Brief description of need and source of evidence to support the chosen level Write A, B or C below: Name of individual Date of completion C B A Continence Continent of urine and faeces. OR Continence care is routine on a day-to-day basis. OR Incontinence of urine managed through, for example, medication, regular toileting, use of penile sheaths, etc. AND Is able to maintain full control over bowel movements or has a stable stoma, or may have occasional faecal incontinence/constipation. Continence care is routine but requires monitoring to minimise risks, for example those associated with urinary catheters, double incontinence, chronic urinary tract infections and/or the management of constipation or other bowel problems. Continence care is problematic and requires timely and skilled intervention, beyond routine care. (for example frequent bladder wash outs/irrigation, manual evacuations, frequent re-catheterisation).
C B A Psychological/ Emotional Psychological and emotional needs are not having an impact on their health and OR Mood disturbance or anxiety symptoms or periods of distress, which are having an impact on their health and/or well-being but respond to prompts, distraction and/or reassurance. OR Requires prompts to motivate self towards activity and to engage them in care planning, support and/or daily activities. Mood disturbance, hallucinations or anxiety symptoms or periods of distress do not readily respond to prompts, distraction and/or reassurance and have an increasing impact on the individual’s health and/or well-being. OR Due to their psychological or emotional state the individual has withdrawn from most attempts to engage them in support, care planning and/or daily activities. Mood disturbance, hallucinations or anxiety symptoms or periods of distress that have a severe impact on the individual’s health and/or well-being. OR Due to their psychological or emotional state the individual has withdrawn from any attempts to engage them in care planning, support and/or daily activities. description of need and source of evidence to support the chosen level Write A, B or C below:
Brief description of need and source of evidence to support the chosen level Write A, B or C below: Name of individual Date of completion C B A Drug therapies and medication: symptom control* Symptoms are managed effectively and without any problems, and medication is not resulting in any unmanageable OR Requires supervision/administration of and/or prompting with medication but shows compliance with medication regime. OR Requires the administration of medication (by a registered nurse, carer or care worker) due to: – non-compliance, or – type of medication (for example insulin); or – route of medication (for example PEG). OR Moderate pain which follows a predictable pattern; or other symptoms which are Requires administration and monitoring of medication regime by a registered nurse, carer or care worker specifically trained for this task because there are risks associated with the potential fluctuation of the medical condition or mental state, or risks regarding the effectiveness of the medication or the potential nature or severity of side-effects. However, with such monitoring the condition is usually non-problematic to manage. OR
Mild pain that is predictable and/or is associated with certain activities of daily living; pain and other symptoms do not have an impact on the provision of care. having a moderate effect on other domains or on the provision of care. Moderate pain or other symptoms which is/are having a significant effect on other domains or on the provision of care. Brief description of need and source of evidence to support the chosen level Write A, B or C below: Name of individual Date of completion C B A
Altered states of consciousness* No evidence of altered states of consciousness (ASC). OR History of ASC but effectively managed and there is a low risk of harm. Occasional (monthly or less frequently) episodes of ASC that require the supervision of a carer or care worker to minimise the risk of harm. Frequent episodes of ASC that require the supervision of a carer or care worker to minimise the risk of harm. OR Occasional ASCs that require skilled intervention to reduce the risk of harm. description of need and source of evidence to support the chosen level Write A, B or C below: Total from all pages