Admission Care Plan

1. Admission Care Plan ADL Data Systems, Inc May-2013

2. Agenda: • Tools used to gather data for Admission Care Plan • Suggestions for items to be included • CNA assignment of tasks • Searching within the Library

3. 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.

4. Admission Care Plan: • 24 Hours from Admission

5. 1. Allergies • Medication Allergies: • NKDA • Food Allergies: • Latex Rxn:

6. Allergies • If resident is allergic, implement allergy plan of care • located in “Safety-Latex Allergy – Food Allergy – Food Intolerances” Version 02 Library

7. 2. Advanced Directives - are included in “ADL Function- CNA CP Tasks” Note, that you can design your Care Plan in a form of a List This way information is presented in clear and effective manner

8. 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

9. 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:

10. 4. Communication Ability • My primary language is: • I speak well • I comprehend conversations in writing • I use sign language • I prefer to be called:

11. 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.

12. 5. CNA Assignment – ADLs

13. 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

14. 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

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

16. 7. Diet • Other items to consider: • difficulty chewing/swallowing • Aspiration Risk • Poor dentition • Holds food in mouth • Assistive eating utensils • NPO • Mechanically altered Diet • Snack:

17. 8. Falls • Determine Risk for Falls - If HIGH Risk, preventative measures should be included in the Care Plan immediately

18. 8. Falls • Best 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.

19. 8. Falls • Different types of assessments available: - Morse Fall Risk - Hendrick II Fall Risk Model - ADL Fall Risk Assessment

20. ADL Fall Risk Assessment

21. ADL Fall Risk Assessment

22. 8. Falls • Interventions are located under “New Admission – New Admit- Falls”

23. 9. Skin • Determine Risk for Pressure Ulcer - If HIGH Risk, preventative measures should be included in the Care Plan immediately

24. 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.

25. 9. Skin • Different types of tools available: • Braden • Morton • Both available in ADL Assessments

26. 9. Skin

27. 9. Skin • Comorbidities – Complex Conditions, polypharmacy, age >75 years old DX button

28. 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

29. 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.

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

31. 18. Miscellaneous – additional information to consider: • Pacemaker • Dominant Hand: • Smoker: yes no • I am able to self-administer medications • I am unable to self-administer medications

32. 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