SCREENING TOOLS AND MANAGEMENT FLIP CHART · SCREENING TOOLS AND MANAGEMENT FLIP CHART ... Document...

SCREENING TOOLS AND MANAGEMENT FLIP CHART

Ref: 3365 Authorised by the Medical Surgical Division Documentation Group July 2012 v.2

CAGE and CRAFFT with ALAC guidelines

CAGE and CRAFFT with ALAC guidelines

CAGE Screen (18 years and over)Positive if 1 or more of following are selectedCut down – has felt should reduce intakeAnnoyed – by criticism of intakeGuilty – about quantity of intakeEye Opener – drinks in the morning

CRAFFT (18 years and under)Positive if 1 or more of following are selected

C ridden in a Car that was being driven by someone (including self) who was consuming alcohol or drugs to get “high”R use of alcohol/drugs to Relax, fit in or to feel betterA use of alcohol/drugs when AloneF Forget actions whilst under the influenceF Family/friends have advised to reduce useT got into Trouble when under the influence

Approx Standard Drink Measures (10 g alcohol) ALAC source • Beer 330 ml • Wine 100 ml • Spirits 30 ml

High Risk/Harmful Amounts Male 6 standard drinks /per occasion or 21 standard drinks/weekFemale 4 standard drinks /per occasion or 14 standard drinks/week

1. CAGE and CRAFFT with ALAC guidelines

2. Cognitive Assessment - CAM and MSQ

3. Smoking Cessation

4. Kessler Screening Tool

5. Falls Screening and Strategies for Care Planning

6. Malnutrition Screening Tool

7. Pressure Injury Screening Steps

8. Pressure Injury Strategies for Care Planning

9. Pressure Injury Staging – Staging categories

10. Pressure Injury Screening - (Braden Scale) Including Sub Scales

11. Ward 17 Care Plan Sample

12. Ward 17 Care Plan Sample 2



Contents

Contents

Please refer to Assessment and Care Planning documentation website for references

Cognitive Assessment – CAM and MSQ

Cognitive Assessment – CAM and MSQ

CAM Score (Delirium)

A positive CAM score requires the patient’s diagnosis to feature 1 and 2 and either 3 or 4 of the following:

1 Acute onset and Fluctuating course and 2. Inattention

and either

3. Disorganised thinking or 4. Altered level of consciousness

Refer to Delirium Services website for additional information on subtypes/management/direction

MSQ Score

A score equal to or below 7 indicates impaired cognition (this can be compared to future scores). Count 1 for each question answered correctly.1. Age (allow one year error) 2. Time to nearest hour3. Address (for recall at end) 4. What year is it?5. Name of hospital 6. Recognition of two people7. Date of Birth 8. Years of Second World War (1939-1945)9. Name of Prime Minister10. Count backwards from 20 to 1Ask for address to be recalled

Smoking status definitions:

Current smoker: has smoked within the last monthNever smoked: has had less than 100 cigarettes in a lifetimeEx- smoker: has smoked more than 100 cigarettes but not smoked in the last month

All Nurses that have completed their Elearning: www.smokingcessationabc.org.nzcan chart NRT under the CDHB “Limited Nurse Admin of NRT “guideline

Assessing nicotine dependence and determining correct product and dosage

Ask: How many cigarettes smoked per day, and how soon he/she smokes after waking?

If possible, review after 24 hours • If person is still craving, increase dose and/or combine products. • If person feels nauseous/dizzy, reduce dose.

These are guidelines only – we need to ensure people get enough NRT to suppress cravingsor agitation.

Smoking Cessation

For pregnancy,<2 weeks post MI or stroke, Quitting without medication is preferable. NRT can be used if smoking is the alternative.

21mg patch + gum or lozengeCombining products improves success rates

See box below to guide dose of gum or lozengeSmokes 10+ a day

Smokes <10 a daySmokes <30 mins after waking - 4mg gum or 2mg lozengeSmokes >30 mins after waking - 2mg gum or 1mg lozenge

Smoking Cessation

Fall risk screening categoriesAPrevious fall/slip/stumble/collapse

BUnable/difficulty to get upand go

CRisk taking behaviour

DComplex medications/sideeffects

EConfusion/disorientation/sensory deficits

(Required to be completed on admission, and redone/reviewed every 24 hr period - start of new care plan)

