Admission Care Plan ADL Data Systems, Inc May-2013

Agenda: Tools used to gather data for Admission Care Plan Suggestions 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. Allergies Medication Allergies: NKDA Food Allergies: Latex Rxn:

Allergies If 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 List This 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 well I comprehend conversations in writing I use sign language I 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

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

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:

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

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.

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

ADL Fall Risk Assessment

8. Falls Interventions 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

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: Pacemaker Dominant Hand: Smoker: yes no I am able to self-administer medications I am unable to self-administer medications

RESOURCES: Hartford Institute for Geriatric Nursing Hendrick II Fall Risk Model his_8.pdf his_8.pdf PAINAD Scale – Pain Assessment in Advanced Dementia Scale PAINAD.pdf PAINAD.pdf