing

-

Enco

urag

e he

alth

y flu

ids

and

bala

nced

die

t -

Enco

urag

e st

op s

mok

ing/

alco

hol i

f app

ropr

iate

-

Enco

urag

e lig

ht e

xerc

ise

plan

mob

ility

/mov

emen

t -

Min

dful

ness

app

roac

hes

-

14.

Psyc

holo

gica

l Ca

re

The

impa

ct o

f Cov

id-1

9 ex

peri

ence

may

ca

use

men

tal d

istr

ess,

anx

iety

and

con

fusi

on

-En

cour

age

pa�e

nt to

talk

abo

ut th

eir f

eelin

gs,

wor

ries,

any

que

s�on

s th

ey m

ay h

ave

-

Enco

urag

e co

mm

unic

a�on

with

fam

ily, f

rien

ds v

ia

mob

ile p

hone

/Wha

tsA

pp e

tc.


13

Ple

ase

writ

e in

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CK

ink

Tick

if

requ

ired

Care

Dom

ain

Pote

n�al

Cov

id –

19 S

ympt

oms

/ Im

pact

Pr

escr

ibed

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e Pl

an –

Exam

ples

of p

riorit

y ac

�ons

Si

gnat

ure

Date

15.

Soci

al C

are

need

s &

Dis

char

ge

plan

ning

Impa

ct o

f Cov

id-1

9 sy

mpt

oms

may

cha

nge

care

req

uire

men

ts fo

r di

scha

rge

plan

ning

i.e.

ho

me

oxyg

en,

-Co

nsid

er p

ervi

ous

pack

age

of c

are

and

chan

ges

to

soci

al a

nd c

are

need

s

-O

n di

scha

rge

advi

se o

n se

lf-is

ola�

on if

dis

char

ged

with

in th

e is

ola�

on g

uida

nce

�mef

ram

es

-Re

fer t

o di

scha

rge

chec

klis

t with

in d

ocum

ent

16.

Any

add

i�on

al

care

nee

ds

17.

Any

add

i�on

al

Care

nee

ds


14


INFORMATION SHARING

I understand that the informa�on recorded on this form is required and will be of importance in decisions regarding my future help and support needs. I consent to the sharing of this report with relevant agencies on a need to know basis for the purposes of planning any care and support I may require and I understand that this informa�on will be stored on relevant wri�en and electronic records in line with Health Board/Trust and Local Authority Data Protec�on Policies.

I agree to the display of relevant informa�on in clinical areas? YES / NO

Is there anybody you would not want to share this informa�on with? YES / NO

Who:

Individuals / Representa�ves Signature: Date:

Registered Professional Signature Date:

DECLARATION – PERSONAL POSSESSIONS

Name Ward Hospital/NHS No

I confirm that it has been explained to me that facili�es are provided by the Health Board/Trust for the safe custody of the cash and valuables in my possession.

I further confirm I have declined to take advantage of these facili�es and understand that the Health Board/Trust cannot be held liable for any loss or damage to the cash or valuables remaining in my possession.

Page Number of Property Book: ................................................ COMPLETED

PP3 YES / NO PP5 YES / NO

Signed:

(if the pa�ent unable to sign, Next of Kin should sign below if appropriate)

Witnessed: Date:

Signed: Witnessed: Date:


15


RECORD OF CARE GIVEN

This sec�on includes: • Care provided & evalua�on of care • Changes to the plan of care • Details rela�ng to mul�disciplinary discussions • Any communica�ons/discussions with pa�ent, next of kin/significant other/carer MUST be documented in this sec�on

including reference to with whom the communica�on was with

Date & Time Details Sign


16







17







18







19







20







21


DISCHARGE CHECKLIST YES NO COMMENTS & ACTIONS

Has a Covid nega�ve swab been confirmed for pa�ents returning to care homes or receiving domiciliary care?

Date confirmed nega�ve

IV cannula removed?

Does the pa�ent have warm clothes for discharge/transfer?

Is the pa�ent being discharged to their own home? If YES, answer ques�ons below

* If the pa�ent does NOT have their house keys, where are they located?

