Nursing Matters



|Document Title and Code: |Assessment and Care Planning Policy / NMA-CP. |

|Version: |3 |

|Author: |Prepared by Eithne Ni Dhomhnaill & Andrea O’Reilly Nursing Matters & Associates. |

|Adapted for local use by: | |

|Issue Date: |February 2016 |

|Review date: |February 2019 |

|Authorised by: | |

Policy Statement:

Assessment and care planning for each resident in the Centre will be based on a person-centred approach involving the resident at all stages as far as he/she is able. Where the resident cannot contribute to any or all aspects of the assessment and care planning process, the views and observations of his/her representative will be sought.

1. Purpose:

To ensure that assessment and care planning for each resident is based on a person-centred approach that addresses his/her needs, known wishes and preferences and informed by best evidence.

2. Objectives:

1 To ensure that assessment and care planning for residents comply with professional, statutory and legal requirements.

2 To ensure that each resident has a documented care plan that involves collaboration between all healthcare professionals, the resident and/or his/her representative.

3 To ensure that each resident has a care plan that addresses his/her individual needs, wishes and preferences.

3. Scope:

This policy and associated documents apply to registered nurses, healthcare assistants and all other healthcare professionals involved in assessment, planning, provision and review of a resident’s care in the Centre.

Definitions.

1 Comprehensive assessment: refers to the gathering of all necessary information related to the resident’s health, personal and social care needs (Health Information and Quality Authority, HIQA, 2008). The comprehensive assessment is completed within seven days of admission or sooner as indicated by the immediate care needs and risk assessment.

2 Person-centred care: Person-centred care is based on the recognition of the uniqueness of the person. It acknowledges the importance of past and present lifestyles such family background, type of work in which the person was employed, personal likes and dislikes, values, leisure activities, religion as well as health status (Kitwood, 1997). Person-centred care is based on a rich understanding of the resident and his/her circumstances and needs. To deliver person-centred care health professionals must come to know the person, his/her anxieties, fears and needs (Price, B. 2006).

3 Person- in –charge: The person whose name is entered on the register as being in charge of or managing the residential care setting (HIQA, 2008).

4 Care Plan: Arrangements to meet each resident’s assessed needs set out in an individual care plan that is developed and agreed with each resident, and/or his/her representative (HIQA, 2008).

4. Quick Reference Guide for Assessment and Care Planning.

Responsibilities.

|Actions |Responsible Person. |

|This policy will be disseminated to and read by all nursing personnel involved in assessment and |Person in Charge/Director of Nursing. |

|care planning for resident. | |

|A record will be kept of all those who have signed the policy acknowledgement forms. |Person in Charge/Director of Nursing. |

|Where a new version of this policy is produced, the previous version will be removed and filed |Person in Charge/Director of Nursing. |

|away. | |

|Every new staff member who will have a role in assessment and care planning will be given an |Person in Charge/Director of Nursing. |

|explanation of this policy as part of his/her induction. | |

|Nurses will be provided with the opportunity to attend training /updates on assessment and care |Person in Charge/Director of Nursing. |

|planning where there is a significant change to practice in this area. | |

|Each new resident will be assigned a designated/named nurse who will be responsible for the |Person in Charge/Director of Nursing. |

|co-ordination and completion of all assessment and care planning activities for the resident. | |

|An index of signatures and approved abbreviations and grading system will be drawn up and agreed |Person in Charge/Director of Nursing. |

|for use. | |

|Except in the case of emergency admissions, each prospective resident will have a pre-admission |Designated / named nurse. |

|assessment completed. | |

|Each new resident will have admission assessment and an initial care plan completed within 48 hours|Designated / named nurse. |

|of admission as outlined in this policy. | |

|Every nurse will update residents’ care plans during their shifts in accordance with changing needs|All registered nurses |

|as outlined in this policy. | |

|Care given to residents will be in accordance with the plan of care developed and agreed by the |All healthcare staff providing care to |

|resident and / or representative and other healthcare professionals involved in the resident’s |residents. |

|care. | |

|Changes in a resident’s condition will be reported to the nurse on duty. |Healthcare assistants. |

|Deterioration in a resident’s condition will be reported to the senior nurse in charge of the shift|Registered nurses. |

|and / or nurse manager on duty and the Person in Charge. | |

|A schedule for continuous monitoring of assessment and care planning using clinical audit will be |Person in Charge/Director of Nursing. |

|drawn up and disseminated to all nursing and healthcare staff. | |

|Accurate, clear and current care plans will be maintained for each resident within a legal and |All registered nurses. |

|ethical framework. | |

Assessment Protocol.

