Admission of a resident to an aged care facility requires -a comprehensive assessment

QUESTION

Mr Ivan Jones, 82 years old, is admitted in your aged care facility this morning from his independent living setting. The referral letter from his physician reveals that he has the following medical history: – Hypertension maintained at around 130/90 mm of Hg with Captopril and dietary management, Diabetes mellitus on medication management and diet control, Myocardial infarction, Hemiparesis of the left side of the body following a stroke in 2013 and had three (3) falls last month with mild to moderate muscular injuries and bruises. Due to increased falls at home and risk in doing self-medication, Ivan has been suggested to move to a residential care facility. Ivan is now in the visitor’s room with his daughter, Ms Colleen Jones. The Registered Nurse asked you to assist Ivan with the transition from his home to the new residential setting.

Ivan appears anxious but is responding to RNs questions appropriately. He is lean and tall and is properly dressed. He walks with his zimmer frame at home and needs his daughter to help him with this. He uses a wheelchair for outdoor. Ivan has partial hearing impairment and uses hearing aids in his left ear. He uses reading glasses. He also has upper partial dentures insitu and tolerates diabetic diet, texture modified to a soft diet. Easy to swallow. Till now the daughter was helping him with his personal hygiene, shopping and home chores. He smokes 4 cigarettes per day.

As per your aged care facility’s policies and procedures in relation to admission, the development of a Nursing Care Plan (NCP), doctor’s review and medication chart would be finalised over a week’s time. This time is utilised to collect information relating to the resident’s physical health status and general well-being. The information gathered must be discussed with the RN who will work with the resident, family and the healthcare team in developing an appropriate NCP for the resident.

You are required to perform the following activities as part of this task and submit the completed forms and templates as additional evidence. The assessor will complete an observation checklist for each task based on the demonstrated skills:

ANSWER

Introduction

The admission of a resident to an aged care facility requires a comprehensive assessment of their physical health status and overall well-being. In the case of Mr. Ivan Jones, an 82-year-old man, his medical history includes hypertension, diabetes mellitus, a history of myocardial infarction, hemiparesis following a stroke, and recent falls. This essay aims to address the activities involved in Mr. Jones’ admission process, including the development of a Nursing Care Plan (NCP), doctor’s review, and medication chart.

Activities Involved in the Admission Process

Collection of Information

The first step in Mr. Jones’ admission process is to collect information about his physical health, medical history, functional abilities, and support needs. This information is crucial for understanding his current health status and developing an appropriate NCP. The information should be gathered through interviews with Mr. Jones, his daughter, and relevant medical documents provided by his physician.

Collaboration with Registered Nurse (RN)

The collected information must be discussed with the RN responsible for developing the NCP. This collaboration ensures that the RN has a comprehensive understanding of Mr. Jones’ health needs, preferences, and goals. The RN will work closely with the resident, family, and healthcare team to develop a personalized NCP that addresses his specific requirements.

Development of Nursing Care Plan

The NCP is a document that outlines the nursing interventions and care goals for the resident. It includes assessments, problem identification, goals, interventions, and evaluation methods. The NCP for Mr. Jones should address his hypertension management, diabetes control, falls prevention, assistance with mobility, personal hygiene support, and smoking cessation strategies.

Doctor’s Review

During the admission process, it is essential to involve the resident’s physician in reviewing their medical history, current medications, and care requirements. The doctor’s review ensures that the resident’s medical conditions are adequately managed and that any necessary adjustments to their medication regimen are made.

Medication Chart

A medication chart is prepared to document the resident’s medication orders, including the name, dosage, route, frequency, and any special instructions. The chart is essential for ensuring accurate administration of medications and monitoring for any potential drug interactions or adverse effects.

Conclusion

The admission process for Mr. Ivan Jones involves collecting comprehensive information about his health status, collaborating with the RN to develop a tailored NCP, involving the physician in the review of his medical history and medications, and preparing a medication chart. These activities are vital for ensuring the provision of person-centered care and addressing Mr. Jones’ specific health needs and support requirements. By following the facility’s policies and procedures, the healthcare team can facilitate a smooth transition for Mr. Jones into the residential care setting and provide him with the necessary support for his well-being.