Key for which area to document in Care plan

Corresponding strategies for care plan considerationOrientate to ward and surroundingsDiscuss reasons for previous fall, discuss with family/whanau and document appropriate strategiesEnsure hearing, visual, and mobility aids are within reach and usedEnsure other aids - urinal, call bell, etc - are within reachDiscuss use of call bell before mobilising and strategies to avoid collapse/syncope when moving from lying to sittingReferral to physio and occupational therapistConsider community referral either at admission or prior to dischargeEnsure walking/mobility aids are in reach and a clear pathway to toiletAdvise to call for assistance before mobilisingReferral to physio or occupational therapistEnsure use of safe well fitting/non slip footwear or socksConsider sensor system and night lightingObserve in highly visible area. Supervise mobility 2-3 times/dayRemove non-essential equipment/furnitureBed kept at appropriate height e.g low for roll risk, just above knee for ease to get out Support/presence of family and familiar objects with risk taking behaviourHospital Aide for frequent risk and no family supportPharmacy referral. Avoid unneccesary hypnoticsApproach medical team regarding calcium & Vitamin D supplementation if over 65yrsSide effect management e.g lying and standing BP for postural hypotensionObserve in quiet area. Promote appropriate wake/sleep patternBaseline assessment with CAM & MSQ - repeat if requiredInterview family/ whanau and document delirium strategies – hydration, (re)-orientation, regular mobilisation, NRT, Alcohol withdrawal mgmt, pain mgmt, family involvement, etcOT referral if further assessment required. Pharamacy reviewEnsure hearing and visual aids are available and well fitting

Fall Screening and Strategies for Care Planning

ADL’s section Elimination section Symptom Obs Discharge planning Risk screening section

Fall in hospital?• Identify causes keep self and patient safe• Inform medical team and family• Anticoagulants/platelet issues with head injury? Perform neuro obs/increase freq of obs/medical team to consider CT scan• Rescreen - where one or more categories identified document strategies/additions in care plan• Complete Fall Event Notification sticker (Ref 2498) and Incident Form (Ref 1077)

One category ticked → • Document appropriate strategies for that category in the Care Plan

Two or more categories ticked → • Inform patient and family / consider sending community referral and record notification/actions• Use fall sign, bracelet and ensure fall risk is noted on whiteboard - document actions• Tick management box in management column

Change in health status / environmentScreen patient for fall risk or if patient is currently a fall risk adjust/add fall risk strategies in care planas appropriate

Move to room near toilet/discuss use and provide a commodeRemember to plan to avoid rushing for toiletDocument hydration planDocument toileting plan - including nocte plan with appropriate lighting/assistanceDocument bowel management plan

FAltered elimination

Fall Screening and Strategies for Care Planning

Kessler Screening Tool

Kessler Screening Tool

• Offer Kessler screening tool to all adults (this table is included in the Patient Questionnaire)

• If the patient hasn’t had the opportunity to complete this assessment offer to any patients who appear depressed or anxious• If any patients score any 4 or 5’s please discuss with patient and action any strategies If the patients total score is 30 or above refer to medical team or GP if discharge imminent.

In the past 4 weeks about how often did you feel...(please circle the number under the heading that applies)

Tired out for no good reason? Nervous? So nervous that nothing could calm you down? Hopeless? Restless or fidgety? So restless you could not sit still? Depressed? That everything was an effort? So sad that nothing would cheer you up? Worthless?

None ofthe time1

11

111

11

1

1

A little of the time2

22

222

22

2

2

Some of the time3

33

333

33

3

3

Most of the time4

44

444

44

4

4

All of the time5

55

555

55

5

5

Total your circled numbers

Total score (Kessler):

MST >3

MST3 - 5

High risk

HPE diet+

Refer to dietitian

Malnutrition Screening Tool and strategies for care planning

Malnutrition Screening Tool (MST)

Patient has lost weight in the last 3 months without trying

Step 1:Score:

Step 2:PMS:

Step 3:Plan:

Patient has been eating poorly because of poor appetite? If no score 0 If yes score 1

Total Malnutrition Risk Score:

Action Planto be documented in care plan

If no score 0 If unsure score 2 If yes - how much weight have they lost (in kg)?