Has home Care Agency been informed of discharge and confirmed start date and �me? (Where applicable)

Does the pa�ent / parent have their house keys for access?

*

Will the hea�ng be on and food supplies at home?

Medica�on

Does the pa�ent /rela�ve /carer have the pa�ents take home medica�on or own drugs to be discharged with?

Does the pa�ent /rela�ve /carer understand the instruc�ons for medica�on administra�on?

Transport Arrangements

Has transport been arranged? If YES, please give details

Will anyone be accompanying the pa�ent? If YES, please give details

If NO will anyone be at the pa�ent’s home to meet them

If YES, please give details

Follow up arrangements

Is a follow up appointment arranged if required?

Does the pa�ent / parent require an ini�al supply of dressings?

If YES please outline ac�ons:

Outstanding Referrals and Discharge Advice

Are there any outstanding referrals to make? If YES please outline:

Any outstanding informa�on advice/leaflets to give?

Signature of Registered Nurse comple�ng discharge assessment

COMPLETED BY: Signed: Countersigned (if needed): Time:

Actual �me of leaving the Ward Time Signed:


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Guidelines for staff comple�ng this document

THIS DOCUMENT IS ONLY TO BE USED DURING COVID-19 SYSTEM SURGE ESCALATION

There are a number of places to sign the document. If you complete the assessment of that sec�on please sign in the relevantarea. If you undertake an aspect of care that has been planned then please ini�al next to the ac�on and document in the Record of Care

Page Sec�on Comple�on guidelines

1 Personal informa�on

Document personal informa�on about the pa�ent and their rela�ves / friends

2 Signatures All staff wri�ng in this document must sign the signature list. Please also complete the details log if the staff are not part of the unit’s normal establishment.

3 Background

Presen�ng Complaint – document the background to the current admission, including relevant pre-hospital informa�on Consent – document the pa�ent’s CURRENT capacity to consent to emergency nursing care / treatment Safeguarding – document any concerns that you may have that require further observa�on and / or ac�on taken

4-5

Rapid Care and Risk Assessment 16yrs and over ONLY

Assessment and care planning – circle what applies and add addi�onal informa�on Complete embedded shortened risk assessments

6-9 COVID-19 Care Plan Care plan – Refer to core care plan and add any addi�onal care needs iden�fied in the space available

10-14 Record of Care

Use this sec�on to document:-• Care provided & evalua�on of care; Changes to the plan of care; Details rela�ng to mul�disciplinary

discussions • Any communica�ons/discussions with pa�ent, next of kin/significant other/carer including reference to

with whom the communica�on was with Please date, �me and sign each entry

15 Discharge Complete the discharge planning prior to discharge to enable complex discharges to be iden�fied and appropriate ac�ons to be taken. Complete the discharge check list just prior to discharge to ensure it con�nues to be a safe discharge

ON TRANSFER - Please transfer the ORIGINAL record with the pa�ent and photocopy and retain original in pa�ent record on discharge

Mobility Classifica�on Tool (LOCOmotor ©)

AAmbulatory, but may use a walking s�ck for support Independent, can clean and dress oneself. Usually no risk of dynamic or sta�c overload to carer. Simula�on of func�onal mobility is very important

BCan support oneself to some degree and uses walking frame or similar. Dependant on carer in some situa�ons. Usually no risk of dynamic overload to carer. A risk of sta�c overload to carer can occur if not using proper equipment. S�mula�on of func�onal mobility is very important

CIs able to par�ally weight bear on at least one leg. O�en sits in a wheelchair and has some trunk stability. Dependant on carer in many situa�ons. A risk of dynamic and sta�c overload to carer when not using proper aids. S�mula�on of func�onal mobility is very important

DCannot stand and is not able to weight bear. Is able to sit if well supported. Dependant on carer in most situa�ons. A high risk of dynamic and sta�c overload to carer when not using proper equipment. S�mula�on of func�onal par�cipa�on is very important.

EMight be almost completely bedridden, can sit out only in a special chair. Always dependent on carer. A high risk of dynamic and sta�c overload to carer when not using proper equipment. S�mula�on of func�onal par�cipa�on is not a primary goal

Covid 19 Care Assessment using Purpose T

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