Physical health policy

1 Introduction

1.1 Rationale

Rotherham Doncaster and South Humber NHS Trust (RDaSH) provides a variety of services beyond mental health and learning disability services, such as community integrated services. The physical health services that the trust has diversified into will have assessment of physical health needs and interventions at the very core of their care provision and will build upon the previously developed networks with primary and secondary care to maintain health and wellbeing. This policy focusses on the specialist mental health and learning disability service provision within RDaSH to ensure that assessment and intervention meets patient need and reflects research, guidance, policy and legislation as detailed below.

Individuals diagnosed with severe mental illness (SMI1) are not consistently offered appropriate or timely physical health assessments despite facing one of the greatest health inequality gaps in England. The life expectancy for people living with SMI is 15 to 20 years lower than the general population. The largest avoidable cause of death is smoking, more than 40% of adults with SMI smoke. People with SMI have:

double the risk of obesity and diabetes
three times the risk of hypertension
five times the risk of dyslipidaemia compared to the general population (NHS England, 2018)

The five-year forward view for Mental Health has highlighted the lack of access to physical healthcare for people with mental health problems (NHS England, 2016). Despite their higher risk of poor physical health, individuals with SMI are not consistently offered appropriate or timely physical health assessments (NHS England, 2016).

People with learning disabilities have poorer physical health than those without a learning disability. The Conﬁdential Inquiry into the deaths of people with learning disabilities (CIPOLD) found that men and women with learning disabilities died 13 and 20 years earlier respectively than their counterparts in the general population (Heslop et al., 2013). Other key findings from CIPOLD include:

22% were under the age of 50 when they died
42% percent of deaths were identified as being premature due to delays with diagnosis or treatment and problems with identifying needs and providing appropriate care in response to changing needs (Heslop et al., 2013)

Regrettably, being in contact with mental health services does not necessarily mean that people will have a physical health assessment, have their physical health monitored, or receive the information and support they need to adopt a healthier lifestyle. Mental health nurses or clinical staff have unparalleled opportunities to help people improve their physical health alongside their mental health, both in inpatient settings and in the community.

1.2 Care planning and physical health and wellbeing

Although care programme approach (CPA) (Department of Health, 2008) is being replaced, the guidance emphasises the importance of physical health needs always being assessed and addressed as a high priority and considered as part of a holistic care plan.

Assessments and care plans should identify and tackle the impact that mental illness symptoms and possible treatment programmes can have on physical health and the impact that physical symptoms can have on an individual’s mental wellbeing. This includes an awareness of physical complications associated with common psychiatric conditions and treatments such as lithium, clozapine, electroconvulsive therapy (ECT), rapid tranquillisation and high dose medications, especially antipsychotics.

1.3 Ongoing assessment and follow-up of physical health needs

Incapacity arising from physical illness or disability is one of the identified core risk domains within the clinical risk assessment and management policy. Whilst the assessment of risk is a continuous process, a formal assessment of risk must be completed at the point of referral, at each subsequent CPA or alternative equivalent review or when prompted by a significant change of circumstances, for example, admission, discharge, movement between services, shared care etc. See clinical risk assessment and management policy.

1.4 Making every contact count

Making every contact count (MECC) encourages conversations based on behaviour change methodologies (ranging from brief advice, to more advanced behaviour change techniques). It is about making the best of every appropriate opportunity to raise the issue of healthy lifestyle, for example, smoking cessation, healthy eating, and physical activity. Making every contact count (opens in new window).

2 Purpose

The purpose of this trust policy is to improve the physical health and wellbeing of mental health and learning disability patients and reduce health inequalities wherever possible through:

a consistent approach to inpatient physical assessment and examination
a consistent approach to the assessment of physical health for community patients
promoting timely access to expert advice and specialist services when specific conditions are already established or identified in the course of assessment

3 Scope

This policy applies to all clinical staff who have a responsibility for providing and promoting good physical healthcare in the following areas:

All clinical staff in mental health (adult and older people), learning disability and drug and alcohol services provided by the trust, delivering inpatient care working to undertake or contribute to the physical assessment and examination of patients and who are responsible for facilitating appropriate follow-up of physical symptoms
RDaSH community clinical staff working in mental health (adult, older people and child and adolescent mental health services (CAMHS)), learning disability and drug and alcohol services

Some aspects of implementation may differ between services.

This policy does not apply to improving access to psychological therapy (IAPT) services as patients falling under these services are unlikely to have SMI or other chronic mental health problems requiring secondary mental health or learning disabilities input, and as such are not within the target population of the key national guidance and policies driving this policy. These individuals are unlikely to have impeded access to or engagement with physical healthcare services.

