R O Y A L C O L L E G E O F N U R S I N G
Nursing
assessment and
older people
A Royal College of
Nursing toolkit
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Acknowledgements
Project Leader:
Pauline Ford RCN Geronotological Nursing Adviser
Project Team:
Sharon Blackburn Former Chair, RCN Mental Health and Older People Forum. Director of Homes,Elizabeth Finn Trust.
Hazel Heath Former Chair, RCN Forum for Nurses Working with Older People and Independent Nurse Adviser
Brendan McCormack Former Co-Director, RCN Gerontological Nursing Programme.Currently, Professor and Director of Nursing Research and Practice Development, RoyalHospitals, Belfast
Lynne Phair Former Project Director for Royal Surgical Aid Society Age Care and former member, RCNForum for Nurses Working with Older People. Currently, Consultant Nurse for Older People,Crawley Primary Care Trust
For their help with the piloting of this RCN Assessment Tool, sincere thanks to:
Sharon Blackburn (formerly of) Care First
Jim Marr (formerly of) Westminster Health Care
Lynne Phair (formerly of) RSAS Age Care
and all the nurses who undertook assessments for the pre-pilots and piloting of the toolkit.
First revision
Peter Fox Independent Nursing Consultant
Pauline Ford RCN Geronotological Nursing Adviser
Published by the Royal College of Nursing, 20 Cavendish Square, London, W1G 0RN
© 2004 Royal College of Nursing. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or byany means electronic, mechanical, photocopying, recording or otherwise, without prior permission of the Publishers or a licence permitting restricted copyingissued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1T 4LP. This publication may not be lent, resold, hired out or otherwise disposedof by ways of trade in any form of binding or cover other than that in which it is published, without the prior consent of the Publishers.
Nursing assessment and older people A Royal College of Nursing toolkit
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R O Y A L C O L L E G E O F N U R S I N G
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Contents
1. Introduction 2
2. About this assessment tool 3
3. Nursing and older people 4
4. The role of assessment 5
5. The role of the nurse 6
6. Nursing and assessment 7
7. The five stages of the RCN assessment tool 9
Stage 1 9
Stage 2 10
Stage 3 12
Stage 4 13
Stage 5 15
8. Conclusion 15
9. References and further reading 16
Appendix: Assessment sheets 19
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Introduction
Older people have increasingly been the focus of healthand social care policy (DH, 1999, 2001, 2003; DSSSP, 2002,2004; WAG 2003 a & b; Scottish Executive, 2001 a & b,2002). Health and social care policy impacts significantlyon older people, and in particular on their continuing careneeds. Changes in the boundaries of health provision andpressures for cost containment have profoundly affectedolder people as well as service providers.
Many older people have found themselves means-testedfor services that have historically been provided free ofcharge. Arrangements for NHS-funded nursing care forolder people (DH, 2003) limits the money available inEngland by the use of a formula that interprets low,medium and high need. In Wales and Scotland acontribution to the cost of care is paid.
The RCN supports the principles of a multi-agencyapproach to assessment, like, for example, the singleassessment process (SAP) (DH, 2002b) and the nationalservice framework (DH, 2001). However, any multi-agency approach needs to reflect, in both its structureand process, good, contemporary nursing practice. Theintroduction of the registered nursing care contribution(RNCC) in England (DH, 2001) requires nurses tocalculate registered nursing time within a prescribedframework.
This RCN assessment tool was initially developed toassist nurses in the identification and articulation oftheir contribution to the health and social wellbeing ofolder people. This new edition aims to continue withthat aim, in the light of contemporary health and socialcare policy developments.
The tool is the first of its kind to focus on determiningthe level and type of registered nursing input needed byan individual older person. It has been developed byexpert gerontological nurses to identify the specificareas where nursing is needed and to provide evidenceto justify the required nursing intervention.
This booklet:
✦ explains why nursing assessment is important
✦ describes the role of the expert nurse in the care ofolder people
✦ outlines how the debate about continuing careaffects the nursing care of older people
✦ draws on the work of a 1997 RCN report, What adifference a nurse makes (RCN, 2004a) on thebenefits of expert nursing to the clinical outcomes inthe continuing care of older people
✦ explains each of the tool’s five stages, including therationale that underpins them.
Primarily intended for use by registered nurses who areundertaking an assessment of an older person currentlyin a care home, it may also be used by nurses working inthe community and in hospitals to assess an olderperson’s need for nursing care.
Included in this publication are some simple tables thatprovide you with a key to some of the questions asked.In addition, examples and case studies are provided toshow how the tool might be used in your everyday work.
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About thisassessment tool
This RCN assessment tool enables:
✦ comprehensive assessment of an older person’shealth status
✦ identification of the need for input by a registerednurse, through the application of astability/predictability matrix
✦ an estimate of the level of nursing intervention needed
✦ an estimate of the number of registered nurse hoursrequired, through the use of a scoring formula
✦ identification of evidence to support decision-making and practice.
Designed to be used as part of the overall assessment ofa resident in a care home, it can be used to contribute tothe SAP process and the funded nursing determinations.Continuing its primary intention, it can also be used todevelop nursing care plans that are person-centred andthat facilitate best nursing practice. The tool will assistnurses to both articulate and quantify the nursingcontributions to care, within the context ofcontemporary good practice. It is not meant to be usedin isolation, but rather as the nursing component to themulti-disciplinary assessment of need in older people.
The tool links with the framework for outcome definitiondeveloped by expert gerontological nurses and outlinedin What a difference a nurse makes. The framework wasformulated from the work of Seedhouse (1986) andKitwood (1997), evidence of good practice and a reviewof the literature on the care of older people. It promotesthe concept of holistic care and the aim that older peoplelive as independent a life as possible (RCN, 1996).
As a result, this assessment tool offers a nursingframework for decision-making by nurses thatencompasses a comprehensive range of essential carecomponents. For example, the tool could be used toidentify a nursing intervention that could stabilise ormonitor a health problem, so enabling an older personto follow their chosen lifestyle as closely as possible.
Primarily for use in care homes, this tool assumes thatnursing care will be delivered within a nursingframework. However, it seeks to make effective use of allavailable skills and resources. There is no intendedsuggestion of exclusivity in the nursing input within anyof the categories. Sometimes a nursing intervention willresult in the disappearance of the need for nursing care.The ‘no nursing’ option can be selected in any category,or the decision made that, rather than delivering thecare directly, a registered nurse is needed to manage aspecific aspect of care or to supervise others.
Finally, while the tool aims to guide nurses to the needfor specific specialist assessment, it is only part of anassessment process that must take as its starting pointthe biography of the older person. Within this tool,ethnicity and culture are seen as integral components ofevery category.
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Nursing and olderpeople
Individuals who need continuing care have inter-relatedhealth and social care needs. Nurses have long arguedthat distinctions between the two are unworkable (RCN, 1993 a & b, 1995, 2004a).
The SAP is intended to ensure that older people receiveappropriate, effective and timely responses to theirhealth and social care needs and that professionalresources are used effectively (DH, 2002b).
The challenge for nurses in articulating their distinctcontribution to the overall care of older people has beenthat much of their work is invisible - it is not directlyobserved. These ‘hidden’ aspects (McKenna, 1995) canencompass highly intricate assessment, detection,monitoring and evaluation techniques, as well as subtlecommunication skills, which can help a patient tobalance their health needs with their chosen lifestyle.
Nurses use clinical judgement to enable older people toimprove, maintain, or recover health, to cope with healthproblems, and to achieve the best possible quality of life,whatever their disease or disability, until death (RCN, 2003).
Further, nurses work in partnership with patients, theirrelatives and other carers, and in collaboration with othersas members of a multi-disciplinary team.Whereappropriate they will lead the team, prescribing, delegatingand supervising the work of others.At other times they willparticipate under the leadership of others, but alwaysremaining personally and professionally accountable fortheir own decisions and actions (RCN, 2003).
In the drive for cost containment in services, it is oftensuggested that ‘nursing care as a product is highlysimplified by non-nurse buyers not possessing a clearidea of what professional nurses can/should do and howit differs from less skilled, cheaper labour… thesehealth care managers may accept unfoundedassumptions and myths about nursing costs, care-givermix and nursing productivity’ (Patterson, 1995). But ‘ifwe cannot name it, we cannot control it, finance it,
research it, teach it, or put it into public policy’ (Clark Jand Lang N, 1992 in Defining nursing, RCN, 2003).
As key providers of health and social care, nurses havecome under increasing scrutiny from policy makers andservice providers (Bagust and Slack, 1991; Buchan andBall, 1991; Bagust, Slack and Oakley, 1992; Carr-Hill,Dixon and Gibbs et al, 1992; Buchan, Seccombe andBall, 1997; Savage, 1998; Needleman et al, 2002). Thisextensive work demonstrates that nursing is a cost-effective service, particularly when registered nurses arepresent in sufficient numbers within the skill mix. Thesame studies also show that nursing interventions canresult in significant positive patient outcomes.
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The role ofassessment
Systematic and sensitive assessment has been a keyrequirement of government policy in primary healthand community care. A multi-agency and multi-disciplinary partnership enhances patient care, preventsthe waste of valuable resources, and could have apositive impact on the whole of the health and socialcare system for older people.
Joint NHS and social services assessment is viewed as anecessity to enable successful hospital discharge andshould not only be offered before entering a care home.A successful multi-agency assessment will preventdelayed hospital discharge.
In the face of the converging reliance on caremanagement and the targeting of public funding,assessment has increasingly become an importantpolicy tool (Challis et al, 1996). Much of the researchand debate has focused on the role of assessment inrelation to placement (Peet, Castle, Potter et al, 1994).
It is the view of the RCN that nurses in all settings willcontinue to work collaboratively with colleagues in thedevelopment and delivery of integrated,‘joined up’assessments. However, it is also the view of the RCNthat nurses will continue to need a nursing assessmenttool to guide their day-to-day nursing practice, inkeeping with their professional accountability andresponsibility to older people.
In its policy development work, the RCN has focused onthe need for nursing care, rather than the location ofcare delivery (RCN, 1993 a & c, 1995, 2004a). Evidentthroughout has been absence of a tool that articulatesthe specific need the older person may have for anintervention from a registered nurse.
Assessment strategies in nursing have been influenced bythe problem-solving framework of the nursing process andnursing models. Assessment of need is integral to the careprocess and has received much attention in relation to theestablishment of eligibility criteria for long-term care. Fewpeople would dispute the assertion that good quality andeffective care for older people is influenced by the use of
comprehensive,client specific assessment (Rubenstein,Calkins and Greenfield et al,1988). The quality ofassessment will be greatly enhanced by the participation ofthe client and carers to the assessment process ensuringthat the client’s wishes are foremost and,wherever possible,the client’s own words are used to reflect their needs.
Assessment is a multi-disciplinary activity, and a rangeof instruments has been developed. These include theindex of independence in activities of daily living (Katzand Stroud, 1963), the Barthel index, (Mahoney andBarthel, 1965) the Crighton Royal behaviour rating scale(Wilkin and Jolley, 1979), the Clifton assessmentprocedures for the elderly (Pattie and Gilleard, 1979),the general health questionnaire (Goldberg, 1972) andthe geriatric mental health state schedule (Copeland,Kelleher and Keller et al, 1976).
A number of assessment tools have attempted tomeasure outcomes in care in terms of quality of life, butthis has remained elusive to define and difficult tomeasure (Bowling, 1991 and 1995; Fletcher, Dickinsonand Philip, 1992).
Some tools have been developed specifically to assessneed, dependency and quality, for example:
✦ Monitor: an index of the quality of nursing care foracute medical and surgical wards (Goldstone, Balland Collier et al, 1984)
✦ Senior monitor: an index of quality nursing care forsenior citizens of hospital wards (Goldstone,Maselino and Okai et al, 1986)
✦ Nursing home monitor II: an audit of the quality ofnursing care in registered nursing homes (Morton,Goldstone and Turner et al, 1992)
✦ Criteria of care (Ball and Goldstone, 1984)
✦ REPDS (Fleming and Bowles, 1984)
✦ Quality of patient care scale (QUALPACS) (Wandeltand Ager, 1974).
