Documents / Notes / Care Plan Date Yes /No Comment

1 Register Complete up to date

2 Next of Kin details complete and up to date

3 Doctor's Notes complete and up to date

4 Medication Kardex completed and up to date

5 Personal Profile details complete and up to date

6 Comprehensive ADL assessment complete and up to date

7 Screening Page complete and up to date

8 ADL Map Page complete and up to date

9 Care Plan complete and up to date

Activities of Daily Living Date Yes /No Comment

1 Communication needs up to date

2 Controlling Body Temp needs up to date

3 Safe Environment details up to date

Fall risk assessment complete and up to date

4 Mobility needs up to date

Manual Handling assessment complete and up to date

5 Personal Care needs up to date

Barthel assessment complete and up to date

5 Skin Integrity assessment up to date

Waterlow Assessment complete and up to date

Skin assessment complete and up to date (if required)

Wound assessment and up to date (if required)

6 Pain (if indicated)

Pain assessment complete and up to date (if required)

7 Breathing & Circulation needs up to date

8 Nutrition Status up to date

Dietary needs and assessment complete and up to date

9 Elimination details up to date

10 Self Image details up to date

11 Recreational & Social details up to date

12 Rest & Sleep details up to date

13 Dying & Spirituality details up to date

14 Other, if indicated and include, complete and up to date

Data collection taken by:Date of Data colection:

Assessment Date

ADL Signature of Assessing Nurse

1 Communication

SPEECH

1. Normal Function

2. Dysarthria / Dysphasia

3. Loss of ability due to Cognitive Dysfunction

HEARING

1. Normal Function

2. Hearing Impairment, Use of hearing aid NA / N / Y (specify)

3. Deaf

VISION

1. Normal

2. Impaired, Use of Spectacles NA / N / Y, (specify)

3. Blind

EMOTIONAL STATE

1. Alert

2. Orientated

3. Confused

4. Anxious

5. Apathetic / Depressed

6. Agitated

7. Content

8. Challenging Behaviour

COGNITIVE STATUS

1. Mini mental test score MMSE (if indicated)

2. Depression score (if indicated)

3. Other relevant details: known to CPN, Old Age Psyhchiatry

Care Plan N / Y

Assessment Date

ADL Signature of Assessing Nurse 2 Controlling Body Temp

1. Independent

2. Assisted

Care Plan N / Y

3 Safe Environment

1. Independent

2. Assisted

3. Risk of Fall; , see Fall Risk Assessment CANNARD

3-8 Low risk; 9-12 Medium risk; 12+ High risk

Care Plan N / Y

4 Mobility; see Manual Handling Assessment chart

1. Independent

2. Assisted

2a. Walking, 2b. Transfer, 2c. In / Out Bed, 2d. Aids used, specify

3. Chair / Bedfast,

4. Hoist, see Manual Handling Assessment chart

Physio / Physical therapy referral NA /N / Y

Care Plan N / Y

5 Personal Care & Skin Integrity

Barthel; Independent, Low, Medium, High, Maximum

Waterlow; 10+ At Risk; 15+ High Risk; 20+ Very High Risk

PAC AID -Specify, e.eg Mattress, Cushions, Turn Chart etc

Hygiene & Dressing

1. Independent

2. Assisted

Skin Integrity, complete Skin Assessment if indicated

1. Skin Integrity; Intact Yes / No. If NO see Skin Assessment

2. Dry ; 3. Red;

4. Wound(s), Pressure Ulcers, Surgical, Other

Wound Assessment Y / N

Treatment Plan, See Care Plan

Care Plan N / Y

Assessment Date

ADL Signature of Assessing Nurse

6 Presence of Chronic Pain

1. No Pain

2. Moderate Pain

3. Severe Pain

If Chronic Pain identified specify as follows

Site

Duration

Effect on daily life

Treatment & Management, e.g. Analgesic, Positional, Massage

Pain Scale Assesssment completed N / Y

Care Plan N / Y

7 Breathing & Circulation

PMH of Cardiac, Respirarory or Circulatory Disease

Respirations RPM

Base line O2 Sats

Blood Pressure BP

Pulse BPM

Colour, Palour, Breathing Pattern

Use of ; inhaler-(specify); O2; nebs; etc

Positioning

(Ex) Smoker N / Y

Resident informed of Smoking Policy NA / N / Y

Care Plan N / Y

Assessment Date

ADL Signature of Assessing Nurse 8 Nutrition Status

Height (mts)

Weight (kgs)

BMI

MUST

1. Usual diet & appetite etc.

2. Any recent weight loss or gain N / Y

MUST Assessment if indicated

3. Likes & Dislikes

Likes

Dislikes

4. Special diet, specify

Care Plan N / Y9 Elimination

A. Urinary1. Voiding normally

2. Incontinent of urine N /Y, e.g, stress, occasional, continous

3. Daytime N / Y

4. Nightime N / Y

5. Assessment required NA / N / Y

5.a. Assessment completed and submitted to HSE, Date

6. Incontinence aids used specify

7. Catheter, size ____ type _____ site ______

8.. Date last changed

B. Bowel Pattern1. Continent

2. Incontinent

3. Frequency of motions

4. Prone to constipation

5. Normal Bristol Score Stool

6. Any known bowel diorders e.g. Diverticular, haemorroids

C. History of apperient useSpecify

Care Plan N / Y

Assessment Date

ADLSignature of Assessing Nurse

10 Self ImageDetail relevant information regarding Resident's sense of selfPreferred style in dress

Care Plan N / Y11 Recreational & Social

Previous / Present Occupation

Hobbies / Interests

Family Involvement

Social interaction with family & staff

Preferred activities e.g. outings, Sonas etc.