4 Responsibilities, accountabilities and duties

4.1 Board of directors

The board of directors is responsible for the trust having policies and procedures in place to promote best practice and meet national and local requirements.

4.2 Physical health and wellbeing strategy group

The role of the physical health and wellbeing strategy group is:

to drive the physical health and wellbeing agenda
to promote national guidance and standards to improve the physical health of patients
to review and communicate the learning from physical health related mortality and morbidity of patients
representatives to promote the delivery of physical health CQUIN targets within their care groups
representatives to communicate agreed actions within their care groups and to provide updates on progress
to provide assurance on the delivery of physical health and wellbeing priorities

4.3 Care group directors

Care group directors are responsible for:

the effective implementation of this policy in their areas of responsibility
the implementation of any action plans arising from audits of the policy, which are undertaken at least annually
identifying training needs of nursing staff and other staff colleagues that fall within the remit of this policy

4.4 Modern matrons or service managers

Modern matrons or service managers are responsible for:

advising and instructing nursing staff on the policy requirements via local induction arrangements and ongoing communication mechanisms, such as staff meetings, supervision, etc
the purchase, maintenance and availability of the medical equipment which is necessary for undertaking the physical assessment and examination of patients specified in appendix A

4.5 Team or ward managers

Team or ward managers are responsible for making staff aware of this policy and monitoring adherence to its contents.

4.6 Care group medical directors

Care group medical directors are responsible for:

the effective implementation of this policy in their areas of responsibility
the implementation of any action plans arising from audits of the policy
identifying training needs of medical staff that fall within the remit of this policy

4.7 Consultants (medical and non-medical) working in inpatient services

Consultants working in inpatient services are responsible for:

confirming whether an appropriate physical examination has taken place at admission or within 24 hours of admission (Royal College of Psychiatrists, 2017)
supervision of the doctors in training, staff and associate specialist doctors and other clinicians in regard to the effective implementation and audit of this policy
ensuring physical assessment and examination is provided at least annually to any patient in their care who is an inpatient for one year or longer

4.8 Medical staffing department

The medical staffing department is responsible for the induction of medical staff, including doctors in training, in regard to this policy.

4.9 Admitting clinician

The admitting clinician is responsible for:

explaining to patients the importance and purpose of the physical assessment and examination, and keeping them informed of the outcomes
completing the physical assessment and examination of all new patients on admission, or where this is not possible, for arranging for it to be completed within 24 hours of admission (Royal College of Psychiatrists, 2017)
making a comprehensive record within the inpatient physical health examination template in the electronic patient record (EPR, currently SystmOne)
appropriate following up of physical symptoms by undertaking or requesting any blood or further test(s) that are deemed necessary and for referring to specialist services or primary care for expert advice or input as required

4.10 Clinical staff

Clinical staff are responsible for the implementation of this policy.

4.11 Acute and primary liaison learning disabilities nurses

The acute and primary liaison learning disabilities nurses will facilitate:

support people with learning disabilities in both primary and secondary care
health promotion or health experience groups
health action planning
monitoring of annual health checks
updating of general practice (GP) registers
GP practices having a learning disability (LD) resource file
training in learning disability awareness, hospital and primary care passports in primary and secondary health care, emergency services and the independent sector
easy read literature to support the individual with their health

4.12 Care coordinator or lead professional

The responsibilities of the care coordinator or lead professional are:

offer signposting to health promotion for common conditions relevant to their patients or health promotion offered directly if appropriate
care coordinators (or lead professionals if the sole mental health professional involved) liaise with the patient’s GP every year to ensure an annual physical health assessment or examination has been carried out. If it is not possible for physical health assessment or examination to take place in primary care, alternative arrangements should be made for patients to have a physical assessment within secondary care where possible, for example, non-engagement with primary care due to mental health problems, not being registered with a GP due to mental health problems, homelessness etc.
communicate physical health needs back to primary care and facilitate access to screening and health improvement interventions in primary and secondary care when appropriate
assess and record physical health needs and outcomes within the physical health check (PHC) tool on the EPR
work in partnership with voluntary and statutory sector providers to improve physical health outcomes
obtain results of physical checks from primary care
responsibilities may vary between services depending on local arrangements; some of these functions may initially be undertaken by single point of access or through physical health clinics

5 Procedure and implementation

5.1 General principles

The PHC is not the same as medication-related monitoring but is the assessment captured on the EPR via the RDaSH physical health check template. It covers:

smoking, alcohol and substance misuse
body mass index (BMI), bloods, blood pressure, pulse and electrocardiogram (ECG)
diet and exercise and access to healthcare (eye test, bowel screening, contact with physical health services)
current physical symptoms
family history (ischaemic heart disease, stroke, cancer, diabetes)
sexual health education and screening (prostate, testicles, pregnancy, breasts and smear)

In using the PHC tool staff can be assured that the minimum standard of observations identified by the Lester antipsychotic monitoring guidance and the cardiometabolic screening will be met as well general health screening and promotion necessary for the SMI population.

