Nursing assessment and older people - rcn.org.uk · and process,good,contemporary nursing practice.The introduction of the registered nursing care contribution (RNCC) in England (DH,2001)

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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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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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

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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


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.


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


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.


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


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.


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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


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.


15

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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


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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.


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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.

18


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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


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

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© 2

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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


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


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


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


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


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


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


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


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


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

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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

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eview

date.

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ith ca

ution

Documents

Nursing assessment and older people - rcn.org.uk · and process,good,contemporary nursing practice.The introduction of the registered nursing care contribution (RNCC) in England (DH,2001)