1 Pre-Admission Assessment:

1 Referrals for admission to the Centre can be received from hospitals, community care services; other residential care centres and by private contact by a prospective resident and / or their representative.

2 For planned admissions, an assessment is completed using the Centre’s pre-admission assessment. The purpose of the pre admission assessment is to ascertain the Centre’s ability to meet the needs of any prospective resident.

3 The pre admission assessment is carried out by the (Specify-Person in Charge/Deputy or another designated nurse). This assessment is carried out in the referring facility or for private referrals, in the prospective resident’s home.

4 Completed pre admission assessment forms are given to the designated admitting nurse in order to prepare for the prospective resident’s admission and to commence the admission assessment.

2 Admission

1 On admission, the admitting and/or designated nurse will complete the Centre’s admission assessment form.

2 An appropriate place that ensures privacy and quiet, such as the resident’s room must be used for assessment.

3 The admitting/named nurse will explain the purpose of all assessments to the resident and seek their agreement to proceed.

4 The admitting/named nurse will seek the resident’s consent to share information with other relevant healthcare team members and ascertain the resident’s wishes for relatives / next of kin to be involved in the assessment and care planning process.

5 Where the nurse judges the resident not to have the capacity to provide information for assessment, he/she will seek the views and observations of the resident’s relative’s next of kin to complete the assessment.

3 Admission assessment encompasses completion of the Centre’s admission assessment form the following:

Barthel Index.

Falls Risk Screen (Insert name of scale being used eg. Stratify; FRAT etc).

Body Mass Index (BMI) and Malnutrition Universal Screening tool (MUST)

Pressure Ulcer Risk Screen (Insert name of scale being used)

Mini Mental State Exam (MMSE) (Or other, such as QMCI hseland.ie)

1 Where indicated, further focused assessments may be required as per the residents assessed needs or as identified in the admissions assessment form, e.g. oral cavity assessment, pain assessment, assessment for depression and so on. These should comply with appropriate protocols identified in other policies including the use of identified risk assessment scales.

2 Where risks are identified in the admission assessment and there is no corresponding validated risk assessment tool is not available a generic risk assessment form should be used e.g. risks associated with smoking, sexually inappropriate behaviour. An attempt to address and reduce the identified risks should be carried out straight away.

3 Residents that have dementia and are unable to clearly communicate the presence of pain should have an Abbey Pain Scale completed.

4 Use of Risk Assessment Tools and Scales.

1 Risk assessment tools and scales provide indicators of the level of risk for a particular area. They must be used in conjunction with the nurses’ professional opinion. However, most risk assessment scales are based on the presence of risk factors.

2 Nurses must refer to completed risk assessment tools and scales when completing the resident’s care plans.

3 Care plans must reflect the information gathered through completion of risk scales, including specific risk factors identified. For example where the pressure ulcer risk assessment identifies a resident as having ‘tissue paper’ skin, the nurse must identify the need for interventions to prevent skin tears.

4 Residents commenced on logs or diaries such as the ABC/Behaviour Monitoring Log or a falls or food diary should be done so for a pre-determined length of time. An ABC/Behaviour Monitoring log can be completed for a period of 7 days, a food diary from 3 to 7 days and a falls diary for 3 to 6 months (depending on the number of falls the resident is experiencing). Rather than using these diaries/logs for simply recording an incident, they should be used as a tool to aid analysis of the behaviour that is being recorded so as to learn more by identifying patterns, themes or trends. This information in turn is used to guide person-centred care interventions appropriate to the residents needs.

5 The assessing nurse should use all available sources of information to complete the admission and comprehensive assessment including referral letters; discharge summaries; laboratory results; vital signs; weight and urinalysis and assessment information from other healthcare professionals.

6 The assessing nurse must liaise with other relevant healthcare professionals involved in the resident’s care when completing the resident’s comprehensive assessment. This, for example may include liaison with the physiotherapist to establish the resident’s needs for mobility.

Care Planning.

1 A care plan to meet the actual or potential needs of the resident should be commenced on admission to the Centre and prepared no later than 48 hours of admission.

2 The initial care plan will be based on the assessment information gathered on admission but must be added to amended and updated in accordance with any additional information gathered and changes to a resident’s needs such as information gathered from focused assessments, discussions with the resident and /or representative, liaison with other healthcare professionals and observation of the resident.