While such dependency tools can help to identify needfor care, they do not assist in articulating the specificneed for nursing. The RCN believes this is one of thereasons why it has been impossible to separate thesocial care needs of older people from their health careneeds. In Selecting and applying methods for estimatingthe size and mix of nursing teams, Hurst et al (2002)examine the contribution of 43 articles, books and
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reports that address the special issues of nursing olderpeople for nursing workforce planners.
Nolan and Caldock (1996) believed that any frameworkfor assessment should be:
✦ flexible and able to be adapted to a variety ofcircumstances
✦ appropriate to the audience it is intended for
✦ capable of balancing and incorporating the views ofa number of carers, users and agencies
✦ able to provide a mechanism for bringing differentviews together, while recognising the diversity andvariation within individual circumstances.
The role of thenurse
Older people’s continuing care needs are met in a varietyof settings, including their own home, supportedhousing, residential care, a nursing home or hospital. Atsome stage many older people are likely to requireregistered nursing care.
Older people in hospital or who live in care homes arelikely to be vulnerable. Indeed the RCN would argue thatif older people are vulnerable enough to requireplacement in a care home, then it is likely that somelevel of nursing intervention will be needed. The role ofthe nurse as an enabler of health in older people iscrucial in continuing care settings (RCN, 2004a).
In a care home, registered nurses have multiple rolesthat reflect the diverse nature of nursing. Differentfunctions that contribute to the optimum health andoverall wellbeing of older people include:
✦ supportive - including psychosocial and emotionalsupport, assisting with easing transition, enhancinglifestyles and relationships, enabling life review,facilitating self-expression and ensuring culturalsensitivity
✦ restorative - aimed at maximising independenceand functional ability, preventing furtherdeterioration and/or disability, and enhancingquality of life. This is undertaken through a focuson rehabilitation that maximises the older person’spotential for independence, including assessmentskills and undertaking essential care elements, forexample, washing and dressing
✦ educative - the registered nurse teaches self-careactivities - for example, self-medication - healthpromotion, continence promotion and healthscreening. With other staff, the registered nurseengages in a variety of teaching activities that areaimed at maximising confidence in competence andcontinuously improving the quality of care andservice delivery
✦ life-enhancing - activities that are aimed atenhancing the daily living experience of older
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people, including relieving pain and ensuringadequate nutrition
✦ managerial - the registered nurse undertakes arange of administrative and supervisoryresponsibilities that call for the exercise ofmanagerial skills. Such responsibilities include thesupervision of care delivered by other staff and theoverall management of the home environment.
(RCN, 1996)
Nursing andassessment
In general, outcome measurement has focused on ahealth gain or health maintenance score, or an overallwellbeing result (French, 1997). However, becausequality of life is difficult to define and even moredifficult to measure - particularly with physically andmentally vulnerable people - outcomes from nursing incontinuing care are not easily articulated (RCN, 2004a).The focus of the RCN’s assessment tool is therefore onincreasing quality of life, rather than perceiving healthgain simply as increased longevity.
Assessment is considered to be the first step in theprocess of individualised nursing care. It providesinformation that is critical to the development of a planof action that enhances personal health status. It alsodecreases the potential for, or the severity of, chronicconditions and helps the individual to gain control overtheir health through self-care.
Assessment of older people requires a comprehensivecollection of information about the physical, biological,psychosocial, psychological and functional aspects ofthe older person. It will enquire into physiologicalfunctioning, growth and development, familyrelationships, social networks, religious andoccupational pursuits. (DH, 2002b). It is vital that thehealth assessment includes a thorough appraisal ofwhat are commonly referred to as ‘activities of dailyliving’. The RCN believes that this must be linked to theoverall health assessment. Nurses should relate theperson’s ability to undertake daily living activities to anassessment of health status, which is linked to medicaldiagnosis (Figure 1). The key throughout is theindividual’s biography and personal circumstances.
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The knowledge, skills and experience
of nurses
Registered nurses have:
✦ Broad empirical knowledgeThis derives from the fundamental sciences fromwhich nursing is synthesised - such as philosophy,physiology, sociology - from nursing knowledgeand research, or from an allied profession, such asmedicine, pharmacology or ergonomics.
✦ Tacit knowledgeThis enables nurses to act on hunches or intuitionand engage in holistic problem solving. This canbe particularly significant in unpacking thecomplexities of change in the health of olderpeople.
✦ Broad experience This enables nurses to recognise similarities inpatterns of events from previous encounters witholder people. Registered nurses recognise thesubtle changes in an older person’s health status,understand the potential consequences and thenact appropriately.
✦ A broad range of skillsIn everyday practice, registered nurses use avariety of skills including:– Observation - for example, recognising
significant changes and formulating opinions – Psychological – for instance, interpersonal
communication with residents, their familiesand colleagues
– Supporting, encouraging, facilitatory andcounselling skills
– Reflecting, challenging and giving constructivefeedback.
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The more expert the nurse, the more speedy andaccurate are their judgements and predictions (Bennerand Wrubel, 1989). Studies that distinguish between theability of expert nurses and novice nurses in relation toassessment and decision-making have helped identifythe nature of expert assessment in relation to practiceoutcomes. (Benner, 1984; Benner, Tanner and Chesla,1992).
For the purpose of this work, nursing is defined as ‘a service for older people who have their nursing needsidentified by a nurse, receive that care either directly orunder the supervision and management of a nurse’(RCN/ Age Concern, 1997). Nurses must be registeredby the Nursing and Midwifery Council (NMC).
Both the RCN and Age Concern believe that, in theinterests of equity and economy, long-term nursingshould be funded for all older people who need nursingcare.
Clearly many older people have care needs, but not allneed their care to be given or supervised by a registerednurse. Care is provided by a mixed workforce. The costof that care can best be determined by establishing skillmix weightings. Therefore the RCN’s assessment toolprovides a code to skill mix – the level of nursing
intervention required and the number of hours. It hasbeen designed to assist both commissioners andproviders in costing more accurately nursing care forolder people. In order to achieve this there is a need toarticulate the processes involved in ‘expert’ nursing witholder people, and a need to identify the criteria for themeasurement of effective practice.
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Biography
Health status
Medical diagnosis
Personal circumstances
Nursing assessment
Health care needs
Self care deficits
Care plan
Nursing needsIdentified need for nursing
Figure 1: A framework for assessing the needs of older people
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The five stages ofthe RCN assessmenttool
The completion of all the stages of the RCN’s assessmenttool ensures that the decision-making process is explicitand transparent, illustrating the contribution of expertnurses to the care of older people. Together, the stagesresult in a holistic assessment of the nursing needs of anolder person.
The importance of the older person’s contribution to theassessment cannot be over-emphasised. It is vital thatthe client and their carer are involved in its completion.If the person being assessed is unable to contribute - forexample because of lack of mental capacity - the viewsand experiences of their carers should be taken intoaccount.
The assessment tool is intended to inform everyoneinvolved in the care of an older person - includinginformal carers and the client themselves - of theprocess leading to a care plan. To that end, it should bewritten in simple, easy to understand language.Wherever possible it should include the words andphrases used by the client and their carer.
Stage 1
Background
This stage assesses the older person’s health statusthrough essential care components and categories ofability or need. It can be used alone to formulate a careplan.
There are three essential care components:
✦ maximising life potential
✦ prevention and relief of distress
✦ maintenance of health status.
These are based on Seedhouse’s (1986) concept ofhealth as ‘potential’, and derived from the domains ofthe RCN framework for outcome definition in the care
of older people, outlined in What a difference a nursemakes. They generate up to 25 categories of ability orneed that can be used to assess an individual’s complexhealth status.
How it works
Within each category of need, five descriptor statementsdistinguish varying levels of an older person’s ability ordisability, and their need for care. The headings are:
Essential care component 1 – maximising lifepotential
Categories: Personal fulfilmentSpiritual fulfilmentSocial relationsSexualityCognition
Essential care component 2 – prevention and relief of stress
Categories: CommunicationPain controlThe sensesMemoryOrientationLoss, change and adaptationBehaviourRelatives and carers
Essential care component 3 – promotion andmaintenance of health
Categories: Personal hygieneDressingMotivationSleepingMobilityElimination of urine and faecesRiskEating and drinkingBreathingEmotion
Within each category, the nurse should assess the olderperson, selecting the most appropriate descriptor, usingthe letters A, B, C, D or E, for the individual’s abilities ordisabilities and their needs for care. This letter shouldbe placed under the appropriate stability/predictabilitycolumn – as assessed in stage 2.
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Not all statements within the selected descriptor may berelevant to the individual, but the nurse should selectthe statement that most closely represents their abilitiesand needs – in other words, the best fit.
At the end of the assessment form, there is space forthree additional categories. These can be used forspecific interventions that the assessor believes cannotbe captured within other categories. For example, aresident may require frequent assessment and treatmentby a registered nurse because of a wound, or may requirefrequent assessment and administration of medicationto control pain during an acute or terminal illness.
These additional categories will also include problemsnot referred to in the main text of the assessment - suchas falls, managing medication, or specific issues relatingto financial management. Wherever possible, needssuch as wound care, self-medication or stoma careshould be assessed within the 23 pre-set categories.However, where this is not possible, then the ‘extra’ blankcategories should be labelled and used accordingly.
Stage 2
Background
This stage assesses the stability and predictability of aperson’s health status by applying a matrix, which actsas the trigger for potential registered nursing input. Thiswould be in the form of both preventive and reactivenursing interventions. This second stage is perhaps themost complex, as it analyses how an individual’s careneeds might be met – in other words, what skills,knowledge and expertise are required.
The stability and predictability matrix has beenspecifically devised to acknowledge and encompass thecomplex factors that influence health status in older age.For example:
✦ the physical processes of ageing can cause instabilityin various body systems at any one time
✦ multiple pathologies are usually present. Olderpeople entering the health care system commonlyhave upwards of four medical diagnoses
✦ diseases present differently in older age, makingrecognition and diagnosis more complex
✦ older people tend to be prescribed more drugs, and
to more commonly experience adverse drugreactions (ADRs) which may present differently inyounger people
✦ older people’s personal adaptation to life changes -and the changes associated with moving intocommunal living – create the need for managementof transition
✦ older people’s individual responses to day-to-daysituations are based on their personality and lifeexperiences.
While some factors might be stable at any one point intime, not all of them will be. The instability of variousfactors at different times complicates the situation.Individuals also react psychologically andphysiologically to changes in health status in ways thatcan be predictable or unpredictable.
Added to this, once any of these influences on an olderperson’s health begin to become unstable, a dominoeffect can be set off. This may exacerbate an alreadyprecarious homeostasis that results in a rapiddeterioration in health.
You may find the following definitions useful:
✦ stable – health or disease processes are in a steadystate and likely to remain so, providing correcttreatment and care regimes continue
✦ unstable – a fluctuating disease process resulting inan alternating health state and requiring frequent orregular intervention or treatment
✦ predictable – a person’s response to internal and/orexternal triggers can be anticipated with somecertainty, through established interventions andregularly reviewed care plans
✦ unpredictable – a person’s response to internal orexternal triggers cannot be anticipated with anycertainty. Continuous assessment, care planning,intervention and review are required.
How it works
Place the descriptor code letter - A, B, C, D or E – thatyou assessed in stage 1 under the appropriate stabilityand predictability column.
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Some examples
The following examples demonstrate how stability andpredictability can be assessed within specific categories.The examples deal with four different women in anursing home. Each is trying to retain her independence,despite a series of strokes and multiple disabilities.
It might be assumed that each woman has the samenursing needs. However, by making decisions about thestability of each individual’s health, and thepredictability of her responses, the need for nursingintervention becomes clear in each case.
Example 1 – stable and predictable
Category – social relations
This resident actively seeks and enjoys social contact.She openly acknowledges her physical difficulties andjokes with other residents about them. In this category,she would be assessed as stable and predictable.
