a42_initial_nursing_assessment_july_2012

Client Name: NHS Number NURSING ASSESSMENT FOR ADULTS WITH LEARNING DISABILITIES (Oldham Adult Learning Disability Service) (Version 1) © Oldham Adult Learning Disability Service - Specialist Service Division Pennine Care NHS Foundation Trust July 2012 Client Name: NHS Number This assessment will be completed in accordance with the Clinical Guidance for Adults with a Learning Disability All information in this assessment is confi dential and will be recorded in accordance with Pennine Care NHS Foundation Trust (Records Management policy 2011) and the Nursing and Midwifery Council (The code: Standards of Conduct Performance and Ethics for Nurses and Midwives 2008) Before this assessment can be carried out, consent is required; individuals have the right to refuse If a person co - operates, this will be taken to be implied consent for the assessment Should treatment be required a Mental Capacity Assessment may be required and a Best Interest discussion may be required Please consider the threefold test when seeking consent – Can the person understand the information? Can they retain the information? Can they use the information to make a decision or a choice? (Mental Capacity Act 2007) © Oldham Adult Learning Disability Service - Specialist Service Division Pennine Care NHS Foundation Trust July 2012 Client Name: NHS Number Personal Information Name: Gender: Date of Birth: NHS No: Address: Telephone: Religion: GP: Address: Named Nurse: Telephone: Base: Main Carer / Next of Kin: Address: Telephone: Telephone: Relationship to you: Does the person have the capacity to give their consent to this assessment being carried out in full? If yes, they consent, if no are you making the professional decision that the assessment is in their ‘best interest’ Yes/No Please document how consent has been given (Verbal, written, implied) Health professional/clinician/nurse to sign here if a Best Interest decision has been taken Please sign if able, to show consent to assessment: Would the person like a copy of this assessment once it has been completed? Yes/No Does the person agree to information being shared about them with other agencies and health professionals? Yes/No Does the person have any caring responsibilities? Yes/No If person is unable to supply any of the following information, please provide the name of the person assisting in providing the information and their relationship to the person Name: Relationship: Date of assessment Name of assessor Signature Does the person have / require a pictorial Health Action Plan? Name & contact details for Health Facilitator When was it last updated? Please record additional information which may have implications on health e.g Down syndrome, Cerebral Palsy, Autism, diagnosed illnesses or conditions e.g asthma, diabetes etc: © Oldham Adult Learning Disability Service - Specialist Service Division Pennine Care NHS Foundation Trust July 2012 Client Name: NHS Number Allergies Does the person have any allergies? (Include any allergies to food, medication etc) If yes please give details: Yes/No COMMENTS/ NOTES **Assessor to please compete any allergy details as per Pennine Care Foundation trust Management policy CO20 ** Learning Disability Status How would the person describe their learning disability? a No learning disability b Mild learning disability c Moderate learning disability d Severe learning disability e Profound learning disability COMMENTS/ NOTES Communication A How does the person communicate? COMMENTS/ NOTES (consider verbal, gestures, signing systems, communication dictionary etc.) B How does the person communicate pain? COMMENTS/ NOTES (consider verbally, gestures, behaviour, self injury etc.) C Has the person had any input or been referred to a Communication Therapist? COMMENTS/ NOTES Yes/No (If yes, whom and when.) © Oldham Adult Learning Disability Service - Specialist Service Division Pennine Care NHS Foundation Trust July 2012 Client Name: NHS Number Medication Please list any medication currently used, including those prescribed and those bought over the counter Include details of dose and frequency (Include: Tablets, medicines, injections, patches, inhalers, creams, shampoos, lotions, vitamins, painkillers, herbal remedies, homeopathic, support stockings, dressings, other (specify)) Name of Drug Dosage Frequency Reason for taking How long been prescribed A In what form does the person take their medication? a Tablets - whole b Tablets - broken c Tablets - crushed d Liquid e With food f Other (specify) B Do they have any problems or are they reluctant to take their medication? COMMENTS/ NOTES Yes/No If yes, please describe the problem Consider guidance - Management of Medicines in the Community C Would the person like more information about their medication and its side effects? Yes/No D Does the person use a medication system? Yes/No COMMENTS/ NOTES If yes what? E Which pharmacy is used? F Is medication delivered/collected? COMMENTS/ NOTES G When did the person last see their GP/Consultant about their medication? COMMENTS/ NOTES What changes, if any, were made? © Oldham Adult Learning Disability Service - Specialist Service Division Pennine Care NHS Foundation Trust July 2012 Client Name: NHS Number Heart And Circulation DATE BLOOD PRESSURE PULSE A Does the person have any known heart conditions? COMMENTS/ NOTES Yes/No Consider; chest pains, swollen ankles, breathless on lying down, blueness of lips, varicose veins etc Respiration A Does the person have any problems with breathing? COMMENTS/ NOTES Yes/No Consider exertion, resting, wheezing B Does the person have any problems with coughing? COMMENTS/ NOTES: Yes/No Describe the cough, ie dry, productive, upon eating Height And Weight A Measure height without shoes, where possible If not possible, note that shoes were worn If person is unable to stand, measure the length noting how this was done If height cannot be measured, use length of ulna to calculate the person’s height using the guidance for alternative measurements (Malnutrition Advisory Group (M.A.G) 2004) Date Height/Length (state unit used) B Measure weight without shoes, where possible If not possible, note that shoes were worn RECORD TYPE AND LOCATION OF SCALES USED Date Weight (state unit used) C Body Mass Index - Specify BMI a UNDERWEIGHT b HEALTHY c OVERWEIGHT 18 OR BELOW 19 - 25 26 - 31 d OBESE e VERY OBESE f B.M.I 31 - 41 42 OR ABOVE Specify See Malnutrition Universal Screening Tool (M.U.S.T) (Clinical Guidance 2011) if Body Mass Index is below 18 or above 30 © Oldham Adult Learning Disability Service - Specialist Service Division Pennine Care NHS Foundation Trust July 2012 Client Name: NHS Number D Waist Circumference Date Measurement (state unit used) COMMENTS/ NOTES Nutrition A Has the person had any investigations done relating to diet and nutrition? Yes/No COMMENTS/ NOTES B Does the person have any problems eating or drinking? COMMENTS/ NOTES If so, please give details C Has the person had any investigations done relating to diet and nutrition? COMMENTS/ NOTES Yes/No If yes, who and when? F Does the person have any eating related issues? COMMENTS/ NOTES Yes/No Who recommended this diet, when and why? E Has the person ever seen a dietician? COMMENTS/ NOTES Yes/No If so, please give details D Does the person have a special diet for any reason? COMMENTS/ NOTES Yes/No Yes/No Consider reluctance to eat, peculiar habits/ behaviours, Pica © Oldham Adult Learning Disability Service - Specialist Service Division Pennine Care NHS Foundation Trust July 2012 Client Name: NHS Number G How much fluid does the person have in a 24 hour period? COMMENTS/ NOTES Consider types of drink they have H Does the person have a balanced diet? COMMENTS/ NOTES Yes/No Consider; a day, carbohydrates, protein, fibre, dairy, food/dietary supplements Continence A Has the person had an assessment of their continence? (OPCT 2007) Yes/No B Does the person receive a supply of products? Yes/No COMMENTS/ NOTES Type of products, effectiveness C Does the person have or ever had any urinary issues? COMMENTS/ NOTES Yes/No Consider incontinence, pain/discomfort, urgency, frequency Urinalysis Results D Does the person have or ever had any bowel related issues? Yes/No E Has the person had a change in bowel habit in the last months? Yes/No COMMENTS/ NOTES Consider incontinence, pain/discomfort, urgency, frequency 10 Pain and Mobility A Does the person receive any input from a Physiotherapist? If yes, who & when? © Oldham Adult Learning Disability Service - Specialist Service Division Pennine Care NHS Foundation Trust Yes/No Go to question 11 July 