3 The care plan must identify realistic and measurable goals that reflect the resident’s goals for living, preferences and wishes.

4 Each resident’s care plan, at a minimum must include the resident’s abilities, needs, preferences and risks and how these will be addressed for the following:

1. Cognition.

2. Communication

3. Breathing.

4. Elimination

5. Nutrition and hydration.

6. Mood and behaviour.

7. Personal hygiene, including skin care and oral/dental care.

8. Mobility.

9. Mood and behaviour.

10. Medication.

11. Psychosocial care.

12. Religious and spiritual care.

13. End of life.

14. Pain

15. Sleep and rest.

16. Expressing sexuality.

5 Specific problems, care needs and care interventions should be documented under the relevant domain eg. If the resident is at risk of falling, this should be identified and addressed under the resident’s mobility needs.

6 Specific care interventions should be evidence based and comply with the resident’s known wishes and preferences

7 When writing care plans the nurse must include recommendations from other disciplines e.g. physiotherapy, speech and language therapy, in the residents care plan.

8 Where the resident is unwilling or unable to contribute to the care plan, the designated nurse will document this in the resident’s record and seek the views and observations of relatives / significant others in preparation of a person-centred plan.

9 Care plans must provide evidence of the involvement of the resident / representative. This includes for example, how the resident/ representative describes a problem, what the resident’s wishes and / or preferences are.

10 Care interventions should be in keeping with the Centres organisational policies and protocols affecting specific care domains e.g. wound care, nutrition and hydration.

11 Care interventions should also focus on the abilities and strengths of the resident, not just of the need, problem or level of assistance a resident requires.

12 The resident and designated nurse will agree on review schedules for specific problems and designate a date for reassessment no less than three months from the initial assessment.

13 The designated nurse will document the care plan and arrange for the plan to be communicated to all healthcare team members involved in the resident’s care.

14 Nurses delegating aspects of care to care assistants should comply with professional requirements for delegation and clinical supervision as outlined in the Centre’s Delegation and Supervision Policy.

15 All nursing and healthcare staff should continue to identify opportunities to get to know the resident and share information for on-going assessment and care planning.

16 Attempts to get to know the resident should not be intrusive and should always comply with the resident’s wishes.

17 Resident’s with dementia should be supported in the development of life stories to enable the development of activity focused care plans that are individualised to their abilities, strengths, goals and needs.

2 Daily Recording of the Resident’s Progress.

1 Residents’ daily care and condition is recorded by healthcare assistants in the resident’s daily record / flow sheet during each shift. (Enter what you use here).

2 Nurses must complete a narrative note for each resident at the end of shift. Narrative notes must be made for the following:

Visits/reviews by other healthcare professionals and their outcomes.

Changes in a resident’s condition and what has been done to address this.

A list of any care plans that have been updated so as to alert on coming nurses to read the updated care plans.

Any special treatments or procedures received by the resident.

Medications that were omitted or refused and what was done to address this and reason for omissions.

Harm or injury suffered from any incident as well as treatments and care given.

(This list is not exhaustive).

3 Entries to the nursing narrative notes should be timely, that is, recorded as soon as possible after an event.

4 Before completing the nursing narrative notes for each shift, the nurse should review any daily / monitoring records completed by healthcare assistants on that shift.

3 Updating Care Plans.

1 Daily narrative notes can be used to record any problem arising during a shift and what action that was taken to address this. If the action included the need to change a specific care plan, the narrative notes must include this information.

2 Care plans must be updated in accordance with the resident’s changing needs. This means that where there is a change in the resident’s condition that will result in a change to the daily care, the care plan for that domain must be updated to reflect this. For example, if the resident develops a urinary tract infection that results in a change to their daily care until the infection is treated the change to their care must be documented in the elimination domain. This can be discontinued where the infection is gone and the daily care received during the period of infection is no longer required.

3 Each nurse is professionally accountable for ensuring that care plans are updated in accordance with a resident’s changing needs that arise during the nurses’ shift.

4 The nurse must inform his/her line manager if, during his/her shift, he/she has any difficulty with updating a care plan and seek the necessary support to ensure that care plans are updated as required.

5 Following formal reviews, any changes to care needs and how these will be addressed must be reflected in the resident’s care plan under the specific headings/domains.

6 A note informing oncoming nurses of the completion and outcome of the review, that is, what care plans have been updated must be recorded in the resident’s narrative notes.

Protocol for Charting Entries in the Residents’ Records.