Category – eating and drinking
Despite some speech difficulties, this resident is able tomake and express choices in food and drink. Shegenerally enjoys food, and although she takes longer toeat than other residents at the table, she engages theirpatience until she finishes her meal. In this category, shewould be assessed as stable and predictable.
Example 2 – stable but unpredictable
Category – social relations
This resident actively seeks and enjoys social contactbut sometimes becomes very upset by this. There is noapparent pattern to her emotional upset and so far ithas not been possible to predict when this mighthappen. In this category, she would be assessed as stablebut unpredictable.
Category – eating and drinking
Despite speech difficulties, this resident is able to makeand express choices in food and drink. She enjoys herfood but will occasionally choke, usually when shebecomes embarrassed and tries to eat as quickly asother residents at her table. She then intermittentlybecomes distressed. In this category, she would beassessed as stable but unpredictable.
Example 3 – unstable but predictable
Category – social relations
This resident has enjoyed playing bridge for years buthas recently experienced transient ischaemic attacksduring which she loses touch with reality. Sheacknowledges her deterioration but is determined tocontinue playing bridge. Despite dysphasia, she jokesthat there are worse places to die than at the bridgetable. In this category, she would be assessed asunstable but predictable.
Category – eating and drinking
This resident is able to make and express choices, butsometimes does not have the clarity of thought to do so.Her swallowing reflex is not reliable and she oftenchokes. Although obviously frustrated at these changes,she usually tries to eat and sometimes glances at thefeed aids as if to say,‘Oh well, this is what it’s come to’.In this category she would be assessed as unstable butpredictable.
Example 4 – unstable and unpredictable
Category – social relations
Although this resident has always enjoyed socialcontact, her transient mental ‘absences’ and unstablephysical disabilities are making this progressivelydifficult. She has begun to become frustrated and angryat these changes, and is often aggressive with otherpeople. It can be difficult to calm her. In this category,she would be assessed as unstable and unpredictable.
Category: eating and drinking
This resident is sometimes able to make and expresschoices in food and drink, but often does not have thepresence of mind or the interest to do so. Herswallowing reflex causes frequent choking whichfrustrates her greatly. Often she refuses food and drink,despite sensitive encouragement and support. In thiscategory, she would be assessed as unstable andunpredictable.
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Stage 3
Background
This stage assess the level and frequency of input by aregistered nurse, determining what form the nursinginput will take, including a ‘no nursing’ option. Itdefines the level of nurse intervention, differentiatingbetween management, supervising and actual ordirective care giving roles. It does this by measuring theneed for four types of assistance that reflect the degreeof engagement between the nurse and the older person.These are:
✦ actual - the registered nurse directly engages withthe resident and/or significant others, undertakingclinical/technical or therapeutic activities on theresident’s behalf
✦ directive - the registered nurse uses teaching,guiding, advisory and supportive interventions aspart of the rehabilitation/maximising potential/re-enablement of the resident and/or significant others
✦ supervisory - the registered nurse monitors orguides care without frequent direct engagementwith the patient and/or significant others
✦ management - the registered nurse either managesa specific, stand alone care intervention on anintermittent basis, or the service, which deliversnursing on a continuous basis.
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Figure 2: Model illustrating nursing assistance
MANAGEMENT ASSISTANCE
SUPERVISORY ASSISTANCE
DIRECTIVE ASSISTANCE
ACTUAL ASSISTANCE
LIFE-ENHANCING
FUNCTIONS
SUPPORTIVE
FUNCTIONS
TEAM
FUN
CTION
S
EDUCATIVEFUNCTIONS
RESTORATIVEFUNCTIONS
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How it works
Each type of assistance carries a score:
✦ 0 = no nursing
✦ 1 = management
✦ 2 = supervision
✦ 3 = actual
✦ 4 = directive
Determine the level of nursing intervention needed tomeet nursing care need for each category. Once this hasbeen identified, place the score number in the boxdirectly beneath the appropriate heading and alongsidethe category.
When the level of assistance within each category hasbeen identified the scores can be aggregated to assist inworkforce planning – see the box on page 14.
Stage 4
Background
This stage identifies the number of registered nursehours required, through the use of the registerednursing indicator.
A review of the literature and expert opinion informedthe process of developing this tool’s scoring system.Existing assessment tools were analysed in order toestablish the principles on which the level of nursingintervention was determined. The review demonstratesthat Criteria of care (Ball and Goldstone, 1984) areestablished on similar principles to the RCN’sassessment tool.
In the Criteria of care formula, different aspects of careare awarded different weightings – in other words,number of hours. Research concluded that themaximum contact between a patient and a registerednurse was 8.8 hours during a 24-hour period. This wascalculated through continuous observation of nursingover 24 hours and through an analysis of different typesof nursing activity - direct care versus indirect care.
The researchers highlighted four levels of ‘patientdependency’. They also identified maximum contactbetween nurses and patients for each level ofdependency.
Dependency level I = 1 hour
Dependency level II = 1.2 hours
Dependency level III = 2.5 hours
Dependency level IV = 4.1 hours
Using this formula, a scoring system was developed forthe RCN’s assessment tool. To allow for the addition of a‘no nursing’ score, five score ranges were developed.Scores were calculated by dividing the total possibleassessment score achievable (100) by the maximumnumber of hours of contact with a registered nurse (8.8hours). For example, if in each of the 25 carecomponents, an older person is assessed as needing thehighest level of nursing care - which carries a score of 4for each care component. Thus 25 x 4 = 100.
Working with this formula the score ranges were set atintervals of 11 and calculated according to theweightings - maximum contact time in hours - fromCriteria of care.
The registered nursing indicator
Assessment score Registered nursing input
0 = 0 hour
1-11 = 1 hour
12-23 = 1.2 hours
24-48 = 2.5 hours
49-100 = 4.1 hours
As the RCN’s assessment tool focuses on ability ratherthan dependency, the scoring system positively rejectsdependency in favour of working towardsindependence. To this end, it is weighted to reflect thenursing role in maximising potential. Extensive pilotingdemonstrates results that clearly validate the tool’sscoring system.
R O Y A L C O L L E G E O F N U R S I N G
13
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How it works
After completing stages 1 to 3, you can begin tocalculate the scoring by:
✦ adding the nursing intervention score for all thedescriptors in each of the three essential carecomponents using the summary assessment sheet
✦ adding the three sub totals to achieve one overalltotal
✦ checking the total alongside the registered nursingindicators
✦ checking that the registered nursing indicator scoreequates to a number of hours
✦ inserting the number of hours of registered nurseintervention that is required each 24 hours.
14
N U R S I N G A S S E S S M E N T A N D O L D E R P E O P L E
Workforce planning
You can use the RCN’s assessment tool to help you with workforce planning and time management. The formulawill enable you to work out the number of hours spent on management, supervision, actual and directive nursing.
To calculate how the total nursing input is divided up, first convert the total registered nursing input from hours tominutes - multiply by 60. Then add up the nursing input for each level of intervention - management,supervision, actual and directive.
To work out the number of minutes spent on management each 24 hours, divide the score for management by thetotal assessment score and then multiply input, in minutes. Using the same calculation – the workforce planningformula – this exercise can then be repeated for supervision, actual and directive nursing.
Workforce planning formula
total score for each nursing intervention x total registered nursing = number of minutes total assessment score input (in minutes) spent on each nursing
intervention (per 24 hours)
The following example shows how you can calculate the number of minutes spent on ‘actual’ nursing when thescores for actual nursing add up to 9 and the total assessment score is 37. Using the registered nursing indicator,we know that the total registered nursing input is 2.5 hours.
✦ First calculate the registered nursing input in minutes:2.5 hours x 60 = 150 minutes
✦ Using the actual nursing score - 9 - apply the workforce planning formula:9
x 150 = 36.5 minutes37
✦ So in every 24 hours, the resident needs 361/2 minutes of actual nursing care.
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Stage 5
Background
This final stage provides the evidence for decision-making and practice – encouraging nurses to collectevidence to support the decisions they have made. Thiscould include research in support of the decision,knowledge gained from working with the resident or thepreferences of an individual resident.
How it works
Review your decision-making through the process ofthe assessment. It is important to remember that theresulting assessment may differ from your currentperception of the number of hours of nursing available.In other words the assessment may indicate that youneed more or less nursing hours that are currentlyavailable. Identify the evidence that supports yourdecisions and your intended practice.
When identifying evidence it is useful to consider levelsof ‘best evidence’. Is there robust research or knowledgegained from working with the resident? Have theyexpressed preferences that support your decisions?
Conclusion
This assessment tool can be used to:
✦ contribute to the generation of a care plan
✦ identify the need for registered nursing involvement
✦ define the precise nature of that involvement
✦ state the hours of registered nursing required foreach of the residents
✦ state the hours needed on different elements ofnursing intervention for each resident
✦ act as a trigger for further specific assessment – forexample, pressure damage risk.
Additionally, each resident’s assessment can be used as aworkforce-planning tool. Individual assessment scorescan be aggregated to achieve organisational scores thatrelate both to skill mix and staffing.
R O Y A L C O L L E G E O F N U R S I N G
15
8
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References andfurther reading
Audit Commission (1991) The virtue of patients: makingthe best use of ward nursing resources, London: HMSO.
Ball J and Goldstone L (1984) Criteria of Care,Newcastle: Newcastle Polytechnic.
Bagust A and Slack R (1991) Ward nursing quality,University of York: York Health Economics Consortium.
Bagust A, Slack R and Oakley J (1992) Ward nursingquality and grade mix, University of York: York HealthEconomics Consortium.
Benner P (1994) From novice to expert – excellence andpower in clinical nursing practice, London: AddisonWesley Publishing Company.
Benner P and Wrubel J (1989) The primacy of caring –stress and coping in health and illness, California:Addison Wesley.
Benner P, Tanner C and Chesla C (1992) From beginnerto expert – gaining a differentiated clinical world incritical care nursing, Advances in Nursing Science, 14 (3)pp.13-28.
Brocklehurst J, Carty M, Leeming J and Robinson J(1978) Care of the elderly: medical screening of oldpeople accepted for residential care, The Lancet, ii,pp.141-2.
Bowling A (1991) Measuring health, Milton Keynes:Open University Press.
Bowling A (1995) Measuring disease, Buckingham:Open University Press.
Buchan J and Ball J (1991) Caring costs: nursing costsand benefits, report 208, Brighton: Institute ofEmployment Studies.
Buchan J, Seccombe I and Ball J (1997) Caring costsrevisited: a review for the Royal College of Nursing report321, Brighton: Institute of Employment Studies.
Carr-Hill R, Dixon P, Gibbs I et al (1992) Skill mix andthe effectiveness of nursing care, University of York:Centre of Health Care Economics.
Centre for Policy on Ageing (1990) Community life: acode of practice for community care, London: Centre forPolicy on Ageing.
Challis D, Carpenter I and Traske K (1996) Assessment incontinuing care homes: towards a National StandardInstrument, Kent: PSSRU.
Clark J and Lang N (1992) Nursing’s next advance: aninternational classification for nursing practice,International Nursing Review, 38 (4), pp.109-112.
Copeland J, Kelleher M, Keller J et al (1976) A semi-structured clinical interview for the assessment ofdiagnosis and mental state in the elderly: the geriatricmental state schedule – 1 development and reliability,Psychological Medicine, 6, pp.439-449.
Department of Health (1990) NHS and Community CareAct, London: HMSO.
Department of Health (1993) Vision for the future,London: HMSO.
Department of Health (1995) NHS responsibilities formeeting continuing health care needs, HSG (95)8, LAC(95)5, London: HMSO.
Department of Health (1999) Systems andmethodologies for assessing nursing care and costs innursing and residential homes, London: Department ofHealth.
Department of Health (2001) National serviceframework for older people, London: Department ofHealth.
Department of Health (2002) Guidance on free nursingcare in nursing homes, Health Select Committee 2001/17,London: HMSO.
Department of Health (2002) Guidance on the singleassessment process for older people; HSC 2002/001, LAC(2002)1, London: HMSO.
Department of Health (2003) Guidance on NHS fundednursing care, HSC2003/006, London: HMSO.
