Person-centred Nursing Assessment and Plan of Care – Adult Inpatient Care Setting Webinar
Why implement the document? • To provide one document for Registered Nurses to complete when people are admitted into Adult Inpatient Care Settings • To reduce variation across the clinical settings in the region • To prepare for digital adoption (Encompass) • To ensure the document relates to current evidence within nursing and risk assessment • To support the introduction of PACE in order to improve the standard of communication between nurses, and because …..
“Good record keeping is an integral part of nursing and midwifery practice and is an essential component of safe, effective and person centred care provision” (NIPEC, 2017, p. 5). Nurses and Midwives MUST ‘Prioritise people’ and ensure “their needs are recognised, assessed and responded to” (NMC, 2018, p. 6).
Person-centred Nursing Assessment and Plan of Care – Adult Inpatient Care Setting was d esigned, tested, reviewed and refined by ‘Adult Nurses’ in NI facilitated by NIPEC
On One e standa andard, rd, reg egio ional nal doc ocument ument to o be e us used ed for for ALL L ad adul ults ts in in the e Adult ult In Inpatie atient nt Car are e Se Settings tings
You will either use …. PACE (if implemented in your clinical setting) or Traditional care planning (if PACE is not implemented in your clinical setting )
but you must ALWAYS have a person- centred approach and ALWAYS… McCormack and McCance (2017 )
Use known information from assessment/current knowledge/critical Begins with initial assessment, identifying thinking/professional judgement needs (acute and existing). The Person must have the opportunity to tell his/ her story and discuss concerns and desires regarding his/ her care For each identified need (either during initial assessment or when need is and identified) DOCUMENT in a continuous cycle!!! Consider best evidence/ policies/ Every identified need guidance and its plan of care must be evaluated
Nurses should be aware of ….. for everything we do!!! at everything we do!!! Imaging from ‘Enabling professionalism in nursing and midwifery’ (NMC, 2018)
The Adult Inpatient Care Setting Document • Roper, Logan and Tierney Model of Nursing was applied when the booklet was created. It was also mapped with Gordon’s functional assessment patterns (1982) • Format is PACE approach • Within the sections of the booklet, information is being recorded from the Person’s perspective and from the Registered N urse’s assessment i.e.
The Adult Inpatient Care Setting Document • ‘Life critical information’ sections are in red filled banners and are located on mainly on Page 1 e.g. • Risk assessment sections are in green filled banners e.g. • Identification of needs sections, whether acute or existing, are in blue filled banners e.g.
The Adult Inpatient Care Setting Document A ‘traffic light’ colour format is throughout the document e.g. This system can help to indicate the: • level of risk that is present • level of nursing intervention that may be required when considering a plan of care i.e. red indicating a high level of risk/ a high level of nursing intervention may be required, green indicating a low level of risk/ a low level of nursing intervention may be required It is only indicative of the P erson’s condition/ symptoms/ abilities at a ‘moment in time’
Risk Assessments P.2 IPC P.4 Moving and P.5 Bedrails P.6 MUST P.8 Braden P.10 Audit-C P.45-49 Reviews of Risk Handling/Falls Assessments Assessments
The Person’s assessment , plan of care and If trained evaluation of that care should be recorded to use PACE here, as it happens, with his/her input!!! The Person’s assessment and evaluation of care, referencing related care plans, should If NOT be recorded here, contemporaneously with trained to use PACE the Person’s input!!!
Person-centred Nursing Assessment and Plan of Care – Adult Inpatient Care Setting P.1 P. 5 • • Person ‘s demographics Bedrails Assessment • • Important information about the Person e.g. preferred name, Maintaining a safe environment Resuscitation status P. 6 • • Admission journey e.g. date and time of admission MUST • • Allergy and medicine information Eating and drinking • Alerts e.g. neck breather P. 7 • P.2 Elimination • • IPC Personal Care • Information such as reason for admission, medical P. 8 and P.9 • history, the Person’s story The Braden Scale • P. 3 Skin Check • Communication e.g. cognitive assessment P.10 • • Airway/ Breathing/ Circulation Sleep • • Health and Wellbeing e.g. smoking status Audit - C i.e. alcohol intake score and advised P. 4 action (if applicable) • Moving and Handling Assessment • Falls Assessment • Mobility
Person-centred Nursing Assessment and Plan of Care – Adult Inpatient Care Setting P.11 and P.12 P.16 – p.42 • Psychological/ Emotional Record of person- centred assessment, care • and evaluation Body image • Religious/ Spiritual/ Cultural P.43 • • Palliative Care (if applicable) Hospital/ward transfer • • Social e.g. ‘are you a main carer’ question Alerts/ food allergies since admission • Social and Home Support P.44 • • Referrals Work and recreation P.13 P.45- 49 • • Pain Reviews of risk assessments • Person’s medications including Time Critical Medications P.50 & 51 • P.14 Discharge information including medication, • wound management, transport Summary of identified needs P.15 P.52 • • Person’s valuables Signature register • Record of incomplete sections from initial assessment
Resources for the Adult Inpatient Care Setting Document http://www.nipec.hscni.net/resource-section/improve-record-keeping/resources /
Finally … The ‘Adult Inpatient Care Setting’ document encourages Registered Nurses to: Prioritise people by involving “the person for whom the care is being provided for” (NIPEC, 2017, p. 6) Prioritise people by documenting their person-centred assessment, plan of care and evaluation in a structured, factual and holistic manner, while ensuring the person shares “in decisions about their treatment and care” through “informed consent” (NMC, 2018, p. 7)
The ‘Adult Inpatient Care Setting’ document encourages Registered Nurses to: Practise effectively’ by “keeping clear and accurate records” (NMC, 2018, p. 9) to show that safe, effective, compassionate and person- centred care is being given to people and their families/ carers Practise effectively by “ keeping clear and accurate records” (NMC, 2018, p. 9) to show evidence of decision making processes and professional ability. This should include documentation showing evidence based ways of working in clinical practice Practise effectively by being “accountable for your decisions to delegate tasks and duties to other people” (NMC, 2018, P. 12 )
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