0.5 - 5 kg score 1 5 - 10 kg score 2 >10 kg - 15 kg score 3 >15kg score 4

*Includes special or modified texture diets

MST0 - 1

Low risk

MST 0 - 1unchanged:

Continue usualor full diet

MST 2HPE diet

+monitor

MST2

Moderate risk

Usual or full diet*

HPE diet+

Monitor foodintake and

weight

Rescreen every 5 days and document in care plan

Pressure Injury Prevention Screening, Identification and Care planning requirements

Pressure Injury Prevention Screening, Identification and Care planning requirements

Steps – on admission and every 24 hr period1. Perform Braden Score using the Braden Scale.2. Includes identifying the higher risk subscales (any in 1-3 range) and documenting prevention strategies on the care plan.3. Document your Braden score on the risk screening section and subsequently on the care plan every 24hrs4. Identify any additional factors that will increase the patients risk e.g. advanced age, fever, poor nutrition/protein intake, diastolic BP under 60, haemodynamically unstable, co morbidities such as diabetes with neuropathy, PVD, lengthy surgical procedures, use of medical related devices, POP,s NGT’s, nasal prongs, CPAP masks – use clinical judgement – Document judgement in the clinical notes or care plan.5. Use the table attached to assist with documenting appropriate prevention strategies as above.

Patient already has a P.I. on admission?• An ACC45* form needs completing when the patient has come from an Aged Residential Care Facility or the PI developed in hospital – this form needs to be signed by the patient• Score the patient using the Braden Scale daily and place in ‘very high risk’ category• Document strategies for every category of risk in Care plan as appropriate• Daily skin assessment for further deterioration or new areas • Re stage PI daily (never downgrade)• Complete incident form (ref 1077)• Complete wound care chart Ongoing ACC treatment requirementsIf 2‐3 days prior to discharge the wound will require further treatment after discharge, anACC2152* form must be completed. The free text sections must be completed providing as much information as possible.

Who can complete the ACC formsBoth the ACC45 and the ACC2152 can be completed by nursing staff if the patient does not requiretime off work – if time off work is required the ACC45 must be signed by a Doctor.

How to obtain the ACC formsBoth the ACC45 and the ACC2152 forms are available from Supply department.When both forms are complete, and signed by the patient, they are to be sent to The PatientInformation Office, Christchurch Hospital.* The ACC45 form notifies ACC of the personal injury.* The ACC2152 is the Treatment Injury form which must be completed to notify ACC of the Treatment Injury.

If the initial ACC45 form has not been received by ACC they will not be able to process the Treatment Injury claim, hence the importance of completing an ACC45 when a pressure wound is identified.

Key for which area to document in Care plan

PI screening categoriesAny RiskBraden score 0-18 or Can identify strategies fromany category of the Bradenscore chart/descriptors oradditional factors/judgementincrease risk

Moisture

Nutrition

Friction shear

Additional Moderate RiskBraden score 13-14 or ifclinical condition denotesmoderate risk

Corresponding strategies for care plan considerationEducate patient, family and whanauMove them - encourage mobilisation/position changesProtect heels - heel protector bootsProtect elbows/nostrils/ears/bony prominences and protect frommedical related device injuries e.g NGT, catheters, POP’sRemove creases from sheets and clothing

Keep wound exudate controlled - freq of changeIndividualised continence management plan - toileting or absorbent pad use for incontinence/excess skin moisture and freq of change/checksPh balanced cleanser use or Peri Foam (DME) - document freq of washesUse skin protectant barrier on intact skin after washMonitor and maintain stable temperature to avoid excessive perspirationAvoid plastic sheets and multiple layers of linenHigh protein energy diet where MST 2 or aboveMST 3 or above - Dietitian referralExcessive wound exudant - HPE and increased fluid intakeMST rescreen every 5 days - note date of rescreenUse of manual handling equipment trapeze/monkey barTransfer sheetElevate foot of bed 10 - 20 degrees to avoid slippingKeep head of bed below 30 degrees to avoid pressure on sacrum asMedical condition allowsCheck elbows and heels (mirrors may be useful) if any persistent butblanching erythema apply protective silicone dressings to elbows andheels bandage insitu

Foam wedges/pillows for lateral positioning - document frequency ofpositioning changes

All the aboveTwo hourly turns - note times, use turn chart - if skin is marking orredness not recovering - review support surface

All the aboveOrder and use Pressure Redistribution Mattress

Additional Very High RiskBraden score 9 or below or if clinical condition denotesvery high risk

Additional High RiskBraden score 10-12 or ifclinical condition denoteshigh risk

ADL’s section Elimination section Symptom/Obs Discharge planning Risk screening section

Nutrition Wound

Pressure Injury Strategies for Care Planning

Pressure Injury Strategies for Care Planning

NPUAP/EPUAP Pressure Injury Classification SystemStage I Pressure Injury: Non-blanchable erythema• Intact skin with non-blanchable redness of a localised area usually over a bony prominence.• Darkly pigmented skin may not have visible blanching: its colour may differ from the surrouding area.• The area may be painful, firm, soft, warmer or cooler compared to adjacent tissue.• May be difficult to detect in individuals with dark skin tones.• May indicate “at risk” persons (a heralding sign of a risk).