Department of Health and Social Sciences, NorthernIreland (1995) Health and personal social servicestatistics 1 April 1993 –31 March 1994, Belfast: DHSS.
16
N U R S I N G A S S E S S M E N T A N D O L D E R P E O P L E
9
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date.
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Department of Health and Social Sciences, NorthernIreland (1997) Community statistics 1 April 1995 – 31March 1996, Belfast: Health and Social ServicesExecutive and DHSS.
Department of Health, Social Sciences and Public Safety(2002) Investing for Health, Northern Ireland: DSSPSNI.
Department of Health, Social Sciences and Public Safety(2004) Community health nursing: current practice andpossible futures, Northern Ireland: DSSPSNI.
Dickinson E and Ebrahim S (1990) Adding life to youryears: quality and the health care of the elderly, GeriatricMedicine, September 112, pp.14-17.
Fearon M (1995) Monitor 2000: an audit of the quality ofnursing care for medical and surgical wards, Newcastleupon Tyne: Unique Business School.
Fleming R and Bowles J (1994) REPDS, Australia:Macsearch.
Fletcher A, Dickinson E and Philip I (1992) Review –audit measure: quality of life instruments for everydayuse with elderly patients, Age and ageing, 21, pp.142-150.
Ford P and Walsh M (1994) New rituals for old: nursingthrough the looking glass, Oxford: ButterworthHeinemann.
French B (1997) British studies which measure patientoutcome 1990-1994, Journal of Advanced Nursing, 26(2), pp.320-328.
Goldberg D (1972) The detection of psychiatric illness byquestionnaire: a technique for the identification andassessment of non-psychotic psychiatric illness, Oxford:OUP.
Goldstone L, Ball J and Collier M (1994) Monitor: anindex of the quality of nursing care for acute medical andsurgical wards, second edition, Newcastle: Newcastleupon Tyne Polytechnic Projects.
Goldstone L, Maselino-Okai C (1986) Senior monitor: anindex of quality nursing care for senior citizens ofhospital wards, Newcastle: Newcastle upon TynePolytechnic Projects.
Health Select Committee (1996) Long-term care: futureprovisions and funding, 3rd Report 1995-1996 Vol 1.London: HMSO.
Hurst K, Ford J, Keen J, Mottram S and Robinson M(2002) Selecting and applying methods for estimating thesize and mix of nursing teams, London: DH.
Katz S and Stroud M (1963) Functional assessment ingeriatrics: a review of progress and direction, Journal ofthe American Geriatrics Society, 37, pp.267-271.
Kitwood T (1995) ‘Cultures of care: tradition andchange’, in Kitwood T and Benson S, The new culture ofdementia care, London: Hawker Publications.
Kitwood T (1997) Dementia reconsidered - the personcomes first, Buckingham: Open Press.
LGMB and ADSS (1997) Independent sector workforcesurvey, 1996, residential homes and nursing homes inGreat Britain, London: Local Government ManagementBoard Publications.
Mahoney F and Barthel D (1965) Functional evaluation:the Barthel index, Maryland State Medical Journal, 14,pp.61-65.
McKenna H (1995) Nursing skill mix substitutions andquality of care: an exploration of assumptions fromresearch literature, Journal of Advanced Nursing, 21 (3),pp.452-459.
Morton J, Goldstone L A, Turner A et al (1992) Nursinghome monitor II: an audit of the quality of nursing carein registered nursing homes, Loughton, Essex: GaleCentre Publishing.
Needleman J, Buerhaus P, Matthe S and Stewart B A(2002) Staffing levels and the quality of care inhospitals, New England Journal of Medicine, 3346:22,pp.1715-1722.
Nolan M and Caldock K (1996) Assessment: identifyingthe barriers to good practice, Health and Social Care inthe Community, 4 (2), pp.77-85.
Patterson C (1992) The economic value of nursing,Nursing Economics, 10(3), pp.193-204.
Pattie A and Gilleard C (1979) Manual of the Cliftonassessment procedures for the elderly, Essex: Hodder andStoughton.
Peet S, Castleden C, Potter J et al (1994) The outcome ofa medical examination for applicants to Leicestershirehomes for older people, Age and Ageing, 23, pp.65-68.
R O Y A L C O L L E G E O F N U R S I N G
17
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eview
date.
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ith ca
ution
Royal College of Nursing (1993a) The value and skill ofnurses working with older people, London: RCN.
Royal College of Nursing (1993b) Older people andcontinuing care: the skill and value of the nurse, London:RCN.
Royal College of Nursing (1993c) Guidelines for assessingolder people with mental health needs, London: RCN.
Royal College of Nursing (1995) Nursing and olderpeople: report of the RCN taskforce on nursing and olderpeople, London: RCN.
Royal College of Nursing (1996) Nursing homes: nursingvalues, London: RCN.
Royal College of Nursing and Age Concern (1997)Funding nursing in nursing homes, London: RCN.
Royal College of Nursing (2003) Defining Nursing,London: RCN. Publication code 001 998.
Royal College of Nursing (2004a) What a difference anurse makes: a report on the benefits of expert nursing tothe clinical outcomes for older people on continuing care(2nd edition), London: RCN. Publication code 000 632.
Royal College of Nursing (2004b) Caring in partnership:older people and nursing staff working towards thefuture. London: RCN. Publication code 002 294.
Royal College of Physicians, British Geriatrics Society(1992) Standardised assessment scales for elderly people,London: RCP/BGS.
Rubenstein L, Calkins D, Greenfield S et al (1988) Healthstatus assessment for elderly patients: a report of theSociety of General Internal Medicine Taskforce onHealth Assessment, Journal of the American GeriatricsSociety, 37, pp.562-569.
Savage EB (1998) An examination of the changes in theprofessional role of nursing outside Ireland: a reportprepared for the commission on Nursing, Dublin: TheStationery Office.
Scottish Executive (2001a) National Care Standards: carehomes for older people, Edinburgh: Scottish Executive.
Scottish Executive (2001b) Caring for Scotland: thestrategy for nursing and midwifery in Scotland,Edinburgh: Scottish Executive.
Scottish Executive (2002) Adding life to years: report ofthe expert group on health care of older peopleEdinburgh: Scottish Executive.
Scottish Office Department of Health (1989) Modelguidelines for the registration and inspection of nursinghomes for the elderly, Edinburgh: Scottish Office.
Scottish Office Department of Health (1992) Modelguidelines for the registration and inspection ofindependent hospitals and nursing homes providing acuteservices, Edinburgh: Scottish Office.
Scottish Office Department of Health (1997) Nursinghomes (Scotland) care standards, Edinburgh: ScottishOffice.
Seedhouse D (1986) Health – the foundations ofachievement, Chichester: John Wiley & Sons.
Wandelt M, Ager J (1974) Quality of patient care scale(QUALPACS), New York: Appleton-Century-Crofts.
Welsh Assembly Government (2003a) The strategy forolder people in Wales, Cardiff: WAG.
Welsh Assembly Government (2003b) Quality offundamental aspects of health and social care for adults,Cardiff: WAG.
Wilkin D and Jolley D (1979) Behavioural problemsamong older people in geriatric wards, psychogeriatricwards and residential homes 1976-1978, Research reportno 1, Manchester: Psychogeriatric Ward, UniversityHospital of South Manchester.
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Appendix: Assessment sheets
✦ Supporting information
✦ Essential care components
1 Maximising life potential
2 Prevention and relief of distress
3 Promotion and maintenance of health status
4 Spare care components
✦ Summary assessment
R O Y A L C O L L E G E O F N U R S I N G
19
The following assessment sheets are intended to bephotocopied. The sheets can also be downloaded andprinted from the website at www.rcn.org.uk
When photocopying the sheets, please retain the RCNcopyright logo.
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© 2004 Royal College of Nursing
Resident's name
Client’s expectationsWhen completing the assessment, this tool is intended to reflect a person-centred approach throughout. Please add a statementthat reflects the views, wishes, strengths, preferably using the client’s own words.
Supporting information
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© 2004 Royal College of Nursing
Resident's name
Clinical backgroundDetails of medical conditions and diagnosis.
Disease prevention history
History of blood pressure monitoring __________________________________________________________________________________________________________________________________________
Vaccination history ____________________________________________________________________________________________________________________________________________________________________
Drinking and smoking history _____________________________________________________________________________________________________________________________________________________
Exercise pattern_________________________________________________________________________________________________________________________________________________________________________
Health screening:
Breast ____________________________________________________________________________________________________________________________________________________________________________________________________ Prostate ______________________________________________________________________________________________________________________________________________________________________________________________________________
Cervical _______________________________________________________________________________________________________________________________________________________________________________________________ Cholesterol ___________________________________________________________________________________________________________________________________________________________________________________________________
Other ________________________________________________________________________________________________________________________________________________________________________________________________________
Immediate environment and resources at home
Location _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Heating ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Access ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Amenities ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Problems managing the home _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Problems with access to local facilities and services ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Financial managementDoes the client have a problem with budgeting?
How much help does the client receive in managing money?
Supporting information
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© 2
004
Roya
l Col
lege
of N
ursi
ng
Cate
gory
: Per
sona
l ful
film
ent
A.
Inde
pend
ent i
n se
lf-fu
lfilm
ent.
B.
Nee
ds e
ncou
rage
men
t to
expr
ess
need
s an
d w
ants
tow
ards
sel
f-fu
lfilm
ent.
C. N
eeds
ass
ista
nce
to a
chie
ve n
eeds
and
wan
ts.
D. N
eeds
ass
ista
nce
tow
ards
ach
ievi
ng fu
lfilm
ent,
or t
owar
ds re
conc
iliat
ion
of n
on-f
ulfil
men
t.
E. N
on-fu
lfilm
ent c
ausi
ng p
hysi
cal o
r men
tal d
istr
ess
requ
iring
con
side
rabl
e in
terv
entio
n.
Rati
onal
e/ev
iden
ce
Rati
onal
e/ev
iden
ceCa
tego
ry: S
piri
tual
fulfi
lmen
t
A.
Inde
pend
ent i
n fu
lfilli
ng s
piri
tual
nee
ds.
B.
Nee
ds s
ome
assi
stan
ce w
ith
mee
ting
spi
ritu
al n
eeds
.
C. N
eeds
som
eone
to b
e pr
esen
t whi
le s
piri
tual
nee
ds a
re m
et, a
nd/o
r as
sist
ance
to fu
lfil r
elig
ious
ritu
als.
D. W
ants
to fu
lfil s
piri
tual
nee
ds a
nd/o
r rel
igio
us ri
tual
s, b
ut u
nabl
e to
do
so
for p
hysi
cal o
r men
tal r
easo
ns.
E. D
istu
rbed
abo
ut c
ircu
mst
ance
s, s
eeks
regu
lar a
nd c
onst
ant s
piri
tual
co
mfo
rt.
Nee
ds to
tal a
ssis
tanc
e w
ith
mee
ting
spi
ritu
al n
eeds
and
/or
relig
ious
ritu
als.
Stable and
predict
ableSta
ble andunpre
dictable
Unstable and
predict
ableUnsta
ble and
unpredict
able
1 M
ax
imis
ing
lif
e p
ote
nti
al
No nursing Management Supervisi
on Actual
Directi
ve
01
23
4
Rati
onal
e/ev
iden
ceCa
tego
ry: S
ocia
l rel
atio
ns
A.
Rela
tes
wel
l wit
h ot
hers
, mix
es w
ell,
init
iate
s an
d ac
cept
s so
cial
con
tact
an
d/or
pre
fers
ow
n co
mpa
ny, o
r is
indi
ffer
ent t
o th
e co
mpa
ny o
f oth
ers.
B.
Pref
ers
own
com
pany
, or i
ndiff
eren
t to
the
com
pany
of o
ther
s. N
eeds
he
lp to
init
iate
com
mun
icat
ion.
C. R
elat
es w
ell t
o a
few
peo
ple
only
, res
erve
d. A
ppea
rs to
enj
oy c
ompa
ny
but s
eem
s to
lack
con
fiden
ce.