1 Before making an entry in the resident’s record the nurse must establish that the record belongs to the correct resident. The resident should be clearly identified on the bottom of each page of the record / care plan using an identifier (first name, middle initial if known, surname, date of birth, GMS number, general practitioners name and room number).

2 Legibility.

1 Black Ink should be used for writing in manual records.

2 Writing should be legible, with entries signed and dated. Difficult to read handwriting should be printed.

3 Where there is an issue of clarity about an entry, it should be re written.

4 A record of all nursing signatures (as registered with An Bord Altranais) and initial will be maintained in each residents care plan folder and by the Person in Charge/Director of Nursing.

5 Only approved abbreviations and grading systems should be used.

6 Initials and abbreviations should never be used on consent forms, death certificates, incident report forms and communications sent to other healthcare services / facilities or for medication names.

7 Every healthcare professional should provide their signature, printed name and initials in the signature bank record before making their first entry to a resident’s record/care plan.

3 Alerts, Warnings and Allergies.

1 Any major risks, alerts, warnings or known allergies must be clearly documented, highlighted and recorded in the designated area of the resident’s record and care plan.

4 Person-Centred Care.

1 Records should provide evidence of the resident’s involvement in care planning process.

2 The resident’s care plan should provide evidence that the views and observations of his/her representative have been sought as far as is practicable, where the resident is unwilling or unable to provide information needed for assessment and care planning.

3 Records should provide information regarding the resident’s preferences and wishes as well as identified needs.

5 Verbal Instructions / information via telephone.

1 If information is given over the phone, it should be recorded as such by the nurse who took the call and should identify the name of the person who gave the information. This entry should be dated and signed by the nurse making the entry. In the case of a verbal instruction, this must be verified by a second nurse/healthcare assistant; signed by both and countersigned at the earliest possible opportunity by the healthcare professional who gave the instruction.

6 Corrections

1 Entries to records should not be erased or destroyed but should be amended if incorrect

2 Correction fluid must not be used. The original entry must remain visible.

3 Deletion or alteration should be made by scoring out with a single line followed by: signature and counter signature if appropriate, date and time of correct entry, and reason for amendment.

4 Corrections / amendments should be made as close to the original recording as possible

7 Recording Consent –

1 It is essential for any person who provides health and social care to a resident to document clearly both the resident’s agreement to the intervention and the discussions that led up to that agreement if:

17. the intervention is invasive, complex or involves significant risks;

18. there may be significant consequences for the service user’s employment, or social or personal life;

19. providing clinical care is not the primary purpose of the intervention e.g. clinical photographs or video clip to be used for teaching purposes or blood testing following needle stick injury to staff;

20. the intervention is innovative or experimental;

21. or in any other situation that the service provider considers appropriate.

(HSE, 2013 National Consent Policy)

2 Consent to nursing care should not be presumed. While it is not necessary to seek written consent for most nursing interventions, where an intervention / procedure carries a significant risk, the resident’s consent should be sought (An Bord Altranais, 2003).

3 Consent to any nursing intervention should comply with the requirements for informed consent. As outlined in the Centre’s Consent and Advocacy Policy.

4 Consent for interventions that carry a significant risk must be easily and clearly identifiable either on the appropriate consent form which is retained as part of the clinical record, or documented within the resident’s care plan and must include the discussions that led up to the agreement.

5 Consent documentation must never contain abbreviations.

6 Recording consent should clearly state the procedure, treatment, care involved and the risks and benefits of and / or alternatives to the procedure that have been explained to the resident.

7 If a consent form is being completed, it must clearly identify the name and date of birth of the resident.

8 Entries regarding consent should include a documented record of how the information had been provided e.g. information leaflets, verbally etc.

9 The consent form must be dated and signed by the healthcare professional obtaining the consent including their full name and grade.

10 Where a resident refuses a recommended procedure this should be documented. The nurse’s explanation / advice given to the resident about the possible consequences of the refusal should also be documented.

11 If a consent form is used and the service user is unable to write, a mark on the form to indicate consent is sufficient. It is good practice for the mark to be witnessed by a person other than the clinician seeking consent, and for the fact that the service user has chosen to make their mark in this way to be recorded in the healthcare record (HSE, 2013)

8 General -

1 Entries should be factual and accurate and should where possible quote what the resident says.

2 Opinions should be supported by a description of observable behaviour e.g. rather than stating that the resident was agitated, a description of behaviour should be recorded.

