Nursing Needs Assessment AM/016 PATIENT NAME HOME ADDRE GP & ADDRE DOB IC / HOPITAL NMBER / RECORD NMBER CRRENT LOCATION e.g. Ward, Care Home AEMENT REETED BY NAME & ADDRE OF NRING HO,E PLACEMENT DATE OF ADMIION / TRANFER TO NRING (CARE) HOME DATE OF NRING NEED AEMENT() Date, ignature & name of Nurse Assessor & Place of Work & Phone Number DATE INITIAL RNCC Date, ignature & name of Nurse Assessor & Place of Work & Phone Number DATE 3/12 REVIEW FOR NEW PALCEMENT / CRITERION 1, JOINT FNDING / FNC REVIEW COMPLETED Date, ignature & name of Nurse Assessor & Place of Work & Phone Number DATE OF COMPLETION OR ANNAL REVIEW Date, ignature & name of Nurse Assessor & Place of Work & Phone Number REVIEW / NEW PLACEMENT ARRANGED Y / N
Primary Health Problem: (is the patient clinically stable?) Previous Medical History Care Freq Daily, weekly, mth, 24hr Care By nqualified, ualified. upervised (Circle all that apply) Review Describe Changes Date / ign Mobility / Bartel core ( ) Ability / Restrictions? Aids sed / crutches / hoist / transfer belt / turn table / sliding sheet / describe mobility & transferring / stairs / Manual Handling issues: Falls History; Tullamore Risk Assessment ocre ( ) Prevention / Action Implemented: Document Falls Risk High / Medium / Low (circle) Breathing: (Oxygen / supplied via / condenser / nebulisers / own machine?) Nutrition: (Diet / swallow / PEG / Feeds self / Needs Help / All Meals / All drinks) Nutritional creening Tool core High / Medium / Low Known to Dietician Y / N Referred to Dietician Y / N Date: Continence / Elimination: (urinary / faecal / double / catheter urethral / supra pubic / IC / stoma / aids to continence / proximity to facilities) If use pads document amount & appropriateness No. Pads Day / Night ( ) Consider in depth continence assessment if appropriate
Personal Hygiene: (washing & dressing / self care / assistance / by 1/2 carers / bath aids) Care Freq Daily, weekly, mth, 24hr Review Describe Changes Date / ign Tissue Viability / Waterlow core ( ): (Tissue Viability Proforma included? Consider Weight / Nutrition / Mattress Hire / record step down options explored if patient requires Airwave mattress but does not trigger Tissue Viability proforma i.e. PA s intact). kin Condition / Wounds / Dressings: (Treatment / Type / chronic / acute / trauma / frequency / by / reviewed) Communication / ensory Deficit: (memory / orientation / cognitive abilities / impairment / sight / hearing). Known to ALT Y / N Referred to ALT Y / N Date: Known to troke Coordinator Y / N Referred to troke Coordinator Y / N Date: leep Pattern / Night Concerns: (frequency / every night / occasionally / sedation / risk / level of Night care required / recent change in sleep pattern) Overview of Mental Health: (Joint CPN Assessment required for EMI placement / consider is separate mental health assessment needed?) 6 CIT (Cognitive Impairment Test) core ( )
Emotional Well-Being (consider loss of confidence, self-neglect, substance misuse, recent change in sleep pattern, short term memory loss, disorientation to place and time, recent bereavement) pecific Behavioural Issues (consider agitation, history of violence/aggression to self/others / behaviour placing self or others at risk / indicators of physical, emotional, sexual abuse, wandering / absconding) pecific Risk Assessment (if not documented above): Include comments and plans to manage e.g. wandering / insight / anxiety / aggression / behaviour / mood management consider CPN / Learning Disability assessment. Identify specific risk factors and risk management plan Current Medication (>4 medication per day consider link to falls, list drugs & frequency, date of last medication review) Medication Management (Administration / self medicating / patients understanding / side effects / allergies / specific pain issues) Other pecial Health Care Input / upervision tate reason & intended care plan, (e.g. peech & language / Macmillan / ALT / dietician / multidisciplinary / bloods / tests) ymptom Control (Is there any evidence of unpredictable, hard to manage, symptoms occurring?)
Rehabilitation Needs: (Potential / Options considered / delivered / complete. Multidisciplinary Assessment e.g. In / out patient therapy, residential rehab programme, community therapy) Care Freq Daily, weekly, mth, 24hr Review Describe Changes Date / ign Prognosis: (are there any significant conditions / issues which will affect prognosis?) Other Relevant Issues: (not documented elsewhere) Carer Circumstances: (consider need for carers assessment) Patients / Carers Views of the Proposed Care Plan: Reason for Assessment: (FNC review / new placement / change of status. going out of funds / criterion review / home care package) pecialist Continuing Care / Funded Nursing Care advice: (Document Intermediate Care Coordinator / Continuing Care specialist assessor / FNC Coordinator discussed with, date & outcome) pecific Equipment Needs. List all Items (e.g. Commode provided by Nursing Home, does the patient need specialist equipment only usually available through hospitals or on prescription?) Provided By Ordered Form Expected Delivery Date
ummary of Continuing Care Assessment & Recommendations: Which Criterion is met? Please circle which of the following Continuing Care Criterion 1, Joint Funding or None are indicated: Criterion 1 (Please indicate all that apply a d) A B C D Joint Health & ocial Care Package Recommended No Continuing Healthcare Criteria met Recommendation & Rationale for Decision (Please Explain) Any further information you wish to add, e.g. Criterion 2a the amount of health input service / fee to be paid above that funded by RNCC RNCC banding: (Complete if recommending Nursing Home Placement, NB if you recommend a Nursing Home your patient will probably not be low band RNCC or you would have recommended a residential care home placement. (elf-funders can be the exception if they have chosen a Nursing Home but could be cared for elsewhere) ignature of Assessor: Name & Designation: Date: Contact Tel No: Care Plan NH upport to Placement ocial Care upport to Placement Care Home Category of Patient: circle / delete as appropriate OP (Old Age) DE (E) ervice ser over the age of 65 with dementia) MD (E) ervice ser suffering from a mental disorder, excluding learning disability and dementia) Provisional Discharge Date (if appropriate): Provisional Discharge Location (if known / appropriate): COPY OF NRING NEED AEMENT & RNCC BANDING TO BE GIVEN TO PATIENT FAMILY ON DICHARGE Given To / Date: Given By: ummary of PCT Officer Grey sections to be completed by PCT Responsible Officer igned PCT Panel Officer: Name (print): Date: Designation: Future Plans for Patient Follow p Action By Health Lead: PCT Commissioner informed of decision Options considered and discussed with PCT Commissioner Patient / Carer informed in writing Case presented to local funding panel Decision communicated to PCT Commissioner Placement / Care Plan arranged Written care plan / copy of Nursing Needs Assessment forwarded to ervice Provider and ser Review date set (Please state)
RNCC BAND HIGH nstable and/or unpredictable, at risk. Complex needs (Needs frequent registered nursing intervention over 24 hours) DECIION (TICK RELEVANT BOX) RATIONALE: MEDIM table and/or predictable, minimal risk (Needs daily intervention by a registered nurse and may need access to a nurse at any time) LOW elf selected placement, care cold be provided in another setting with minimal registered nurse intervention