D. A
void
s or
resi
sts
soci
al c
onta
ct a
nd/o
r app
ears
relu
ctan
t to
com
mun
icat
e.
Lim
ited
eff
ecti
ve c
onta
ct.
E. I
s w
ithd
raw
n, o
r exh
ibit
s ov
er-in
volv
emen
t. E
xhib
its
disr
upti
ve o
r dy
sfun
ctio
nal b
ehav
iour
.
Es
se
nti
al
care
co
mp
on
en
t
Resi
dent
's n
ame
Past r
eview
date.
Use w
ith ca
ution
© 2
004
Roya
l Col
lege
of N
ursi
ng
Cate
gory
: Sex
ualit
y
A.
Inde
pend
ent i
n fu
lfilli
ng in
divi
dual
nee
d to
exp
ress
sex
ualit
y th
roug
h pe
rson
al p
rese
ntat
ion,
rela
tion
ship
s or
act
ivit
ies.
B.
Abl
e to
exp
ress
sex
ualit
y in
depe
nden
tly.
Req
uire
s so
me
assi
stan
ce w
ith
faci
litat
ing
priv
acy,
rela
tion
ship
opp
ortu
niti
es o
r per
sona
l pre
sent
atio
n.
C. N
eeds
ass
ista
nce
to e
xpre
ss s
exua
lity
for e
.g. p
erso
nal p
rese
ntat
ion.
En
joym
ent o
f des
ired
rela
tions
hips
requ
ires
man
agem
ent o
f the
env
ironm
ent.
D. N
eeds
sta
ff a
ssis
tanc
e in
est
ablis
hing
app
ropr
iate
env
iron
men
t to
fulfi
l se
xual
nee
ds a
nd e
xpre
ssio
n of
sex
ualit
y. M
ay n
eed
spec
ialis
t ass
essm
ent,
su
ch a
s fr
om a
psy
chos
exua
l the
rapi
st.
E. E
xhib
its
sign
ifica
nt c
halle
ngin
g be
havi
our i
n re
spec
t of s
exua
lity.
M
ay n
eed
ther
apeu
tic
inte
rven
tion
and
/or c
lose
sup
ervi
sion
or s
uppo
rt.
Rati
onal
e/ev
iden
ce
Rati
onal
e/ev
iden
ceCa
tego
ry: C
ogni
tion
A.
Abl
e to
man
age
own
affa
irs
and
mak
e ap
prop
riat
e de
cisi
ons
wit
h pa
st,
pres
ent a
nd fu
ture
in p
ersp
ecti
ve.
Can
talk
and
/or p
rese
nt in
form
atio
n in
a
clea
r log
ical
man
ner a
nd in
con
text
.
B.
Reas
ons
and
thin
ks a
dequ
atel
y bu
t has
occ
asio
nal d
iffic
ulti
es w
ith
mem
ory
and/
or m
akin
g de
cisi
ons.
C. A
ble
to th
ink
but h
as d
iffic
ulty
wit
h m
emor
y an
d de
cisi
on-m
akin
g.
Abi
lity
to re
ason
inhi
bite
d, b
ut is
abl
e to
mak
e de
cisi
ons
if of
fere
d lim
ited
op
tion
s, g
uida
nce
and
reas
sura
nce.
D. U
nabl
e to
reas
on a
nd th
ink
adeq
uate
ly w
ithou
t con
tinuo
us s
uppo
rt.
Able
to m
ake
deci
sion
s if
offe
red
limite
d op
tions
, gui
danc
e an
d re
assu
ranc
e.
E. U
nabl
e to
thin
k or
reas
on fo
r sel
f, or
to m
ake
a de
cisi
on.
Nee
ds c
onst
ant c
ompe
nsat
ory
acti
ons.
Stable and
predict
ableSta
ble andunpre
dictable
Unstable and
predict
ableUnsta
ble and
unpredict
able
1 M
ax
imis
ing
lif
e p
ote
nti
al
No nursing Management Supervisi
on Actual
Directi
ve
01
23
4
Es
se
nti
al
care
co
mp
on
en
t
Resi
dent
's n
ame
Past r
eview
date.
Use w
ith ca
ution
© 2
004
Roya
l Col
lege
of N
ursi
ng
Cate
gory
: Com
mun
icat
ion
A.
Com
mun
icat
es in
thei
r usu
al w
ay.
Is a
ble
to u
se th
eir f
irst
lang
uage
an
d/or
exp
ress
thei
r vie
ws,
nee
ds a
nd d
esir
es in
a m
anne
r und
erst
ood
by m
ost p
eopl
e,
B.
Is a
ble
to c
omm
unic
ate
verb
ally
but
non
-ver
bal o
r em
otio
nal
com
mun
icat
ion
skill
s ar
e no
t alw
ays
cong
ruen
t wit
h ve
rbal
com
mun
icat
ion.
C.H
as d
evel
oped
a m
etho
d of
com
mun
icat
ion
usin
g ve
rbal
and
non
-ver
bal
met
hods
whi
ch re
quir
e cl
ose
atte
ntio
n by
oth
ers.
Abl
e to
com
mun
icat
e (t
heir
vie
ws
and
desi
res)
in a
luci
d w
ay, w
hich
usu
ally
nee
ds s
ome
conf
irm
atio
n by
the
pers
on li
sten
ing.
D. E
xper
ienc
es s
ome
diff
icul
ty in
exp
ress
ion
and/
or c
ompr
ehen
sion
whi
ch
need
s as
sist
ance
, thr
ough
und
erst
andi
ng a
nd in
terp
reta
tion
and
/or t
he
use
of a
ids/
adap
tati
ons.
Abl
e to
und
erst
and
info
rmat
ion
give
n.
E. H
as li
mit
ed o
r no
com
mun
icat
ion.
The
com
mun
icat
ion
may
be
cond
ucte
d us
ing
aids
, non
-ver
bal s
igns
and
sig
nals
or m
onos
ylla
bles
. Th
e in
terp
reta
tion
of n
eeds
and
vie
ws
is c
ompl
ex.
Rati
onal
e/ev
iden
ce
Rati
onal
e/ev
iden
ceCa
tego
ry:
Pain
con
trol
A.
Pain
free
. Sel
f car
ing
in th
e m
anag
emen
t of p
ain.
B.
Expe
rien
ces
pain
whi
ch th
ey a
re a
ble
to m
anag
e an
d ca
n as
k w
hen
trea
tmen
t is
requ
ired
.
C. E
xper
ienc
es re
gula
r or p
rotr
acte
d pa
in w
hich
can
not b
e m
anag
ed
unsu
ppor
ted,
alt
houg
h ne
eds
can
be e
xpre
ssed
. N
eeds
ass
ista
nce,
su
perv
isio
n or
sup
port
in c
ontr
ollin
g th
e pa
in.
D. A
ble
to e
xpre
ss v
erba
lly p
rotr
acte
d pa
in, b
ut u
nabl
e to
spe
cify
the
type
of
pai
n or
its
effe
cts.
Req
uire
s a
rang
e of
inte
rven
tion
s to
con
trol
pai
n.
E. U
nabl
e to
des
crib
e ne
eds
in re
spec
t of p
ain.
The
leve
l of p
ain
expe
rien
ced
can
only
be
seen
thro
ugh
beha
viou
r, fa
cial
or b
odily
exp
ress
ion
and
emot
iona
l sta
te.
Requ
ires
com
plex
inte
rven
tion
s.
Stable and
predict
ableSta
ble andunpre
dictable
Unstable and
predict
ableUnsta
ble and
unpredict
able
2 P
reve
nti
on
an
d r
eli
ef
of
dis
tre
ss
No nursing Management Supervisi
on Actual
Directi
ve
01
23
4
Es
se
nti
al
care
co
mp
on
en
t
Resi
dent
's n
ame
Past r
eview
date.
Use w
ith ca
ution
© 2
004
Roya
l Col
lege
of N
ursi
ng
Cate
gory
: The
sen
ses
A.
Inde
pend
ent i
n se
nsor
y fu
ncti
on o
r abl
e to
com
pens
ate
usin
g ot
her s
ense
s.
Abl
e to
man
age
aids
inde
pend
entl
y.
B.
Uti
lises
all
sens
es th
roug
h th
e us
e of
aid
s/ad
apta
tion
s. A
ssis
tanc
e re
quir
ed in
rout
ine
care
of e
quip
men
t.
C. S
ense
s si
gnifi
cant
ly d
efic
ient
. N
eeds
ass
ista
nce
in u
sing
aid
s an
d ad
apta
tions
.
D. N
o be
nefit
gai
ned
from
any
aid
s or
ada
ptat
ions
, nee
ds d
irec
tion
to
unde
rtak
e an
y pe
rson
al o
r pub
lic a
ctiv
ity.
E. U
nabl
e to
use
one
(or m
ore)
sen
ses,
or c
ompe
nsat
e fo
r los
s th
roug
h ad
apta
tion
or a
ids.
Nee
ds c
onti
nuou
s su
ppor
t due
to lo
ss o
f abi
lity
to
unde
rsta
nd in
stru
ctio
n, in
terp
reta
tion
or d
escr
ipti
on.
Rati
onal
e/ev
iden
ce
Rati
onal
e/ev
iden
ceCa
tego
ry: M
emor
y
A.
Uni
mpa
ired
mem
ory,
reca
ll ab
ility
wit
hin
usua
l pat
tern
.
B.
Occ
asio
nally
forg
etfu
l but
eas
ily re
min
ded.
C. D
iffic
ulty
in re
calli
ng re
cent
eve
nts,
but
can
com
pens
ate
thro
ugh
conf
abul
atio
n an
d ne
eds
supp
orti
ve re
orie
ntat
ion
to c
lari
fy th
inki
ng.
Doe
s no
t app
ear d
istr
esse
d.
D. D
iffic
ulty
in re
calli
ng v
ery
rece
nt e
vent
s an
d sp
atia
l inf
orm
atio
n. S
ome
dist
ress
evi
dent
but
reas
sura
nce
is a
ccep
ted.
Int
erve
ntio
n re
quir
es
ergo
nom
ic, s
ocia
l and
inte
rper
sona
l mem
ory
cues
. Th
e ri
sk to
per
sona
l saf
ety
has
to b
e as
sess
ed.
E. U
nabl
e to
reca
ll ev
ents
and
spa
tial
info
rmat
ion.
Rep
etit
ive
spee
ch p
rese
nt
and
high
leve
ls o
f pro
long
ed d
istr
ess
evid
ent.
Nee
ds c
onti
nuou
s su
perv
isio
n in
resp
ect o
f erg
onom
ic a
nd s
ocia
l cue
s, a
nd d
irec
t int
erve
ntio
n to
car
ry o
ut a
sm
all l
evel
of p
erso
nal c
are.
Nee
ds c
onti
nuou
s ri
sk
asse
ssm
ent a
nd m
anag
emen
t in
resp
ect o
f per
sona
l saf
ety.
Stable and
predict
ableSta
ble andunpre
dictable
Unstable and
predict
ableUnsta
ble and
unpredict
able
2 P
reve
nti
on
an
d r
eli
ef
of
dis
tre
ss
No nursing Management Supervisi
on Actual
Directi
ve
01
23
4
Es
se
nti
al
care
co
mp
on
en
t
Resi
dent
's n
ame
Past r
eview
date.
Use w
ith ca
ution
© 2
004
Roya
l Col
lege
of N
ursi
ng
Cate
gory
: Ori
enta
tion
A.
Ori
enta
ted
to ti
me,
pla
ce a
nd p
erso
n an
d re
spon
ds a
ppro
pria
tely
.
B.
Evid
ence
of o
ccas
iona
l dis
orie
ntat
ion
and/
or d
istr
ess.
Nee
ds s
uppo
rtiv
e in
form
atio
n to
cla
rify
thin
king
.
C. N
eeds
regu
lar o
rien
tati
on a
nd p
sych
olog
ical
sup
port
to m
aint
ain
func
tion
ing
and/
or p
reve
nt d
istr
ess.
D. D
isor
ient
ated
to ti
me,
pla
ce a
nd p
erso
n, w
ith
occa
sion
al d
istr
ess.
