ASSESSMENT - HIGH INTENSITY CARE

Client Details

First Name:

Last Name:

Date of Birth:

Phone Number:

***

Street Address:

City:

State:

Postcode:

High Intensity Supports and Comments

Complex Bowel Care

NoYes

Comments:

Enteral (Naso-Gastric Tube – Jejunum or Duodenum) Feeding and Management

NoYes

Comments:

Tracheostomy Management

NoYes

Comments:

Urinary Catheter Management

NoYes

What type of Catheter?

In-dwelling Urinary CatheterIn-out CatheterSuprapubic Catheter

Comments:

Ventilator Management

NoYes

Comments:

Subcutaneous Injections

NoYes

Comments:

Complex Wound Management

NoYes

Comments:

Other High Intensity Supports

NoYes

Comments:

Risk Management

Risks to participant:

Risks to staff:

Risks to others:

Environmental risks:

Risk Treatment

PPE (Personal Protective Equipment):

Environmental Treatments:

Escalation

Spill Kit:

In participant's homeMobile (with worker)

Clinical Waste Management:

In participant's homeMobile (with worker)

Primary escalation contact:

Primary escalation contact's phone number:

Secondary escalation contact:

Secondary escalation contact's phone number:

Other / Comments:

Routine Health Checks

Do you consent to regular health checks?

NoYes

I consent for a health practitioner to check my health every:

3 months6 months12 months

I understand that I can change my mind if I want to.

Participant / Participant's nominee Signature *

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Date:

Supervising health care worker's name:

Supervising health care worker's phone number:

Method of feeding:

GravityBolusPump

Position during feeding:

Frequency of feeds:

Feeding plan from dietician available:

YesNo

Name of feed:

Dietician name:

Date tube originally inserted:

Hospital where tube originally inserted:

Date of last tube change:

Changed by:

Anticipated next change of tube:

Current condition of tube:

GoodPoor

Frequency of checking water in balloon:

Previous / Current Issues

Has there been blockage of tube?

YesNo

Details:

Has there been leakage around tube?

YesNo

Details:

Has the tube fallen out?

YesNo

Details:

Health Status of Participant

Is the feed tolerated?

YesNo

Details:

Any coughing during feeds?

YesNo

Details:Please give further details of any coughing during feeds.

Any vomiting?

YesNo

Details:Please give further details of any vomiting.

Any nausea?

YesNo

Details:Please give further details regarding the Nausea

Any bowel movements?

ConstipationDiarrheaAbdominal bloating

Details:Please details Bowel Movements:

Any inflammation, swelling, pain, redness, or oozing or leakage around the tube site?

YesNo

Details:Please give further details regarding any Inflammation, swelling, pain, redness, or ozing or leakage around the tube site:

History of chest infection / aspiration:

YesNo

Details:Please give further details regarding any history of chest infection / aspiration

Infection / aspiration treated with antibiotics?

YesNo

Details:Please give further details regarding any infection / aspiration treated with antibiotics.

Are there any relevant hospitalisations?

YesNo

Details:Please give further details regarding any relevant hospitalisations:

Comments

Registered Nurse's Name:

Date:

Registered Nurse's Signature:

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