2012 Client Name: NHS Number B Does the person have any problems with posture or mobility including any pain COMMENTS/ NOTES Yes/No Consider sitting / standing, walking distance, up / down hill, gait, stairs, surface changes C Does the person stumble / fall / trip? Yes/No D Does the person have any problems with their muscles such as wastage or uncontrolled movements? Yes/No COMMENTS/ NOTES E Does the person require any callipers/splints/insoles? Yes/No If yes, who supplies them? F Does the person have use of a wheelchair? Yes/No If so who maintains it? G Has the person had any recent changes in mobility/movement? Yes/No COMMENTS/ NOTES 11 Osteoporosis A Has the person ever had any of the following? a Any broken bones b Premature menopause (-40yrs) c Missed periods (6 months +) d Early hysterectomy (-40yrs) COMMENTS/ NOTES: Yes/No e Steroid treatment (excluding inhalers) f Smoke cigarettes g Milk/cheese free diet h Low body weight Consider if the person has cerebral palsy, is non-weight bearing or has any conditions that may make them more prone to developing osteoporosis © Oldham Adult Learning Disability Service - Specialist Service Division Pennine Care NHS Foundation Trust July 2012 Client Name: NHS Number 12 Feet Please provide details of Chiropodist / Podiatrist (If seen) a Name b NHS/Private c Home visits? d Clinic appointments? e How often seen? f Date of last visit A Who cuts the persons toe nails? B Does the person have any known chronic foot condition? Yes/No C Does the person have any other problems with their feet? Yes/No COMMENTS/ NOTES: Consider skin, nails, size, shape, difficulty finding correctly fitting footwear 13 Skin, Hair, Nails & Personal Care A Does the person have any problems with their skin? COMMENTS/ NOTES: Yes/No Consider rashes, eczema, pressure area, moles, B Does the person currently have any open wounds? Yes/No C Does the person have or have they ever had any pressure sores? Yes/No COMMENTS/ NOTES: If yes when & where, who dresses / treats these and how often (complete and attach Waterlow (2005) paperwork and/or refer to district nursing/GP if relevant) D Does the person have any problems with their hair or scalp? Yes / No E Does the person have any problems with your finger nails? Yes / No F Does the person need support to maintain a good level of personal hygiene? Yes / No COMMENTS/ NOTES: Consider dandruff, itching, irritation, head lice; cutting of finger nails and any problems related to this © Oldham Adult Learning Disability Service - Specialist Service Division Pennine Care NHS Foundation Trust 10 July 2012 Client Name: NHS Number 14 Sensory A Is the person registered blind or partially sighted? Yes/No B Has the person ever had their eyesight tested? Yes/No a Name of optician b Address of optician c Date of examination d Should glasses/contact lenses be worn? e Are they worn? f Are they in good condition? C Does the person have any problems with their eyes? Yes/No D Has the person ever had their hearing tested? Yes/No a Name of audiologist b Date of examination c Hearing aid prescribed? d Is it worn? e Is it in good condition? f When was it last serviced? E Does the person have any ear problems COMMENTS/ NOTES Consider earache, discharge, difficulty hearing, excess wax, buzzing noises in ears etc F Does the person have any behaviour which suggests problems of hearing or vision? COMMENTS/ NOTES Yes/No Yes/No Consider not talking, tv/radio loud, dislike of noise, slow to answer, self injury to ear/head G Has the person noticed any changes to their hearing or vision recently? Yes/No H Does the person have any input from the Sensory Disability Team for vision or hearing problem? Yes/No COMMENTS/ NOTES 15 Oral Health A Is the person registered with a dentist? If yes, please give details Yes/No a Name of dentist b Address of dentist c When where they last seen? © Oldham Adult Learning Disability Service - Specialist Service Division Pennine Care NHS Foundation Trust 11 July 2012 Client Name: NHS Number B Does the person have natural teeth? Yes/No C Does the person have any oral problems? Yes/No D Does the person clean their teeth / dentures twice daily without assistance? Yes/No COMMENTS/ NOTES Consider pain, eating problem, ulcers, broken teeth, support needed to clean teeth 16 Women’s Health A Has the person ever had