N
eeds
con
tinu
ous
reas
sura
nce,
as
no a
ppro
pria
te c
ues
are
take
n fr
om
the
envi
ronm
ent.
E. D
isor
ient
ated
to ti
me,
pla
ce a
nd p
erso
n. R
equi
ring
con
stan
t reo
rien
tati
on
and
reas
sura
nce
due
to d
istr
ess.
Nee
ds re
gula
r ris
k as
sess
men
t and
in
terv
enti
on.
Rati
onal
e/ev
iden
ce
Rati
onal
e/ev
iden
ceCa
tego
ry: L
oss,
cha
nge
and
adap
tati
on
A.
Abl
e to
iden
tify
, exp
ress
and
ada
pt to
cir
cum
stan
ces.
B.
Is a
djus
ting
em
otio
nally
to c
ircu
mst
ance
s an
d/or
is p
osit
ive
abou
t sel
f im
age.
Abl
e to
init
iate
inte
ract
ions
wit
h ot
hers
. Ex
pres
ses
emot
ions
free
ly.
C. H
as n
ot y
et a
djus
ted
emot
iona
lly to
cir
cum
stan
ces
and/
or h
as a
neg
ativ
e se
lf im
age.
Ide
ntifi
es in
sel
f tha
t moo
ds a
nd e
mot
ions
fluc
tuat
e, a
nd is
aw
are
of th
e st
imul
i tha
t cau
se th
is.
Is a
ble
to e
xpre
ss d
esir
e fo
r em
otio
nal s
uppo
rt.
D. H
as n
ot y
et a
djus
ted
emot
iona
lly to
cir
cum
stan
ces,
resu
ltin
g in
a n
egat
ive
self
imag
e. I
dent
ifies
in s
elf t
hat m
oods
and
em
otio
ns fl
uctu
ate,
but
is
unaw
are
of th
e st
imul
i tha
t cau
se th
is.
Is a
ble
to e
xpre
ss d
esir
e fo
r em
otio
nal s
uppo
rt.
E. H
as n
ot y
et a
djus
ted
emot
iona
lly to
sta
te o
f dep
ende
ncy,
resu
ltin
g in
a
nega
tive
sel
f im
age.
Doe
s no
t ide
ntify
in s
elf t
hat m
oods
and
em
otio
ns
fluct
uate
or t
he re
sult
ing
beha
viou
ral e
ffec
ts.
Is u
naw
are
of th
e st
imul
i th
at c
ause
this
and
doe
s no
t acc
ept s
uppo
rt fr
eely
.
Stable and
predict
ableSta
ble andunpre
dictable
Unstable and
predict
ableUnsta
ble and
unpredict
able
2 P
reve
nti
on
an
d r
eli
ef
of
dis
tre
ss
No nursing Management Supervisi
on Actual
Directi
ve
01
23
4
Es
se
nti
al
care
co
mp
on
en
t
Resi
dent
's n
ame
Past r
eview
date.
Use w
ith ca
ution
© 2
004
Roya
l Col
lege
of N
ursi
ng
Cate
gory
: Beh
avio
ur
A.
Beh
avio
ur is
app
ropr
iate
wit
hin
the
cont
ext o
f ind
ivid
ual c
ultu
re a
nd
ethn
icit
y, th
e cu
rren
t loc
atio
n an
d so
cial
inte
ract
ion
wit
h ot
hers
.
B.
Beh
avio
ur is
app
ropr
iate
wit
hin
the
cont
ext o
f ind
ivid
ual c
ultu
re a
nd e
thni
city
, the
cu
rren
t loc
atio
n an
d so
cial
inte
ract
ion
wit
h ot
hers
and
gui
danc
e or
sup
port
.
C. B
ehav
iour
is a
ppro
pria
te w
ithi
n th
e co
ntex
t of i
ndiv
idua
l cul
ture
and
et
hnic
ity,
the
curr
ent l
ocat
ion
and
soci
al in
tera
ctio
n w
ith
othe
rs.
Nee
ds re
gula
r sup
ervi
sion
to a
ntic
ipat
e be
havi
our a
nd re
spon
ses.
D. H
as d
iffic
ulty
def
inin
g an
d di
spla
ying
app
ropr
iate
beh
avio
ur w
ithi
n th
e co
ntex
t of i
ndiv
idua
l cul
ture
, the
cur
rent
loca
tion
and
soc
ial
inte
ract
ion
wit
h ot
hers
. B
ehav
iour
al re
spon
se w
ill v
ary
acco
rdin
g to
the
soci
al s
tim
uli n
eedi
ng s
kille
d gu
idan
ce, a
dvic
e an
d su
ppor
t.
E. H
as d
iffic
ulty
in d
efin
ing
and
disp
layi
ng a
ppro
pria
te b
ehav
iour
wit
hin
the
cont
ext o
f ind
ivid
ual c
ultu
re, t
he c
urre
nt lo
cati
on a
nd s
ocia
l int
erac
tion
w
ith
othe
rs.
Act
ions
and
resp
onse
s w
ill v
ary
even
to th
e sa
me
stim
uli.
N
eeds
regu
lar i
nter
vent
ion,
sup
port
and
man
agem
ent i
n or
der t
o pr
otec
t se
lf an
d ot
hers
from
the
nega
tive
eff
ect o
f cha
lleng
ing
beha
viou
r.
Rati
onal
e/ev
iden
ce
Rati
onal
e/ev
iden
ceCa
tego
ry: R
elat
ives
and
car
ers
A.
Rela
tive
s an
d/or
sig
nific
ant o
ther
s ar
e su
ppor
tive
and
invo
lved
and
ap
prec
iate
the
care
nee
ds.
They
act
ivel
y pa
rtic
ipat
e.
B.
Rela
tive
s an
d/or
sig
nific
ant o
ther
s ar
e su
ppor
tive
and
app
reci
ate
care
nee
ds.
They
are
not
act
ivel
y in
volv
ed.
C. R
elat
ives
and
/or s
igni
fican
t oth
ers
need
regu
lar s
uppo
rt a
nd g
uida
nce
in re
lati
on to
acc
epti
ng p
lace
men
t and
iden
tifie
d ca
re n
eeds
.
D. D
iffer
ence
s of
vie
ws/
need
s/w
ants
bet
wee
n re
lati
ves
and/
or s
igni
fican
t ot
hers
requ
ires
a h
igh
degr
ee o
f man
agem
ent a
nd s
ensi
tive
sup
port
.
E. T
otal
ly o
ppos
ing
view
s/ne
eds/
wan
ts b
etw
een
rela
tive
s an
d/or
si
gnifi
cant
oth
ers
lead
ing
to c
onfli
ct w
hich
nee
ds m
anag
emen
t bu
t may
be
unre
solv
ed.
Stable and
predict
ableSta
ble andunpre
dictable
Unstable and
predict
ableUnsta
ble and
unpredict
able
2 P
reve
nti
on
an
d r
eli
ef
of
dis
tre
ss
No nursing Management Supervisi
on Actual
Directi
ve
01
23
4
Es
se
nti
al
care
co
mp
on
en
t
Resi
dent
's n
ame
Past r
eview
date.
Use w
ith ca
ution
© 2
004
Roya
l Col
lege
of N
ursi
ng
Cate
gory
: Per
sona
l hyg
iene
A.
Inde
pend
ent i
n at
tend
ing
to o
wn
hygi
ene
need
s
B.
Abl
e to
att
end
to o
wn
hygi
ene
need
s on
ce n
eces
sary
equ
ipm
ent h
as b
een
arra
nged
. Sk
in in
tegr
ity
is in
tact
and
is n
ot a
t ris
k fr
om d
amag
e.
C. N
eeds
som
e he
lp to
att
end
to o
wn
hygi
ene
need
s in
clud
ing
the
arra
ngem
ent o
f ne
cess
ary
equi
pmen
t. S
kin
inte
grit
y is
inta
ct b
ut is
at s
ome
risk
from
dam
age.
N
eeds
ass
ista
nce
wit
h a
bath
/sho
wer
to m
aint
ain
skin
inte
grit
y an
d/or
sel
f est
eem
.
D. N
eeds
hel
p w
ith
mee
ting
hyg
iene
nee
ds in
clud
ing
the
arra
ngem
ent o
f ne
cess
ary
equi
pmen
t. S
kin
inte
grit
y is
inta
ct b
ut is
at h
igh
risk
from
da
mag
e. H
as a
bat
h/sh
ower
whi
ch n
eeds
to b
e fu
lly s
uper
vise
d.
E. F
ully
dep
ende
nt o
n ot
hers
to m
eet h
ygie
ne n
eeds
. Sk
in in
tegr
ity
is in
tact
bu
t is
at v
ery
high
risk
. N
eeds
com
plet
e as
sist
ance
wit
h ba
thin
g to
hel
p m
aint
ain
skin
inte
grit
y an
d se
lf es
teem
.
Rati
onal
e/ev
iden
ce
Rati
onal
e/ev
iden
ceCa
tego
ry: D
ress
ing
A.
Can
dres
s ap
prop
riat
ely
wit
h no
ass
ista
nce
or s
uper
visi
on.
B.
Is a
ble
to id
enti
fy a
nd m
ake
choi
ces
abou
t clo
thin
g pr
efer
ence
s ap
prop
riat
e to
env
iron
men
t and
tem
pera
ture
. H
as a
dis
abili
ty th
at a
ffec
ts a
bilit
y to
dr
ess
inde
pend
entl
y. O
nce
clot
hes
have
bee
n pl
aced
wit
hin
reac
h, c
an
man
age
to d
ress
, but
may
nee
d he
lp w
ith
fast
enin
gs o
r but
tons
. U
ses
aide
s to
put
on
shoe
s an
d so
cks/
stoc
king
s.
C. I
s ab
le to
iden
tify
and
mak
e ch
oice
s ab
out c
loth
ing
pref
eren
ces
appr
opri
ate
to e
nvir
onm
ent a
nd te
mpe
ratu
re.
Has
a d
isab
ility
that
aff
ects
abi
lity
to
dres
s in
depe
nden
tly.
Nee
ds c
loth
es la
ying
in th
e ri
ght o
rder
and
requ
ires
he
lp o
r sup
ervi
sion
wit
h dr
essi
ng (i
nclu
ding
hel
p w
ith
butt
ons/
fast
enin
gs).
Is
una
ble
to p
ut s
ocks
/sto
ckin
gs a
nd s
hoes
on
wit
hout
ass
ista
nce.
D. I
s un
able
to m
ake
choi
ces
abou
t clo
thin
g pr
efer
ence
s ap
prop
riat
e to
en
viro
nmen
t and
tem
pera
ture
. H
as a
dis
abili
ty th
at a
ffec
ts m
otiv
atio
n an
d th
eref
ore
is o
ften
unw
illin
g/un
able
to a
ssis
t in
any
way
. N
eeds
clo
thes
la
ying
in ri
ght o
rder
and
requ
ires
pro
mpt
ing
wit
h dr
essi
ng.
Is u
nabl
e to
put
so
cks/
stoc
king
s an
d sh
oes
on w
itho
ut a
ssis
tanc
e.
E. F
ully
dep
ende
nt o
n ot
hers
to d
ress
.
Stable and
predict
ableSta
ble andunpre
dictable
Unstable and
predict
ableUnsta
ble and
unpredict
able
3 P
rom
oti
on
an
d m
ain
ten
an
ce o
f h
ea
lth
sta
tus
No nursing Management Supervisi
on Actual
Directi
ve
01
23
4
Es
se
nti
al
care
co
mp
on
en
t
Resi
dent
's n
ame
Past r
eview
date.
Use w
ith ca
ution
© 2
004
Roya
l Col
lege
of N
ursi
ng
Cate
gory
: Mot
ivat
ion
A.
Is m
otiv
ated
to a
chie
ve d
aily
livi
ng a
ctiv
itie
s in
depe
nden
tly.
B.
Has
a d
isab
ility
that
aff
ects
per
form
ance
of d
aily
livi
ng a
ctiv
itie
s.