Stage II Pressure Injury: Partial Thickness Skin Loss• Partial thickness loss of dermis presenting as a shallow, open wound with a red-pink wound bed, without slough.• May also present as an intact or open/rupted serum-filled blister.• Presents as a shiny or dry, shallow ulcer without slough or bruising (NB indicated suspected deep tissue injury).• Stage II P.I. should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.

Stage III Pressure Injury: Full Thickness Skin Loss• Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunnelling.• The depth of a Stage III P.I. varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcataneous tissue and Stage III P.I.s can be shallow. In contrast, areas of significant adiposity can develop extremely deep Stage III P.I.s. Bone or tendon is not visible or directly palpable.

NPUAP/EPUAP Pressure Injury Classification System

Unstageable Pressure Injury: Depth Unknown• Full thickness tissue loss in which the base of the P.I. is covered by slough (yellow, tan, grey, green, brown) and/or eschar (tan, brown, or black) in the P.I. bed.• Until enough slough/eschar is removed to expose the base of the P.I., the true depth, and therefore the stage,cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body’s natural biological cover and should not be removed.

Suspected Deep Tissue Injury: Depth Unknown• Purple or maroon localised area or discoloured, intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler compared to adjacent tissue.• Deep tissue injury may be difficult to detect in individuals with dark skin tone.• Evolution may include a thin blister over a dark wound bed. The P.I. may further involve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.

Stage IV Pressure Injury: Full Thickness Skin Loss• Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed.• The depth of a Stage IV pressure injury caries by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these PIs can be shallow. Stage IV P.I.s can extend into muscle and/or supporting structures (e.g. fascia, tendon, or joint capsule) making asteomyelitis possible. Exposed bone or tendon is visible or directly palpable.

Reproduced with permission of AWMA. All rights reserved

Sens

ory

Perc

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Act

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Deg

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r day

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as n

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alks

Fre

quen

tlyW

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out

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at l

east

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day

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om a

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st

once

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akin

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o Li

mita

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Mak

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ajor

and

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pos

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with

out

assi

stan

ce.

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xcel

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mea

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ever

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sual

ly e

ats

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uire

su

pple

men

tatio

n.

Pressure Injury Screening (Braden Scale) including sub scales

Pressure Injury Screening (Braden Scale) Including Sub Scales

Name: John Mario Doe NHI: ABC1234Gender: M DOB: 02/04/1965 Age: 46 Ward: 17

(Attach label here or complete details)

Christchurch Hospital Care Plan - 24 HourThis plan must be rewritten each 24hr period. Identify management requirements and document strategies including frequency. Document “NC” if there has been no change from the previous shift’s strategies.

MANAGEMENT as discussedwith Patient/Whanau/Carer asappropriate(Tick appropriate boxes)

Date:

Night / AM / PM Night / AM / PM Night / AM / PM

STRATEGIES (document within shift columns)

Patie

nt o

r Are

a Sp

ecifi

cR

isk

Scre

enin

g

Daily Braden scoreEducation

If patient at risk: Heels protected Encourage mobilisation Frequent position changes Manage moisture (specify) Manage nutrition (specify) Manage friction & Shear (specify)

Daily Fall Risk Screen No risk or A Previous fall/trip/collapse B Unable/difficulty to get up & go (see ADL section) C Risk taking behaviours D Complex meds/side effects E Confusion/sensory deficits/ disorientation F Altered elimination (see elimination section)

Advanced directives

Cognitive functionMSQ/CAM score: _________

Nicotine dependence

Restraint (specify)

Alcohol withdrawal

Communication deficits

Other (specify)

Moderate to high risk: Foam wedges Two hourly turningVery high risk Pressure redistribution mattress PI area (specify location/mgmt)

PI stage (circle) 1 2 3 4 orUnstageable/suspected deep tissue injury (circle)

Date: Date:

RIF Abdo pain ? causeU/SS - gallstonesDehydratedFistula with abdo collection reqPERC drain

