Download Patient Assessment Guide (PAG)

Patient
Assessment
Guide
For use on admission
2
Contents
Introduction4
Respiratory6
Cardiovascular8
MSK / Mobility9
Neurological11
Gastro-Intestinal / Nutrition
13
Psychological14
Social15
Skin16
Elimination17
Safeguarding18
EOL / DNACPR20
Discharge Planning21
3
Introduction
These prompts are designed to guide and support
the completion of the new community hospital
documentation.
The documentation needs to tell the story of the patient’s
journey whilst in hospital including your objectives in relation
to their stay.
The documentation is designed to provide a holistic
assessment of the patients needs and is divided into different
sections (or systems) in order to facilitate this.
Each system contains its own specific guidance which all staff
undertaking assessments will need to consider when doing
this and include in conversations with patients and carers.
Please remember, when completing the documentation;
• Changes in care or status need to be documented
under each appropriate system.
• The guidance is not exhaustive and some parts of each
section may not be appropriate for your patient.
• ‘SBAR’ should be used as a tool for documentation and
communication throughout.
• Abbreviations should not be used.
• It is ok to think outside of the guidance and add all
relevant information.
• It is ok to just record observations once and to write on
the documents ‘see observations chart’.
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Patient Assessment Guide
Introduction
• Where ALERTS are present they should be
appropriately identified to include infection control
i.e. MRSA, specific falls risk, pressure ulcer risk, DOLS
status.
• The daily record of care needs to be completed on the
continuation sheet and should always include the plan
for the patient’s care assessment and recommend each
shift.
• Tools that have been developed to support care such
as a falls assessment, bed rails, skin, MUST, Braden,
Bartel & manual handling are available as a laminated
resource in a folder on the ward.
• The findings form these assessments should be
recorded on the patient assessment form.
• Recommendations must be made for each section –
even if it is to say ‘no problem identified’.
• Recommendations need to be SMART. That is;
Specific
Measurable
Achievable
Realistic
Time-related
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Respiratory
1
• Confirm relevant history with the patient using
previous and transfer documentation e.g. known
conditions – chronic obstructive pulmonary disease
(COPD), asthma, cancer, bronchiectasis, fibrosis.
• Document previous admissions and interventions
such as artificial ventilation (CPAP, BIPAP, nebuliser
therapy).
• Assess the risk of aspiration dependant on relevant
diagnosis e.g. motor neurone disease (MND).
• What is the current and normal respiratory rate &
pattern?
• Is there a cough or wheeze and is this normal?
• Is there evidence of a respiratory infection and if so
what treatment is required?
• Is there expectorate? If so is the sputum normal for
them – amount, colour, viscosity?
• Complete an oxygen saturation and review against
their normal saturation levels e.g. may be lower than
expected in COPD.
• Which medications are used and to what affect –
history- inhalers, nebs? Check technique.
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Patient Assessment Guide
1
• Are they able to speak in full sentence without
breathlessness – is this their normal?
• How far can they walk before becoming
breathless – is this their normal?
• If in any respiratory distress what is their most
comfortable resting position?
• Do they have oxygen at home; is it effective and how
long have they had it – what rate?
• What does the patient look like? Cyanosis, colour,
breathing pattern; is this normal for them?
Respiratory
• What is the smoking history – smoker, non smoker,
how many a day, how long given up for? Refer for quit
advice if they are a smoker.
• Report concerns in relation to deteriorating breathing
via MEWS escalation.
• When assessing for any expectorate: Ask for a
specimen to be collected for MC&S if clinically
indicated
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Cardiovascular
2
• Confirm relevant history with the patient using
previous and transfer documentation e.g. chest pain,
heart failure, hypotension, angina, vascular disease,
VTE, surgical intervention, syncope, anaemia.
• Take a pulse, observing for rhythm irregularities,
strength and speed and review if this is not normal for
them.
• Perform an ECG; if there are any abnormalities refer
for medical opinion as required.
• Observe and note normal skin colour, current skin
colour & texture e.g. pale, cyanosea.
• If they have lower limb oedema or history/symptoms to
indicate poor circulation complete peripheral pulses
using pedal pulses on both feet.
• Record all cardiac medications and their
effectiveness & side effects e.g. Warfarin, recent
changes to dose or type. Consider other medicines e.g.
antihypertensives.
• Review lifestyle behaviours and note any advice
required e.g. smoking, alcohol, exercise capacity,
lifestyle limitations.
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Patient Assessment Guide
3
• Record the location, time, activity and details of
fall - include pre- fall symptoms.
• Record any witness account if possible.
• If there is a falls history record a lying/standing BP
and if there is a deficit refer for intervention.
• Review footwear issues/safety – type of shoes/
slippers and make recommendations if required.
• Review ability for relevant transfers required for
independence goals to be achieved in a safe manner.
• Does patient have a fear of falling, if so when and
what do they worry about most.
• Confirm how mobility effects their ability to perform
the activities of daily living and what can be done to
promote independence with this.
MSK / Mobility
• Confirm relevant falls history with the patient using
previous and transfer documentation e.g. injuries
sustained where and what happened.