Is m
otiv
ated
to a
dopt
to th
eir e
nvir
onm
ent b
y us
ing
aide
s an
d ad
just
men
ts.
C. H
as a
dis
abili
ty th
at a
ffec
ts p
erfo
rman
ce o
f dai
ly li
ving
act
ivit
ies.
Is
mot
ivat
ed to
ada
pt to
thei
r env
iron
men
t by
usin
g ai
des
and
adju
stm
ents
, bu
t occ
asio
nally
nee
ds e
ncou
rage
men
t, p
rom
ptin
g an
d re
assu
ranc
e.
D. M
otiv
atio
n flu
ctua
tes
due
to c
hang
ing
heal
th s
tatu
s an
d/or
acc
epta
nce
of
disa
bilit
y. N
eeds
regu
lar a
nd fr
eque
nt p
rom
ptin
g, e
ncou
rage
men
t and
re
assu
ranc
e.
E. M
otiv
atio
n ap
pear
s to
be
abse
nt d
ue to
sig
nific
ant d
isea
se p
roce
sses
.
Rati
onal
e/ev
iden
ce
Rati
onal
e/ev
iden
ceCa
tego
ry: S
leep
ing
A.
Mai
ntai
ns u
sual
sle
ep p
atte
rn w
itho
ut a
ssis
tanc
e.
B.
Has
an
esta
blis
hed
slee
p pa
tter
n th
at ra
rely
alt
ers
acco
rdin
g to
ext
erna
l or
inte
rnal
sti
mul
i. H
as a
rout
ine
that
onc
e ad
here
d to
resu
lts
in a
chie
ving
no
rmal
sle
ep.
Nee
ds s
uppo
rt w
ith
adju
stin
g en
viro
nmen
t to
assi
st
wit
h ac
hiev
ing
norm
al s
leep
.
C. H
as a
n es
tabl
ishe
d sl
eep
patt
ern
that
rare
ly a
lter
s ac
cord
ing
to e
xter
nal o
r int
erna
l st
imul
i. H
as a
rout
ine
that
, onc
e ad
here
d to
, res
ults
in a
chie
ving
nor
mal
sle
ep,
but t
he q
ualit
y of
sle
ep is
aff
ecte
d by
em
otio
nal a
nd p
hysi
cal w
ellb
eing
.
D. H
as a
n er
rati
c sl
eep
patt
ern
that
is a
ffec
ted
by e
mot
iona
l and
phy
sica
l w
ellb
eing
. D
oes
not h
ave
an e
stab
lishe
d ro
utin
e, b
ut v
ario
us in
terv
enti
ons
appl
ied
to a
chie
ve c
omfo
rt re
sult
in a
chie
ving
sle
ep.
Nee
ds h
elp
in th
e ni
ght a
nd re
assu
ranc
e th
at s
omeo
ne is
ther
e to
ass
ist.
E. H
as a
n er
rati
c sl
eep
patt
ern
that
is a
ffec
ted
by e
mot
iona
l and
phy
sica
l w
ellb
eing
. D
oes
not h
ave
an e
stab
lishe
d ro
utin
e, b
ut v
ario
us in
terv
enti
ons
appl
ied
to a
chie
ve c
omfo
rt re
sult
in a
chie
ving
sho
rt p
erio
ds o
f sle
ep.
Rest
less
thro
ugho
ut th
e ni
ght f
or a
var
iety
of r
easo
ns th
at a
re d
iffic
ult t
o pr
edic
t. D
isor
ient
ated
and
requ
ires
hel
p in
the
nigh
t and
con
stan
t re
assu
ranc
e th
at s
omeo
ne is
ther
e to
ass
ist.
Stable and
predict
ableSta
ble andunpre
dictable
Unstable and
predict
ableUnsta
ble and
unpredict
able
3 P
rom
oti
on
an
d m
ain
ten
an
ce o
f h
ea
lth
sta
tus
No nursing Management Supervisi
on Actual
Directi
ve
01
23
4
Es
se
nti
al
care
co
mp
on
en
t
Resi
dent
's n
ame
Past r
eview
date.
Use w
ith ca
ution
© 2
004
Roya
l Col
lege
of N
ursi
ng
Cate
gory
: Mob
ility
A.
Inde
pend
ent w
ith
or w
itho
ut a
ssis
tanc
e or
aid
s (i
nclu
ding
whe
elch
air)
. A
ble
to m
anag
e st
eps/
stai
rs in
depe
nden
tly.
B.
Abl
e to
get
out
of c
hair
and
bed
wit
hout
ass
ista
nce.
Wal
ks w
ith
an a
id
or a
ssis
tanc
e, b
ut n
eeds
rem
indi
ng to
use
it.
Is a
war
e of
obs
tacl
es to
saf
e m
obili
ty a
nd d
ange
rs to
per
sona
l saf
ety.
C. A
ble
to g
et o
ut o
f cha
ir a
nd b
ed w
itho
ut a
ssis
tanc
e bu
t abi
lity
to m
obili
se
fluct
uate
s. W
alks
wit
h a
fram
e, b
ut n
eeds
sup
ervi
sion
. Is
aw
are
of
obst
acle
s to
saf
e m
obili
ty a
nd d
ange
rs to
per
sona
l saf
ety.
D. U
nabl
e to
get
out
of c
hair
and
bed
wit
hout
ass
ista
nce
and/
or a
bilit
y to
m
obili
se fl
uctu
ates
. W
alks
wit
h as
sist
ance
and
/or a
ide.
Is
unaw
are
of
obst
acle
s to
saf
e m
obili
ty a
nd d
ange
rs to
per
sona
l saf
ety.
E. U
nabl
e to
get
out
of c
hair
and
bed
wit
hout
full
assi
stan
ce.
Cann
ot s
tand
or
wal
k w
itho
ut p
hysi
cal s
uppo
rt.
Is u
naw
are
of o
bsta
cles
to s
afe
mob
ility
an
d da
nger
s to
per
sona
l saf
ety.
Spe
nds
mos
t of t
he ti
me
in a
cha
ir o
r be
d an
d is
at r
isk
of d
evel
opin
g co
mpl
icat
ions
due
to im
mob
ility
.
Rati
onal
e/ev
iden
ce
Rati
onal
e/ev
iden
ceCa
tego
ry: E
limin
atio
n of
uri
ne a
nd fa
eces
A.
Att
ends
to e
limin
atio
n ne
eds
inde
pend
entl
y an
d/or
is c
onti
nent
.
B.
Is a
war
e of
nee
d to
elim
inat
e ur
ine
and/
or fa
eces
. So
me
drib
blin
g in
cont
inen
ce
but i
s ab
le to
cha
nge
own
pads
whi
ch a
re u
sed
for s
ecur
ity.
Nee
ds a
ssis
tanc
e fr
om
one
pers
on to
get
to th
e to
ilet b
ut is
abl
e to
att
end
to o
wn
need
s on
ce th
ere.
C. I
s aw
are
of n
eed
to e
limin
ate
urin
e an
d/or
faec
es.
Inab
ility
to m
anag
e ow
n to
ileti
ng, i
nclu
ding
sel
ecti
ng a
n ap
prop
riat
e en
viro
nmen
t. A
regu
lar a
nd
plan
ned
cont
inen
ce p
rogr
amm
e m
inim
ises
per
iods
of i
ncon
tine
nce
to le
ss
than
onc
e w
eekl
y.
D. I
s aw
are
of n
eed
to e
limin
ate
urin
e an
d/or
faec
es.
Nee
ds a
ssis
tanc
e fr
om o
ne
pers
on to
get
to th
e to
ilet,
but
doe
s no
t res
pond
to s
tim
uli r
esul
ting
in p
erio
ds o
f in
cont
inen
ce.
Doe
s no
t res
pond
to c
onti
nenc
e pr
ogra
mm
e w
itho
ut s
uper
visi
on.
E. I
s un
awar
e of
nee
d to
elim
inat
e ur
ine
and/
or fa
eces
due
to lo
ss o
f sen
satio
n an
d m
uscl
e to
ne a
nd/o
r men
tal s
tate
, res
ultin
g in
an
inab
ility
to m
anag
e ow
n co
ntin
ence
. H
as p
erio
ds o
f inc
ontin
ence
. Le
vel o
f dis
orie
ntat
ion
requ
ires
cons
tant
sup
ervi
sion
of c
ontin
ence
pro
gram
me.
Stable and
predict
ableSta
ble andunpre
dictable
Unstable and
predict
ableUnsta
ble and
unpredict
able
3 P
rom
oti
on
an
d m
ain
ten
an
ce o
f h
ea
lth
sta
tus
No nursing Management Supervisi
on Actual
Directi
ve
01
23
4
Es
se
nti
al
care
co
mp
on
en
t
Resi
dent
's n
ame
Past r
eview
date.
Use w
ith ca
ution
© 2
004
Roya
l Col
lege
of N
ursi
ng
Cate
gory
: Ris
k
A.
Is a
ble
to a
sses
s th
emse
lves
and
the
situ
atio
n an
d m
ake
an in
form
ed
deci
sion
abo
ut th
e de
gree
of r
isk
to s
elf a
nd o
ther
s. F
eels
saf
e in
a s
ocia
l gr
oup,
sur
roun
ding
s or
env
iron
men
t.
B.
Is a
ble
to a
sses
s th
emse
lves
and
the
situ
atio
n an
d m
ake
an in
form
ed d
ecis
ion
abou
t the
deg
ree
of ri
sk to
sel
f and
oth
ers.
Doe
s no
t fee
l saf
e or
is u
nsaf
e in
a s
ocia
l gro
up, s
urro
undi
ngs
or e
nviro
nmen
t and
nee
ds re
gula
r sup
port
.
C. I
s aw
are
of s
urro
undi
ngs
and
dang
ers
to p
erso
nal s
afet
y, b
ut is
una
ble
to m
ake
safe
dec
isio
ns a
nd/o
r tak
e ap
prop
riat
e ac
tion
to m
aint
ain
safe
ty
for s
elf a
nd o
ther
s.
D. I
s aw
are
of s
urro
undi
ngs
and
dang
ers
to p
erso
nal s
afet
y bu
t unp
redi
ctab
le
heal
th s
tatu
s le
ads
to h
eigh
tene
d po
tent
ial f
or m
akin
g un
safe
dec
isio
ns
and/
or a
n in
abili
ty to
take
app
ropr
iate
act
ion
to m
aint
ain
safe
ty fo
r sel
f and
ot
hers
. N
eeds
sup
ervi
sion
to p
erfo
rm c
erta
in a
ctiv
itie
s an
d/or
task
s.
E. I
s un
awar
e of
sur
roun
ding
s an
d da
nger
s to
per
sona
l saf
ety
lead
ing
to a
n in
abili
ty to
mak
e sa
fe d
ecis
ions
. Is
una
ble
to a
sses
s th
emse
lves
and
the
situ
atio
n an
d m
ake
an in
form
ed d
ecis
ion
abou
t whe
ther
they
are
at r
isk
or
at ri
sk to
oth
ers.
Doe
s no
t fee
l saf
e in
a s
ocia
l gro
up, s
urro
undi
ngs
or e
nvir
onm
ent.
Rati
onal
e/ev
iden
ce
Stable and
predict
ableSta
ble andunpre
dictable
Unstable and
predict
ableUnsta
ble and
unpredict
able
3 P
rom
oti
on
an
d m
ain
ten
an
ce o
f h
ea
lth
sta
tus
No nursing Management Supervisi
on Actual
Directi
ve
01
23
4
Es
se
nti
al
care
co
mp
on
en
t
Resi
dent
's n
ame
Past r
eview
date.
Use w
ith ca
ution
© 2
004
Roya
l Col
lege
of N
ursi
ng
Cate
gory
: Eat
ing
and
drin
king
A.
Is a
ble
to id
enti
fy a
nd m
ake
choi
ces
abou
t foo
d an
d flu
id p
refe
renc
es a
nd
the
need
to e
at a
nd d
rink
acc
ordi
ng to
hun
ger a
nd th
irst
. Is
abl
e to
man
age
own
eati
ng a
nd d
rink
ing
inde
pend
entl
y.