Activity program plan

Care Plan N / Y12 Rest & Sleep

Normal sleeping patternLikes to go to bed atLikes to get up atDaytime rest N / Y

Aids to sleepChemical / Environmental / AlternativeSpecify:

Care Plan N / Y13 Spirituality & Dying

Personal Beliefs

Religion (specify if resident wishes)

Pastoral care needs & wishes

Fears and wishes of resident & family

Expectation of resident and family with regard to LTC

Care Plan N / Y

Assessment Date

ADL Signature of Assessing Nurse Other Relevant Information

ADL Care Plan Map for Activities of Living CP Number

Circle current status as assessed

1 Communication1. Speech, 2. Hearing, 3. Vision, 4. Emotional, 5. Cognitive.

2 Controlling Body Temp1. Independent, 2. Assisted

3 Safe Environment1. Independent 2. Assisted

Risk of Fall; LOW, MEDIUM, HIGH

4 Mobility1. Independent, 2. Assisted

Manual Handling Assessment & Guidelines

5 Personal Care & Skin IntegrityBarthel; Independent, Low, Medium, High, Maximum dependency

Waterlow; 10+ At Risk; 15+ High Risk; 20+ Very High Risk

Skin Integrity, Intact Y / N Wound assessment Y/N

6 Pain, if indicated

7 Breathing & CirculationBlood Pressure BP

Pulse BPM O2 Sats

Respirations RPM Smoker Y / N

8 Nutrition Status Weight Kgs BMI

Height Mts MUST

9 Elimination

Urinary function

Bowel function Apperients Y / N

10 Self Image

11 Recreational & SocialActivity Plan

Hobbies / Interests

12 Rest & SleepPattern / Aids, Chemical, Environmental, Alternate

13 Spirituality & DyingSacrament of the sick Y / N

14 Other: (specify)

RN signature

Resident / Representative signature:

Date

Any other comments:

Register Personal DetailsNumber

Surname

First NameDate of BirthPrevious Address

NationalityOccupation (previous)Marital StatusReligion (if disclosed)

PPS No:GMS No:

Ward of Court N / YYES - Details

Next of Kin contact detailsNameRelationshipAddress

Contact No(s):

GP NameGP address

GP phone & fax No:

MDT involved in care e.g. Psychiatrist, OT, Physio / Physical Therapist, Dietician etc.

Social & Care Summary

Medical History Summary

Known Allergies:

Activities of Living

1 Communication

1. Speech

2. Hearing

3. Vision

4. Emotional State

5. Cognitive Status

2 Controlling Body Temp1. Independent2. Assisted3. Current Temperature

3 Safe Environment1. Independent2. Assisted

3. Risk of Falls; CANNARD Low, Medium, High

4 Mobility1. Independent2. Assisted3. Chair / Bedfast4. Hoist or other Aids, specify

5 Personal Care & Skin IntegrityBarthel; Independent, Low, Medium, High, Maximum dependency

Waterlow; 10+ At Risk; 15+ High Risk; 20+ Very High RiskSkin Integrity; Intact Y / NIf No, specify; Wound(s), Pressure Ulcer, Surgical, OtherCurrent Treatment:

6 Pain, presence of (if indicated)

Site & Severity:Effect on daily livingTreatment & Management

7 Breathing & Circulation Blood Pressure BP

Pulse BPM O2 SatsRespirations RPM Smoker N / Y

PMH of Cardiac or Respiratory disease

8 Nutrition Status Weight Kgs BMI Height Mts MUST Score

Likes and DislikesLikes Dislikes

Special Diet, specify

9 Elimination Urinary function Continent Y / NPMH of bladder disorder e.g. prostate problems, UTI's

Bowel functionNormal Bristol Score Stool Apperients N / Y, specify:Frequency of motions Continent Y / NPMH of bowel disorder,e.g. diverticular, haemorrhoids, IBS, constipation

10 Self Image Summary

11 Recreational & SocialHobbies / InterestFamily involvementSocial interaction with family & staffPreferred activities e.g outings, reading, Sonas etc.

12 Rest & SleepNormal sleeping patternDaytime rest N / Y

Aids to sleepChemical / Environmental / AlternativeSpecify:

13 Spirituality & Dying

Personal beliefs, Religion (if resident wishes to disclose)

Pastoral needs & care

Wishes and fears of resident & family

Expectation of resident, NOK & family

Sacrament of the sick N / Y, Date

Other relevant information

NOK notified of Transfer N / Y

Reason for Transfer

Date & Time

Notes /Comments

RN Signature