Heels protected with heellifter in bedWalks every 3 hrsAdvised move position every 1/2 hrHPE dietAdvised to move out ofchair bed by lifting not sliding

Referral sent to OT andphysio for assessment

Dizzy with dehydrationand antihypertensives - sit at bedside 5 minbefore getting up L/S BPMed review request donePharmacy referral done

18

CARE

PLAN

24

HOUR

C240076B

20.6.12

Ward 17 Care Plan Sample


Date:



Airw

ay R

esp

Sym

ptom

obse

rvat

ion

Flui

d/M

eds/

IVm

anag

emen

tN

utrit

ion/

hydr

atio

nA

DL

Elim

inat

ion

Wou

ndSp

ecs

Cul

ture

di

sabi

lity

Dx

plan

ning

Sign off

Oxygen requirements

Assistive devicesInhaled medicationsSafe swallowingTracheostomyPain relief strategies

Nausea relief strategies

Vital observations (freq)Fluid balance WeightNeurological BGLCirculation checks

Medications/fluids due

Peripheral cannula change dueIV tubing change dueCVAD treatment Dressing due PICC - review length PPC change due Flushes dueS/C management change due

NBM/special/modified dietFluid restrictionParenteral/enteral feeds/oral nutrition supplementsPEG/NGTFood/Fluid chart

Assistance/EnablersEquipmentTEDsSleep devices/treatment

Toileting (freq)EquipmentIDC/SPCAssistance/supervisionOstomyBowel chartBowel management regime

MDT care coordination forsafe dischargeAccomodation/transportdifficulties on dischargeHome supportsExternal agency notification/referral prior to d/cOther (specify)

Cultural/wairua practices(specify)Disability requirements(specify)

Routine blood/drug levelsMSU UrinalysisSputum Other (specify)

Wound management/dressings(specify next due)Wound chartPin care

Drain care

Date: Date:

Inhalers bd via spacer

Q4H pain score and painrelief prnAntiemetics Q8hrly keephydratedQ4H obs/EWS and L/SBPWeigh before bfastFBC til off IV fluids

Q8hrly IV fluids due1300hrs22/622/6

HPEEncourage oral intake1hrly

Hygiene assistancemaneSupervision with frame

Keep call bell in reach3hrly assistanceToilet raiser

Record motionsAperients 22/6 if no BM

PERC drain dressingend of each shift

Bloods 21.6

Arrange wheelchair toattend service downstairsSunday

MOW stopped while inhospital - restart on d/c

A nurseRN1100hrsA nurse

20.6.12

Name:Designation:

Time:Signature:


Ward Care Plan Samples

Name: Margaret Mary Doe NHI: ABC1234Gender: F DOB: 02/04/1922 Age: 92 Ward: 17




Date:



Patie

nt o

r Are

a Sp

ecifi

cR

isk

Scre

enin

g




Advanced directives


Nicotine dependence

Restraint (specify)

Alcohol withdrawal


Other (specify)



Date: Date:

19/6 Abdo pain - ischemic bowel20/6 For comfort cares

Comfort cares - Family isstaying over with patientNFR status discussed withpatient and family

Daughter staying overnightin lazyboy

NCHeels protected with heellifter in bedPosition change every 2-3 hrsSliding sheet for turns

Pillows to keep positioned2 x assist with turns0900, 1100, 1300

Air mattress ordered

OT referral sent

Pharmacy and medicalreview to avoiddelirium

NFR

Very deaf - ensure usinghearing aides andspeaking clearly

18

CARE

PLAN

24

HOUR

C240076B

20.6.12 20.6.12


Sens

ory

Perc

eptio

nA

bilit

y to

resp

ond

mea

ning

fully

to

pre

ssur

e-re

late

d di

scom

fort

Moi

stur

eD

egre

e to

whi

ch s

kin

is e

xpos

ed

to m

oist

ure

Act

ivity

Deg

ree

of p

hysi

cal a

ctiv

ity

Mob

ility

Abi

lity

to c

hang

e an

d co

ntro

l bo

dy p

ositi

on

Nut

ritio

nU

sual

food

inta

ke p

atte

rn

Fric

tion

& S

hear

1. C

ompl

etel

y Li

mite

dU

nres

pons

ive

(doe

s no

t moa

n, fl

inch

, or

gra

sp) t

o pa

infu

l stim

uli,

due

to

dim

inis

hed

leve

l of c

onsc

ious

ness

or

sed

atio

n. O

R li

mite

d ab

ility

to fe

el

pain

ove

r mos

t of b

ody.