B.
Wit
h su
ppor
t is
able
to id
enti
fy a
nd m
ake
choi
ces
abou
t foo
d an
d flu
id
pref
eren
ces
and
the
need
to e
at a
nd d
rink
acc
ordi
ng to
deg
ree
of h
unge
r an
d th
irst
. Is
abl
e to
man
age
own
eati
ng a
nd d
rink
ing
once
food
and
aid
es
have
bee
n ar
rang
ed a
nd p
osit
ione
d. A
t som
e ri
sk o
f und
er n
utri
tion
.
C. W
ith
assi
stan
ce, i
s ab
le to
iden
tify
and
mak
e ch
oice
s ab
out f
ood
and
fluid
pr
efer
ence
s an
d th
e ne
ed to
eat
and
dri
nk a
ccor
ding
to d
egre
e of
hun
ger
and
thir
st.
Use
s ai
des
to a
ssis
t wit
h ea
ting
and
dri
nkin
g an
d ne
eds
supe
rvis
ion
in th
eir u
se.
At r
isk
of u
nder
nut
riti
on.
D. I
s un
able
to id
enti
fy a
nd m
ake
choi
ces
abou
t foo
d an
d flu
id p
refe
renc
es
and
the
need
to e
at a
nd d
rink
acc
ordi
ng to
deg
ree
of h
unge
r and
thir
st.
Use
s ai
des
to a
ssis
t wit
h ea
ting
and
dri
nkin
g an
d ne
eds
cont
inuo
us
supe
rvis
ion
in th
eir u
se.
Has
an
esta
blis
hed
feed
ing
prog
ram
me
whi
ch
need
s m
anag
ing.
At h
igh
risk
of u
nder
nut
riti
on.
E. I
s un
able
to id
enti
fy a
nd m
ake
choi
ces
abou
t foo
d an
d flu
id p
refe
renc
es
and
the
need
to e
at a
nd d
rink
acc
ordi
ng to
deg
ree
of h
unge
r and
thir
st.
Nee
ds c
ompl
ete
assi
stan
ce w
ith
eati
ng a
nd d
rink
ing.
In o
rder
to m
aint
ain
nutr
itio
nal s
tatu
s ha
s an
art
ifici
al fe
edin
g pr
ogra
mm
e w
hich
nee
ds
cont
inuo
us s
uper
visi
on.
Rati
onal
e/ev
iden
ce
Stable and
predict
ableSta
ble andunpre
dictable
Unstable and
predict
ableUnsta
ble and
unpredict
able
3 P
rom
oti
on
an
d m
ain
ten
an
ce o
f h
ea
lth
sta
tus
No nursing Management Supervisi
on Actual
Directi
ve
01
23
4
Es
se
nti
al
care
co
mp
on
en
t
Resi
dent
's n
ame
Past r
eview
date.
Use w
ith ca
ution
© 2
004
Roya
l Col
lege
of N
ursi
ng
Cate
gory
: Bre
athi
ng
A.
Is a
ble
to a
tten
d to
dai
ly n
eeds
inde
pend
entl
y.
B.
Expe
rien
ces
brea
thle
ssne
ss.
Is a
ble
to m
ake
adju
stm
ents
to a
ssis
t wit
h br
eath
ing
and
is in
depe
nden
t in
the
use
of th
erap
euti
c tr
eatm
ents
, but
re
quir
es s
uppo
rt w
ith
thei
r pre
para
tion
.
C. E
xper
ienc
es b
reat
hles
snes
s. D
iffer
ing
trig
ger f
acto
rs a
ffec
t deg
ree
of
brea
thle
ssne
ss e
xper
ienc
ed, b
ut is
aw
are
of li
mit
atio
ns a
nd h
ow to
man
age
thes
e. S
omet
imes
requ
ires
oxy
gen
ther
apy.
Nee
ds a
ssis
tanc
e to
mak
e ad
just
men
ts to
env
iron
men
t to
assi
st w
ith
brea
thin
g.
D. E
xper
ienc
es b
reat
hles
snes
s. D
iffer
ing
trig
ger f
acto
rs a
ffec
t deg
ree
of
brea
thle
ssne
ss e
xper
ienc
ed, b
ut is
una
war
e of
lim
itat
ions
and
how
to m
anag
e th
ese.
Nee
ds a
ssis
tanc
e w
ith
the
use
of th
erap
euti
c tr
eatm
ents
and
in
adju
stin
g en
viro
nmen
t to
assi
st w
ith
brea
thin
g.
E. E
xper
ienc
es b
reat
hles
snes
s. D
iffer
ing
trig
ger f
acto
rs a
ffect
deg
ree
of b
reat
hles
snes
s ex
perie
nced
, but
is u
naw
are
of li
mita
tions
and
how
to m
anag
e th
ese.
Som
etim
es
need
s re
gula
r sup
ervi
sed
oxyg
en th
erap
y an
d is
una
ble
to a
sk fo
r thi
s. N
eeds
full
assi
stan
ce in
mak
ing
adju
stm
ents
to o
wn
envi
ronm
ent t
o as
sist
with
bre
athi
ng.
Rati
onal
e/ev
iden
ce
Rati
onal
e/ev
iden
ceCa
tego
ry: E
mot
ion
A.
Abl
e to
exp
ress
em
otio
ns fr
eely
and
app
ropr
iate
ly.
B.
Mak
ing
adju
stm
ents
em
otio
nally
to li
fe s
tatu
s. M
otiv
ated
and
abl
e to
in
itia
te in
tera
ctio
n w
ith
othe
rs.
Expr
ess
emot
ions
free
ly a
nd a
ppro
pria
tely
.
C. H
as n
ot y
et a
djus
ted
emot
iona
lly to
life
cir
cum
stan
ces.
Ide
ntifi
es in
sel
f th
at m
oods
and
em
otio
ns fl
uctu
ate,
but
is a
war
e of
the
stim
uli t
hat c
ause
th
is.
Is a
ble
to e
xpre
ss d
esir
e fo
r em
otio
nal s
uppo
rt.
D. H
as n
ot y
et a
djus
ted
emot
iona
lly to
life
sta
tus.
Iden
tifie
s in
sel
f tha
t moo
ds
and
emot
ions
fluc
tuat
e, b
ut is
una
war
e of
the
stim
uli t
hat c
ause
this
. Is
abl
e to
exp
ress
des
ire
for e
mot
iona
l sup
port
.
E. H
as n
ot y
et a
djus
ted
emot
iona
lly to
life
sta
tus.
Doe
s no
t ide
ntify
in s
elf
that
moo
ds a
nd e
mot
ions
fluc
tuat
e or
the
resu
ltin
g be
havi
our.
Is u
naw
are
of th
e st
imul
i tha
t cau
se th
is a
nd d
oes
not a
ccep
t sup
port
free
ly.
Stable and
predict
ableSta
ble andunpre
dictable
Unstable and
predict
ableUnsta
ble and
unpredict
able
3 P
rom
oti
on
an
d m
ain
ten
an
ce o
f h
ea
lth
sta
tus
No nursing Management Supervisi
on Actual
Directi
ve
01
23
4
Es
se
nti
al
care
co
mp
on
en
t
Resi
dent
's n
ame
Past r
eview
date.
Use w
ith ca
ution
© 2
004
Roya
l Col
lege
of N
ursi
ng
Cate
gory
:
A.
Inde
pend
ent i
n m
anag
ing
addi
tion
al s
peci
fic n
eed.
No
staf
f in
volv
emen
t req
uire
d.
B.
Nee
ds a
ssis
tanc
e to
man
age
spec
ified
nee
d in
rela
tion
to a
dvic
e/gu
idan
ce.
C. N
eeds
ass
ista
nce
to m
anag
e ad
diti
onal
spe
cifie
d ne
ed in
depe
nden
tly
but w
ill p
arti
cipa
te.
D. I
s un
able
to m
anag
e ad
diti
onal
spe
cifie
d ne
ed in
depe
nden
tly
but
will
par
tici
pate
.
E. I
s fu
lly d
epen
dent
on
othe
rs to
man
age
addi
tion
al s
peci
fied
need
.
Rati
onal
e/ev
iden
ce
Rati
onal
e/ev
iden
ceCa
tego
ry:
A.
Inde
pend
ent i
n m
anag
ing
addi
tion
al s
peci
fic n
eed.
No
staf
f in
volv
emen
t req
uire
d.
B.
Nee
ds a
ssis
tanc
e to
man
age
spec
ified
nee
d in
rela
tion
to a
dvic
e/gu
idan
ce.
C. N
eeds
ass
ista
nce
to m
anag
e ad
diti
onal
spe
cifie
d ne
ed in
depe
nden
tly
but w
ill p
arti
cipa
te.
D. I
s un
able
to m
anag
e ad
diti
onal
spe
cifie
d ne
ed in
depe
nden
tly
but
will
par
tici
pate
.
E. I
s fu
lly d
epen
dent
on
othe
rs to
man
age
addi
tion
al s
peci
fied
need
.
Stable and
predict
ableSta
ble andunpre
dictable
Unstable and
predict
ableUnsta
ble and
unpredict
able
4 S
pa
re c
are
co
mp
on
en
ts
Plea
se u
se th
e bl
ank
sect
ions
bel
ow fo
r add
itio
nal
need
s re
quir
ed b
y yo
ur c
lient
s
No nursing Management Supervisi
on Actual
Directi
ve
01
23
4
Es
se
nti
al
care
co
mp
on
en
t
Resi
dent
's n
ame
Past r
eview
date.
Use w
ith ca
ution
© 2
004
Roya
l Col
lege
of N
ursi
ng
Resi
dent
's n
ame
Nur
se a
sses
sor_
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _
Dat
e_ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_
Revi
ew d
ate
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
Sign
atur
e_ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _
Ty
pe
of
nu
rsin
gTo
tal
sco
reR
eg
iste
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nu
rsin
g i
np
ut
(min
ute
s p
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24
ho
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Man
agem
ent
Supe
rvis
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Act
ual
Dir
ecti
ve
To c
alc
ula
te t
he
nu
rsin
g i
np
ut
for
ea
ch a
rea
of
care
:
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se
ss
me
nt
Re
gis
tere
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sco
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t
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0 ho
urs
1-11
=1
hour
12-2
3=
1.2
hour
s
24-4
8=
2.5
hour
s
49-1
00=
4.1
hour
s
Wor
kfor
cepl
anni
ngsu
b to
tal
Tota
las
sess
men
tsc
ore
num
ber o
f m
inut
essp
ent o
n ea
chnu
rsin
g in
terv
enti
on(p
er 2
4 ho
urs)
x=
Tota
l RN
inpu
t(i
n m
inut
es)
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l a
ss
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t s
core
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Pers
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ulfil
men
tSo
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rela
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and
relie
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Com
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con
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and
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No nursing Management Supervisi
on Actual
Directi
ve
01
23
4
3 Pr
omot
ion
and
mai
nten
ance
of h
ealt
h st
atus
Pers
onal
hyg
iene
Dre
ssin
gM
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nSl
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obili
tyEl
imin
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nd fa
eces
Ris
kEa
ting
and
dri
nkin
gB
reat
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Emot
ion
(Opt
iona
l) A
ddit
iona
l cat
egor
y
Wo
rkfo
rce
pla
nn
ing
su
b t
ota
ls
Sub
tota
l
Sub
tota
l
Sub
tota
l
Sub
tota
l
Su
mm
ary
As
se
ss
me
nt
Es
se
nti
al
care
co
mp
on
en
t:
Use
this
cha
rt to
sum
mar
ise
your
ass
essm
ent s
core
sPast r
eview
date.
Use w
ith ca
ution
Past r
eview
date.
Use w
ith ca
ution
Past r
eview
date.
Use w
ith ca
ution
May 2004
Published by theRoyal College of Nursing20 Cavendish SquareLondonW1G 0RN
020 7409 3333
The RCN represents nurses and nursing, promotesexcellence in practice and shapes health policies
Publication code 002 310
Past r
eview
date.
Use w
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ution
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