• Assess hearing and vision to ensure this isn’t causing
a risk to mobilising or falling.
• Record and review equipment required to maintain
independence e.g. walking aids and/or other
equipment in use or needed.
www.southernhealth.nhs.uk
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MSK / Mobility
3
10
• If a falls history is identified record the osteoporosis
risk and review medication current and required for
bone protection.
• Review posture and seating and how this impacts on
independence e.g. gait, balance, stiffness.
• Review and record the risk of pre-morbid mobility.
• Assess and record their normal and current mobility:
Confidence? Able to dress self? Transfer ability?
• Complete a risk assessment on current and home
risks in relation to their environment: e.g. safe, ward
position, bed rails, need for high/low bed?
• Assess and record if there is pain on mobilising, if so
describe type, duration, treatment and its effectiveness
– use a verified pain score. Review the effectiveness of
treatment.
• Remember to assess falls risk regularly.
Patient Assessment Guide
4
• Record any symptom onset if gradual or rapid and
effective interventions used e.g. dizziness, headache.
• Assess the degenerative or progressive nature of
the disease process – prognosis
• Assess and record any potential deficits – facial/ limb/
sensory and identify risks
• Assess and record their normal and current mood –
normal/ tearful/ depressed
• Confirm their normal and current functionality –
communication/ nutrition/exercises and plan goals with
them for independence
Neurological
• Confirm relevant neurological history with
the patient using previous medical and nursing
documentation e.g. multiple sclerosis, stroke.
• Assess any communication needs and plan goals
with them for improvement if required – hearing/sight/
speech – dysphagia refer to speech and language
therapy (SALT) as required
• Assess the need for communication tools that may
be required and review their effectiveness
• Assess any sensory loss and record the potential risks
including actions for safety
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11
Neurological
4
12
• Assess and record any issues in relation to
proprioception (awareness of body)
• Assess and record normal and current cognition/
perception/praxis/psychosocial - consider impact on
falls risk assessment.
• Body map motor tone from mild hypotonia to
malalignment - refer to occupational therapist &
physiotherapist as required.
• Review and record selective movements/power/
coordination for the whole body
• Assess and record transfer risks and
interventions for;
•
•
•
•
•
•
•
Rolling
Lying to sitting
Bridging
Sit to stand & Bed to chair
Gait
Toilet transfers & Seating
Other e.g. feeding, writing
Patient Assessment Guide
5
• Record weight/BMI identify risks and actions required.
• Perform risk assessment as per policy and develop
a care plan for those at risk. Use MUST form as
guidance.
• Assess any pain, noting type, where, when, treatment
and record score e.g. abdominal pain.
• Assess and record bowel movements; their
frequency and consistency using the Bristol stool chart
– identify changes to normal, blood present, mucous.
• Assess current medication that may cause symptoms.
• Assess skin colour, pallor or other for jaundice.
• Assess appetite and any nausea including
effectiveness of any treatment used
• Perform an oral assessment – check teeth, mouth,
gums and take action if problem identified e.g. teeth
don’t fit, sore mouth.
• Assess normal and current needs relating to diet &
hydration including any equipment required e.g.
puree, diabetic, high protein, feeding cup, cutlery.
www.southernhealth.nhs.uk
Gastro-Intestinal / Nutrition
• Confirm relevant gastro-intestinal history with
the patient using previous medical and nursing
documentation e.g. gastric ulcers / recent abdominal
surgery / inflammatory bowel disease.
Gastro-Intestinal / Nutrition
5
14
• Assess if patient has any diarrhoea of unexplained
cause?
• Is isolation required?
• Review medications / antibiotics
• Has patient been transferred from a ward affected with
D&V?
• Does patient have a PEG (percutaneous endoscopic
gastrostomy) / PEJ (percutaneous endoscopic
jejunostomy) insitu? Does entry site look clean and
healthy?
Patient Assessment Guide
6
• Assess cognition using the MMSE / MOCA tools and
act as required.
• Assess for and note any cognitive impairment e.g.
learning disability and requirements for the individual
e.g. key words for communication.
• Review family situation and / or any recent
bereavement or other stresses.
• Assess current and normal activity levels –
motivation, isolation.
• Assess issues that may be affecting the persons well
being such as insomnia.
Psychological
• Confirm relevant psychological history with
the patient using previous medical and nursing
documentation - memory loss/impairment i.e.
dementia.
• Assess any delerium / confusion and triggers that
cause stress or effective treatments used.
• Assess current emotional well being or mood.
• Consider how this person’s mental health and
well being may affect all areas of their life:
communication, motivation and concordance, pain
management, nutritional intake.
www.southernhealth.nhs.uk
15
Social
7
• Key information on the following should be acquired –
use SBAR framework as a template to recording the
information – this can then be used at MDT meetings.
• Work with the patient to agree a realistic destination
and discharge date.
• Agree the SMART goals and actions required to
enable that discharge short and longer term.
• Involve relevant health care professionals and
agencies to support discharge.