a Mammogram? Yes/No B Does the person examine their breasts for any changes / lumps? Yes/No C Have their breasts ever been examined by G.P or a nurse? Yes/No D Has the person any female relatives that have had breast cancer? Yes/No COMMENTS/ NOTES Consider results of mammogram, any breast problems, family history E Has the person ever had a smear test? COMMENTS/ NOTES Consider results of smear test/best interest and capacity issues F Does the person have periods? COMMENTS/ NOTES Yes/No Yes/No Consider sanitary products, discharge, itching, irregular periods, mood swings, discomfort etc G Has the person ever been sexually active? Yes/No H Would the person like more information about sexual health and awareness? Yes/No I Does the person require anymore information around women’s health and cancer screening services? COMMENTS/ Consider: contraception, pregnancy, risk NOTES © Oldham Adult Learning Disability Service - Specialist Service Division Pennine Care NHS Foundation Trust Yes/No 12 July 2012 Client Name: NHS Number 17 Men’s Health A Does the person have any symptoms related to their sexuality/genital area? Yes/No B Does the person examine their testicles for any changes / lumps? Yes/No C Has the person ever had their testicles examined by G.P or a nurse? Yes/No COMMENTS/ NOTES Consider: pain, discomfort, delay/ hesitancy, dribbling, itching, disturbed sleep, contraception etc D Has the person ever been sexually active? Yes/No E Would the person like more information about sexual health and awareness? Yes/No COMMENTS/ NOTES: Consider: contraception, risk 18 Mental Health, Dementia & Cognition A Has the person ever been diagnosed with a mental illness? COMMENTS/ NOTES If yes, please give details B Has the person ever had input from a Consultant Psychiatrist? COMMENTS/ NOTES Yes/No Yes/No If yes, who and how often? When did they last see them? C Has the person had a Mini-PasAdd assessment? Yes/No D Does the person ever shown signs of any of the following? Please give details Yes/No a Hearing voices when there’s no-one there b Seeing things that aren’t there c Getting the feeling that people are talking about them d Anxiety e Severe mood swings g Depression h Panic attacks i Any other mental health issue? © Oldham Adult Learning Disability Service - Specialist Service Division Pennine Care NHS Foundation Trust 13 July 2012 Client Name: NHS Number E Does the person receive any support / help for a mental health problem? COMMENTS/ NOTES Yes/No Consider GP, Psychiatrist, Psychologist, Nurses F Has the person had any changes over the last months in any of the following? Yes/No a Independence b Self care c.Daily living activities d Communication e Social functioning g Other G Has the person any concerns around memory or skill loss? Yes/No COMMENTS/ NOTES H Has Dementia Screening been carried out? COMMENTS/ NOTES Yes/No If yes, when & by whom? 19 Sleep A Does the person usually sleep well in a regular pattern? Yes/No B Has the person’s sleep pattern changed recently? Yes/No C Does the person sleep during the day? How often? Yes/No D Does the person use any equipment on their bed? Yes/No COMMENTS/ NOTES 20 Epilepsy A Does the person have epilepsy? COMMENTS/ NOTES Yes/No If yes, complete the Epilepsy Questionnaire (ALDS Oldham), and risk assessments © Oldham Adult Learning Disability Service - Specialist Service Division Pennine Care NHS Foundation Trust 14 July 2012 Client Name: NHS Number 21 Behaviour A Does the person have any behaviour that causes distress to themselves or others? Yes/No B Does the person have any behaviours that prevent them from taking part in any activities? Yes/No COMMENTS/ Consider; aggression, violence, compulsions, obsessions, phobias, self harm, risk NOTES: assessments C Has the person ever had any input from any of the following around behaviours? a G.P d Psychologist g C.P.N b Nurse Specialist e Community Nurse h CITRUS strategies used c Psychiatrist f Social Worker i other D Any additional information which may have implications on your behaviour? COMMENTS/ NOTES: Yes/No Yes/No Consider, Autism, Dementia, P.K.U, other (Include names of professionals involved, outline of strategies/treatments risk assessments and dates.) 