1. C

onst

antly

Moi

stS

kin

is k

ept m

oist

alm

ost c

onst

antly

by

per

spira

tion,

urin

e, e

tc. D

ampn

ess

is d

etec

ted

ever

y tim

e pa

tient

is

mov

ed o

r tur

ned.

1. B

edfa

stC

onfin

ed to

bed

.

1. C

ompl

etel

y Im

mob

ileD

oes

not m

ake

even

slig

ht c

hang

es

in b

ody

or e

xtre

mity

pos

ition

with

out

assi

stan

ce.

1. V

ery

Poor

Nev

er e

ats

a co

mpl

ete

mea

l. R

arel

y ea

ts m

ore

than

a o

f any

food

offe

red.

E

ats

2 se

rvin

gs o

r les

s of

pro

tein

(m

eat o

r dai

ry p

rodu

cts)

per

day

. Ta

kes

fluid

s po

orly.

Doe

s no

t tak

e a

liqui

d di

etar

y su

pple

men

t. O

R is

NPO

an

d/or

mai

ntai

ned

on c

lear

liqu

ids

or IV

=s fo

r mor

e th

an 5

day

s.

1. P

robl

emR

equi

res

mod

erat

e to

max

imum

as

sist

ance

in m

ovin

g. C

ompl

ete

liftin

g w

ithou

t slid

ing

agai

nst s

heet

s is

impo

ssib

le. F

requ

ently

slid

es d

own

in b

ed o

r cha

ir, re

quiri

ng fr

eque

nt

repo

sitio

ning

with

max

imum

ass

istan

ce.

Spa

stic

ity, c

ontra

ctur

es o

r agi

tatio

n le

ads

to a

lmos

t con

stan

t fric

tion.

2. V

ery

Lim

ited

Res

pond

s on

ly to

pai

nful

stim

uli.

Can

not c

omm

unic

ate

disc

omfo

rt ex

cept

by

moa

ning

or r

estle

ssne

ss.

OR

has

a s

enso

ry im

pairm

ent

whi

ch li

mits

the

abili

ty to

feel

pai

n or

dis

com

fort

over

1/2

of b

ody.

2. V

ery

Moi

stS

kin

is o

ften,

but

not

alw

ays

moi

st.

Line

n m

ust b

e ch

ange

d at

leas

t on

ce a

shi

ft.

2. C

hairf

ast

Abi

lity

to w

alk

seve

rely

lim

ited

or n

on-e

xist

ent.

Can

not b

ear o

wn

wei

ght a

nd/o

r mus

t be

assi

sted

into

ch

air o

r whe

elch

air.

2. V

ery

Lim

ited

M

akes

occ

asio

nal s

light

cha

nges

in

bod

y or

ext

rem

ity p

ositi

on b

ut

unab

le to

mak

e fre

quen

t or

sign

ifica

nt c

hang

es in

depe

nden

tly

2. P

roba

bly

Inad

equa

teR

arel

y ea

ts a

com

plet

e m

eal a

nd

gene

rally

eat

s on

ly a

bout

2 o

f any

fo

od o

ffere

d. P

rote

in in

take

inclu

des

only

3 s

ervi

ngs

of m

eat o

r dai

ry

prod

ucts

per

day

. Occ

asio

nally

will

take

a d

ieta

ry s

uppl

emen

t. O

R

rece

ives

less

than

opt

imum

am

ount

of

liqu

id d

iet o

r tub

e fe

edin

g.

2. P

oten

tial P

robl

emM

oves

feeb

ly o

r req

uire

s m

inim

um

assi

stan

ce. D

urin

g a

mov

e sk

in

prob

ably

slid

es to

som

e ex

tent

ag

ains

t she

ets,

cha

ir, re

stra

ints

or

othe

r dev

ices

. Mai

ntai

ns re

lativ

ely

good

pos

ition

in c

hair

or b

ed m

ost

of th

e tim

e bu

t occ

asio

nally

slid

es

dow

n.

3. S

light

ly L

imite

dR

espo

nds

to v

erba

l com

man

ds, b

ut

cann

ot a

lway

s co

mm

unic

ate

disc

omfo

rt or

the

need

to b

e tu

rned

. O

R h

as s

ome

sens

ory

impa

irmen

t w

hich

lim

its a

bilit

y to

feel

pai

n or

di

scom

fort

in 1

or 2

ext

rem

ities

.

