Admission Care PlanADL Data Systems, IncMay-2013

Agenda:Tools used to gather data for

Admission Care PlanSuggestions for items to be

included CNA assignment of tasks Searching within the Library

Admission Care Plan:

Objective: specifically designed to be created for the FIRST day the resident arrives into the facility. Information needs to go immediately from the Care Plan to the CNA touch to ensure proper immediate care for the resident.

Admission Care Plan:

24 Hours from Admission

1. AllergiesMedication Allergies: NKDAFood Allergies:Latex Rxn:

AllergiesIf resident is allergic, implement

allergy plan of care

located in “Safety-Latex Allergy – Food Allergy – Food Intolerances” Version 02 Library

2. Advanced Directives

- are included in “ADL Function- CNA CP Tasks”

Note, that you can design your Care Plan in a form of a ListThis way information is presented in clear and effective manner

3. Mental Status

It is suggested to use vocabulary most commonly used in your facility to be included in the Admission Care Plan

This way directives are easily recognized by your IDT members

3. Mental Status-Oriented to Person _ Place _ Time_ -Alert -Lethargic-Comatose-non-responsive-Does not know own name-Does not know age-Does not remember last meal-Cannot repeat sequence of number-other:

4. Communication Ability My primary language is:I speak wellI comprehend conversations in

writingI use sign languageI prefer to be called:

5. CNA Assignment – ADLs

A general suggestion for the ADL Portion of the Care Plan is available under “ADL Function-New Admit-CNA CP Tasks” in Library Version 2.

You can copy this set in its entirety, or only parts of your choice.

5. CNA Assignment – ADLs

5. CNA Assignment – ADLs Note, that Tasks are assigned to CNA – right

here – upon the activation of the Care Plan Tasks will flow to CNA Charting

6. Ambulatory Aids

– are included in “ADL Function – CNA CP Tasks”◦Cane◦Walker◦Wheelchair◦Crutches

In the ADL Library, searching by the keyword “device” locates all devices available

7. Diet Diet directives are included in “ADL Function- CNA CP Tasks”

7. DietOther items to consider:difficulty chewing/swallowingAspiration RiskPoor dentitionHolds food in mouthAssistive eating utensilsNPOMechanically altered DietSnack:

8. FallsDetermine Risk for Falls - If HIGH

Risk, preventative measures should be included in the Care Plan immediately

8. FallsBest Practice Approach –

choose tool which is quick to administer and provides a determination of risk for falling based on gender, mental and emotional status, symptoms of dizziness, and known categories of medications increasing risk.

8. FallsDifferent types of assessments

available:

- Morse Fall Risk - Hendrick II Fall Risk Model - ADL Fall Risk Assessment

ADL Fall Risk Assessment

ADL Fall Risk Assessment

8. FallsInterventions are located under

“New Admission – New Admit- Falls”

9. Skin Determine Risk for Pressure Ulcer

- If HIGH Risk, preventative measures should be included in the Care Plan immediately

9. Skin Best Practice Approach - Use a

reliable and standardized tool for doing a risk assessment, such as the Braden Scale as part of a comprehensive risk assessment.

Include assessment of other risk factors, such as comorbidities, for a comprehensive risk assessment.

9. Skin Different types of tools available:

◦Braden ◦Morton

Both available in ADL Assessments

9. Skin

9. Skin Comorbidities – Complex

Conditions, polypharmacy, age >75 years old

DX button

9. Skin In ADL The Diagnosis

◦Admission DX are available for you ◦DX can generate a Care Plan based

on the ICD-10 codes, if you use the ADL Initial Assessments

10. Dentures – Hearing Aid – Eye Glasses Dentures, Hearing Aid, and Eye

Glasses are always a part of the Admission Care Plan. Note, care for these items is assigned to CNA.

16. Oxygen◦Cannula◦Mask◦_ Litres/Minute◦Constant◦Daily◦Intermittent

18. Miscellaneous

– additional information to consider:

PacemakerDominant Hand: Smoker: yes noI am able to self-administer

medicationsI am unable to self-administer

medications

RESOURCES:

Hartford Institute for Geriatric Nursing http://consultgerirn.org/

Hendrick II Fall Risk Model http://consultgerirn.org/uploads/File/trythis/try_this_8.pdf

PAINAD Scale – Pain Assessment in Advanced Dementia Scale http://www.healthcare.uiowa.edu/igec/tools/pain/PAINAD.pdf