22 Lifestyle Risks A Does the person any exercise? COMMENTS/ NOTES: Yes/No Consider: type, how often and when B Does the person drink alcohol? Yes/No C Does the person smoke, or have they ever smoked? Yes/No D Has the person ever used any smoking/nicotine substitute? Yes/No COMMENTS/ NOTES: Consider: When, how many, how often, smoking cessation strategy © Oldham Adult Learning Disability Service - Specialist Service Division Pennine Care NHS Foundation Trust 15 July 2012 Client Name: NHS Number E Does the person have any risky behaviours or potential threats to their health, safety or well-being? COMMENTS/ NOTES: Yes/No Consider: personal, road, food safety and financial vulnerability, sexual behaviour drug use etc Risk Assessments 23 Other Health Issues Please give details of any other health issues not already covered in any of the other sections: If any current inputs, interventions and or actions taken are not effective, consider completing Continuing Health Care Funding Assessment (DoH 2007) and referring to Care Management for further assessment Supplementary Assessments to consider completing             Continence Assessme nt (O.P.C.T 2007) Continuing Health Care Application (Department of Health 2009) DLD assessment (Pearson 2007) DisDAT assessment for pain (Northgate Palliative Care Team 2004) Epilepsy Assessment (O.A.L.D.S) Health Action Plan (O.A.L.D.S 2007) Mini Pas-Add (Prosser et al 1998) M.U.S.T(Malnutrition Universal Screening Tool)(NHS Oldham 2011) Use of Risk Evaluation tool in LD (NH S Oldham 2011) Waterlow Pressure Area Risk Assessme nt Waterlow (2005) Mental Capacity Assessment (2007) Best Interest Decision Checklist © Oldham Adult Learning Disability Service - Specialist Service Division Pennine Care NHS Foundation Trust 16 July 2012 Client Name: NHS Number References Barnsley Primary Care Trust, Integrated Learning Disability Service Health needs assessment for health action plans Corbett, J (2007) Health care provision and people with learning disabilities: A guide for health professionals Wiley & Sons Ltd Chichester Department of Health (2001) Consent: A guide for people with learning disabilities Department of Health London Department of Health (2001) Seeking consent: working with people with learning disabilities Department of Health London Department of Health (2008) National Framework for Continuing Care: Continuing Healthcare Department of Health London Department Of Health (2001) Valuing People: A new strategy for learning disabilities for the 21 s t century Department of Health London Department Of Health (2007) Valuing People from progress to transformation - a consultation on the next three years of learning disability policy Healthcare for all (2008) Independent inquiry into access to health care for people with a learning disability Malnutrition Advisory Group Bapen (2004) Malnutrition Universal Screening Tool Bapen NHS Primary Care Contracting (2007) Primary care service framework: Management of health for people with learning disabilities in primary care Northgate Palliative Care Team St Oswald’s Hospice, (2004) DisDAT (Disability Distress Assessment Tool) Nursing and Midwifery Council (2004) Code of professional conduct: standards for conduct performance and ethics Nursing and Midwifery Council London Oldham Adult Learning Disability Service Dementia Screening Oldham Adult Learning Disability Service Epilepsy Questionnaire Oldham Primary Care Trust Communication Questionnaire Oldham Primary Care Trust (2007) Confidentiality Policy Oldham Primary Care Trust (2008 a) Consent Policy Oldham Primary Care Trust Continence Assessment Oldham Primary Care Trust (2008 b) Record Management Policy Prosser, H Moss, S Costello, H Simpson, N Patel, P (1998) Mini- PasAdd Assessment Hester Adrian Research Centre, Manchester University Manchester Rotherham Primary Care Trust Health action plan - Facilitators handbook Sheffield Care Trust A health facilitator ’s guide to ‘My health’ booklet Waterlow, J (2005) Waterlow Pressure Ulcer Prevention / Treatment Policy © Oldham Adult Learning Disability Service - Specialist Service Division Pennine Care NHS Foundation Trust 17 July 2012 Client Name: NHS Number Health Action Plan No Action / Intervention Person Responsible Person Responsible Signature Date Achieved Date DATE REVIEW DUE © Oldham Adult Learning Disability Service - Specialist Service Division Pennine Care NHS Foundation Trust 18 July 2012