• Describe the current & future requirements for
domestic arrangements, e.g. main carer, equipment
used, support at home, current or future concerns etc
• What else do we need to do to facilitate a safe and
effective discharge?
• Has the patient a ‘preferred priorities’ or ‘place of
care’ (PPC) documented.
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Patient Assessment Guide
8
• Risk assess the level of skin integrity using a tool
e.g. Braden – reassess in particular when the patient
deteriorates.
Skin
• Perform a body map within 24 hrs of admission to
caseload – check skin all over.
• Assess the patient’s ability to reposition themselves
regularly, with correct seating and good posture.
• Give prevention advice and education to patient
and family and carers – check understanding and leave
written advice.
• Review equipment needs – bed, mattress, pads etc
and implement as required.
• Assess any wounds and provide a care plan re healing
objectives & treatments. Seek tissue viability advice if
necessary.
• Assess dry skin and the need for dressings and
emollient/cream.
• Assess the nutritional and hydration needs – higher
nutritional needs will be required if wound present.
• Check for skin conditions and infections: treat
accordingly.
• Note medications that affect the skin - i.e. steroids.
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Skin
8
• Complete MRSA screening within 48hrs of
admission – stating sites screened, results and
management (isolation, decolonisation, patient
information)
• Assess any wounds and take a swab for MC&S if the
wound shows signs of clinical infection
• Check for Venflons / PICC (peripherally inserted
central catheter) lines – review management and
document actions
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Patient Assessment Guide
9
• Assess any product requirements ensuring
prevention & treatment options are not appropriate.
• What is the normal bowel and urinary habit for
them?
• What are the hydration requirements for the
individual in relation to continence e.g. catheter in situ.
• Review any medicines that affect continence
including aperients.
• If the person wishes to be assessed for continence
promotion techniques refer to specialist services for
bladder re training.
Elimination
• Perform a continence assessment to indicate if active
treatment can improve continence.
• Ensure there is an appropriate reason for catheter
insertion – review management.
• Advise about the risk of infections and actions
required to reduce risk – urinalysis as required.
• Provide written and verbal self care advice.
• Ensure the patients privacy & dignity needs are
maintained at all times.
• Remember to consider the risk of pressure ulcers
and sore skin
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Elimination
9
20
• Recognise the potential sensitivity of the issue
including stigma and embarrassment.
• Does patient have a catheter insitu?
• Assess need, review management and document
actions
• Ensure there is a clear management plan for
catheterised patients
Patient Assessment Guide
10
• Can the patient provide informed consent to care
and treatment?
• Patient’s choice – do they need support to make
decisions about their care?
• Mental Capacity – apply the two-stage test and five
principles if there are concerns the patient may lack
capacity.
• Identity any concerns about the patient’s welfare
including neglect.
• Are there any concerns in relation to other members
of the household’s safety - e.g. a child in the home;
or domestic abuse issues?
• Could Deprivation Of Liberties (DOLS) be an issue
to report?
Safeguarding
• Consider vulnerability including learning disability;
dementia.
• Are there unmet needs putting the patient at risk?
• Are there any signs or symptoms of abuse present
or verbalised?
• Can the patient maintain their own safety
adequately?
• Do they need an Independent Mental Capacity
Advocate (IMCA)?
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Safeguarding
10
22
• Is a referral to other agencies needed for advice/
support - e.g. Adult Services, Fire Service?
• Is information sharing with other multi agency
partners indicated?
• Follow the safeguarding process; clearly document
any best interest decisions when taken and by
whom.
• Document if anyone holds either a Lasting Power of
Attorney for either health and welfare or property and
financial affairs; or an Enduring Power of Attorney.
• Is there an ‘Advance Decision’ in place?
Patient Assessment Guide
11
• If the answer is ‘no, you would not be surprised’ the
patient should be given the opportunity to discuss the
future by asking:
• Does the patient have a Preferred Priorities/Place
of Care?
• Does the patient have an uDNACPR form ( purple
form)?
• Does the patient have an Advanced Care Plan
(ACP) or Advance Directive (AD)?
• Is the patient on the Gold Standards Framework/
end of life care register/Liverpool Care
Pathway?
• Is the patient in the last 72 hours of life?
• Is the patient known to the Specialist Palliative
Care Team?
EOL / DNACPR
• Would you be surprised if this patient was to die in
the next 6 -12 months?
• Have the relatives and/or carers been involved
in decision making?
www.southernhealth.nhs.uk
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Discharge Planning
12
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• Document the equipment provided or ordered.
• Document the current medications, meds stopped
or started in hospital.
• Plan if the drugs are to be reviewed, titrated etc.
• Plan if further investigations are required by
primary care and secondary care.
• Follow up information - outpatient date, readmission
date etc.
• Have the family carers been informed of discharge
so they can start care and prepare the environment?
• Has the GP and community matron been informed
of the discharge and the ongoing needs of the patient?
• Date of admission and discharge
• Single Point of Access/Virtual ward referral and
contact
• Name of social worker/care agencies involved
• Access to property/special instructions
• Transport arrangements
Patient Assessment Guide
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