3 Entries should be timely, written at the time of or as soon as possible after the event described.

4 Entries made by healthcare staff should include their grade.

5 24 hour clock should be used for charting entries.

6 Entries should be in chronological order.

7 A late entry should be identified as such by writing ‘late entry’ beside it, dated, signed and timed.

8 Nurses should chart only for themselves and never chart on behalf of another person.

9 Entries should not contain witty/derogatory comments.

10 Attempts to contact the doctor should be recorded, even if they fail.

11 Where a request is made for the attendance of medical staff or other staff in an emergency, the time of the request should be recorded.

12 Referrals to other healthcare professionals should be recorded noting the date, time and name of that professional.

13 Decisions taken to ‘wait and see’ should be clearly documented.

14 Information, advice, and resident teaching should be recorded by the nurse / professional who provided such information. This should be dated, timed and signed.

15 Nurses should chart the actions taken in response to a complaint eg. if a resident complains of pain, the nurse should make a note of what action was taken and the resident’s response to same.

References.

An Bord Altranais, (2003) Recording Clinical Practice Guidance to Nurses and Midwives. An Bord Altranais. Dublin

1. Health Information and Quality Authority (2009) – National Quality Standards for Residential Care Settings for Older People in Ireland.

2. Health Act 2007 (Care And Welfare Of Residents In Designated Centres For Older People) Regulations 2013

InterRAI (UK). Long Term Care Resident Assessment Instrument User’s Manual.

Australian Government Department of Health and Ageing, Natframe National Framework for Assessment of Older People accessed November 2007 at:

Royal College of Nursing (2001) The RCN Assessment Tool for Older People. Royal College of Nursing. London.

Aucoin-Ratcliffe, D. et al (2002) Charting Made Incredibly Easy. Second Edition. Springhouse. Lippincott, Williams and Wilkins. New York

Price, B., (2006), Exploring person-centred care, Nursing Standard, Vol. 20 No.50, pp.49-54.

3. Health Services Executive (2013) National Consent Policy.[pic][pic]

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Pre Admission Assessment.

■ Referral Received.

■ Pre admission Assessment carried out by Person in Charge or delegated nurse.

■ Completed pre admission form given to admitting nurse to allow for preparation for admission and commencement of pre admission assessment.

Admission Assessment.

▪ Admitting nurse carries out an admission assessment using the Centres comprehensive admissions assessment form to identify risks and immediate care needs.

▪ .The admitting nurse commences the resident’s care plan based on immediate care needs and risks identified.

▪ Admission assessment includes completion of Barthel Index; Falls risk Screen; Pressure Ulcer Risk Screen and MUST Score.

Comprehensive Assessment.

1. The comprehensive admission assessment is completed by the admitting and/ or designated nurse with the resident and/or representative within 48 hours of admission.

2. Comprehensive Assessment includes any additional focused assessments required eg. continence assessments; depression scale and so on.

3. Assessment should focus on the resident’s abilities and strengths and include likes and dislikes where relevant.

4. Assessment data reviewed by resident and /or representative and other relevant healthcare team members.

5. Identification and description of nursing problems / resident needs with resident and / or representative and other healthcare team members.

Care Planning Process.

▪ Care plan commenced on admission based immediate care needs and risks identified.

▪ Initial care plan developed over the first 48 hours based on comprehensive/focused assessments.

▪ Realistic and measurable goals that are negotiated and agreed with the resident as far as he/she is able documented.

▪ Evidence based care interventions to meet needs and wishes of the resident documented.

▪ Care plans cognisant of assessments and inputs from other healthcare professionals involved in the resident’s care.

▪ Care plan documented and communicated to other healthcare team members involved in the resident’s care.

Monitoring and Review.

▪ Resident’s care and condition recorded in daily flow sheets.

▪ Changes to care / condition recorded in progress notes.

▪ Resident’s care plan updated in accordance with changing needs.

▪ Formal review of care plan carried out four monthly with the resident (As able) and / representative.

Writing Problems and Goal Statements.

Problem statements should be specific – ‘impaired mobility’ or ‘reduced mobility’ does not give enough information to plan care. Instead the problem statement should identify the extent of the impairment and any associated or causative factors eg:

‘Mary is unable to walk on her own at any time because she is unsteady and prone to falling’

Or

‘Mary has difficulty walking in the mornings because of stiffness and pain’

Goals statements should be specific, measurable and achievable eg.

‘To keep Mary safe and prevent falls’

Or

‘To address Mary’s pain and promote her comfort when walking’

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