3. O

ccas

iona

lly M

oist

Ski

n is

occ

asio

nally

moi

st, r

equi

ring

an e

xtra

line

n ch

ange

app

roxi

mat

ely

once

a d

ay.

3. W

alks

Occ

asio

nally

Wal

ks o

ccas

iona

lly d

urin

g da

y, b

ut

for v

ery

shor

t dis

tanc

es, w

ith o

r w

ithou

t ass

ista

nce.

Spe

nds

maj

ority

of e

ach

shift

in b

ed o

r cha

ir.

3. S

light

ly L

imite

dM

akes

freq

uent

thou

gh s

light

ch

ange

s in

bod

y or

ext

rem

ity

posi

tion

inde

pend

ently

.

3. A

dequ

ate

Eat

s ov

er h

alf o

f mos

t mea

ls. E

ats

a to

tal o

f 4 s

ervi

ngs

of p

rote

in (m

eat,

dairy

pro

duct

s pe

r day

. Occ

asio

nally

w

ill re

fuse

a m

eal,

but w

ill u

sual

ly

take

a s

uppl

emen

t whe

n of

fere

d.

OR

is o

n a

tube

feed

ing

or T

PN

re

gim

en w

hich

pro

babl

y m

eets

mos

t of

nut

ritio

nal n

eeds

.

3. N

o A

ppar

ent P

robl

emM

oves

in b

ed a

nd in

cha

ir in

depe

nden

tly

and

has

suffi

cien

t mus

cle

stre

ngth

to

lift u

p co

mpl

etel

y du

ring

mov

e. M

aint

ains

go

od p

ositi

on in

bed

or c

hair.

4. N

o Im

pairm

ent

Res

pond

s to

ver

bal c

omm

ands

. H

as n

o se

nsor

y de

ficit

whi

ch

wou

ld li

mit

abilit

y to

feel

or v

oice

pa

in o

r dis

com

fort.

4. R

arel

y M

oist

Ski

n is

usu

ally

dry

, lin

en o

nly

requ

ires

chan

ging

at r

outin

e in

terv

als.

4. W

alks

Fre

quen

tlyW

alks

out

side

room

at l

east

twice

a

day

and

insi

de ro

om a

t lea

st

once

eve

ry tw

o ho

urs

durin

g w

akin

g ho

urs.

4. N

o Li

mita

tion

Mak

es m

ajor

and

freq

uent

ch

ange

s in

pos

ition

with

out

assi

stan

ce.

4. E

xcel

lent

Eats

mos

t of e

very

mea

l. N

ever

re

fuse

s a

mea

l. U

sual

ly e

ats

a to

tal o

f 4 o

r mor

e se

rvin

gs o

f m

eat a

nd d

airy

pro

duct

s.

Occ

asio

nally

eat

s be

twee

n m

eals

. Doe

s no

t req

uire

su

pple

men

tatio

n.


Date:

Night / AM / PM Night / AM / PM Night / AM / PMSTRATEGIES (document within shift columns)

Airw

ay R

esp

Sym

ptom

obse

rvat

ion

Flui

d/M

eds/

IVm

anag

emen

tN

utrit

ion/

hydr

atio

nA

DL

Elim

inat

ion

Wou

ndSp

ecs

Cul

ture

di

sabi

lity

Dx

plan

ning

Sign off

Oxygen requirements




Medications/fluids due

Peripheral cannula change dueIV tubing change dueCVAD treatment Dressing due PICC - review length PPC change due Flushes dueS/C management change due

NBM/special/modified dietFluid restrictionParenteral/enteral feeds/oral nutrition supplementsPEG/NGTFood/Fluid chart







Drain care

Date: Date:

Assess alertness for anyoral intake, sit upright

Q4H pain score and painrelief reg,s/c & PRNAntiemetics PRNNot for obs

S/C insuflon R) arm1hrly checks change25/6

HPE - eat asable/likes/tolerates

Bed rails - reassess hrlyFull assistance hygiene2x assist for changingpositions 2 hrly

Keep call bell in reachIDCJPs under as incontinent

Keep bowel comfortablerecord movements

Chaplaincy ref sent forspiritual care

S/W investigating returnto rest home for comfortcare if appropriate

NC

NC

NC

NC

NC

NC

NC

NC

NC

NC


B nurseRN1700hrsB nurse

20.6.12 20.6.12

Name:Designation:

Time:Signature:


Name: Jan Margaret Doe NHI: ABC1234Gender: F DOB: 02/04/1965 Age: 46 Ward: 23




Date:



Patie

nt o

r Are

a Sp

ecifi

cR

isk

Scre

enin

g




Advanced directives


Nicotine dependence

Restraint (specify)

Alcohol withdrawal


Other (specify)



Date: Date:

AnxietyFall before hospitalisationWheel chair bound

Management of anxietiesrelaxation, breathing,planning

Heels protected with heellifter in bedBd standTransfer to chair for mealsEducate on correcttechnique to get up

Pillow used to hold on sideTurns 0800, 1000, 1200

Sacral anal cleftcavalon to protect

Referral sent to OT andphysio for assessmentSocial work referral forcoping assessment

Anxiety - reinforcesafety techniques

12

CARE

PLAN

24

HOUR

C240076B

20.6.12



Date:



Airw

ay R

esp

Sym

ptom

obse

rvat

ion

Flui

d/M

eds/

IVm

anag

emen

tN

utrit

ion/

hydr

atio

nA

DL

Elim

inat

ion

Wou

ndSp

ecs

Cul

ture

di

sabi

lity

Dx

plan

ning

Sign off

Oxygen requirements




Medications/fluids duePeripheral cannula change dueIV tubing change dueCVAD treatment Dressing due PICC - review length PPC change due Flushes dueS/C management change due

NBM/special/modified dietFluid restrictionMalnutrition rescreen dueParenteral/enteral feeds/oral nutrition supplementsPEG/NGTFood/Fluid chart







Drain care

Date: Date:

Q4H pain score and painrelief prn

Bd obs or as EWS indicatesWeigh before bfastM and Th - due 21/6

23/6

HPE diet

25/6

Transfer with 2WCF with2 assistWheelchair bound

Keep call bell in reach3hrly assistanceToilet raiser

Aperients nocte if BNOfor 2 days - 22/6

Cavalon to PI bd

Wheelchair bound,Supportive husband whowants to be involved withcares

OT/PT/SW referralsdoneDietician assessmentpending

Reinstate PC and DA ond/c


20.6.12

Name:Designation:

Time:Signature:


Name: John Michael Doe NHI: ABC1234Gender: M DOB: 03/03/1950 Age: 62 Ward: 27




Date:



Patie

nt o

r Are

a Sp

ecifi

cR

isk

Scre

enin

g




Advanced directives


Nicotine dependence

Restraint (specify)

Alcohol withdrawal


Other (specify)



Date: Date:

Palliative care team involvement

PT and family Educationon disease process

Heels lifters in bed2-3 hrly stand/walk,Advised to changeposition in bed frequentlyHPE dietUse sliding sheet

Family aware of fall riskOT and physio referralfor mobility assessmentdoneTrialling sensor clip andHA checks 1/2 hrly

NFR

Needs orientating to time,place, person regularly

Assess 2hrly for non verbalpain cues

17

CARE

PLAN

24

HOUR

C240076B

20.6.12

7



Date:



Airw

ay R

esp

Sym

ptom

obse

rvat

ion

Flui

d/M

eds/

IVm

anag

emen

tN

utrit

ion/

hydr

atio

nA

DL

Elim

inat

ion

Wou

ndSp

ecs

Cul

ture

di

sabi

lity

Dx

plan

ning

Sign off

Oxygen requirements




Medications/fluids duePeripheral cannula change dueIV tubing change dueCVAD treatment Dressing due PICC - review length PPC change due Flushes dueS/C management change due

NBM/special/modified dietFluid restrictionMalnutrition rescreen dueParenteral/enteral feeds/oral nutrition supplementsPEG/NGTFood/Fluid chart







Drain care

Date: Date:

Assess pain score 2hrly4QH pain relief and prnAssess 2 hrlyAntiemetics prn4QH or as per EWSWeight mane before bfast

0800 and 2000hr IVHydrocortisone

HPE diet

due 25/6/12supplements with lunch

Food chart

2 assist to stand1 assist to walk with frame

IDCAssist bd for bowels

Bowel chartApperients daily no BMfor 3 days - medical assess

Arrange transport forSunday service in Chapel

OT home visit beforedischarge

MOWNotify Palliative Carebefore discharge


20.6.12

Name:Designation:

Time:Signature:


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