Carers and family should be involved in the patient’s physical healthcare.

This could include:

enabling carers or family to provide staff on the ward with information about the patient’s physical health
access to clear information on what general physical health assessments are carried out when a patient is admitted to the ward
access to health lifestyle advice and how carers or family can support good physical health
with patient consent, patients and their carers or family can:
- receive updates on the patient’s physical health including transfer to physical healthcare settings
- feel able to ask questions about the patient’s physical health needs
- contribute to the development of or receive a copy of the patient’s physical health care plan
- receive clear information about any post-discharge follow-up physical health plans
avoiding unnecessary separation of patients with dementia from their carer or family member across healthcare settings (from community clinics to inpatient units), supporting carers or family of people living with dementia (or patients with intellectual disability) staying on wards throughout the 24-hour period.

The above approach of including carers and family in the patient’s care is in keeping with the principles of the triangle of care and the trust’s pledge in supporting John’s campaign (opens in new window).

5.2 Mental health inpatient services (adult, older people and forensic)

5.2.1 Requirements for physical assessment and examination of patients on admission to a service, including timeframes

All Inpatients should receive a comprehensive physical health review starting within 4 hours of admission, or as soon as practically possible. This should include the following,

5.2.1.1 Clinical history

Medical history, details of existing physical health conditions and any acute changes since the last clinical review
Medications, physical and mental health medication reconciliation (within 24 hours; NICE, 2016), their side effects, adherence and prescribing
Allergies and sensitivities
Substance use history, this includes smoking, alcohol, illicit substances and misuse of prescribed or acquired medications
Level of physical activity
sexual health history, immunisation status, oral health history as appropriate

5.2.1.2 Examination

Physical examination, full systems examination; it is expected that this is completed with 4 hours of admission. Where it is not possible to complete it within this timeframe, the admitting clinician must make arrangement for it to be completed within 24 hours of admission.
Baseline observations including blood pressure, heart rate, respiratory rate, temperature, oxygen saturation and level of consciousness using the national early warning score (NEWS2)

5.2.1.3 Investigations

Height, weight, relevant blood tests (use recent blood tests if appropriate) and an ECG within 24 hours of admission (see appendices B and C).
Consideration of other investigations where appropriate such as blood glucose, urine dipstick, urine drug screen, pregnancy test, blood-borne viruses.

5.2.1.4 Assessment and management

Venous thromboembolism (VTE) assessment within 14 hours (see VTE policy)
Nutritional status, malnutrition universal screening tool (MUST) within 24 hours (see nutrition policy)
Falls risk assessment within 12 hours (see falls risk assessment and management policy)
Tissue viability assessment within 6 hours, may be extended up to 12 hours if the service user’s mental health state will not allow it to be undertaken within 6 hours (see tissue viability and wound care manual)
Hydration status or fluid balance
Dysphagia, If the admission process (history and examination) as completed within 24 hours identifies adverse signs that may indicate dysphagia, complete a referral to the Speech and Language Therapy team (see dysphagia management policy)
Whether the patient is at risk of withdrawal from drugs or alcohol
Assessment for acute risks to their physical health, including physical health risks associated with rapid tranquilisation and take appropriate action
Review of cardiopulmonary resuscitation (CPR) status where applicable (see do not attempt cardiopulmonary resuscitation procedure)

5.2.1.5 Physical health care plan

Within 24 hours of admission to a mental health inpatient setting, start to collaboratively develop and document an initial physical healthcare plan with every patient, based on their initial physical health assessment. Where required a more comprehensive physical health care plan should be completed within 7 days of admission. Where applicable include:

the most appropriate healthcare location to treat the patient’s physical healthcare needs (for example, mental health or physical health hospital)
monitoring and treatment plans, including:
- how frequently to review the physical health risk assessment, recognising acute or chronic health conditions
- how often to repeat physical health observations
- a nutrition plan
the physical health support needed
escalation plans in the event of deterioration (linked to the NEWS2 score) or patient not consenting to be assessed, that include who to contact and when
identification of gaps in clinical history and a plan to address them

The physical examination for patients admitted to new beginnings, aspire drug and alcohol services, is undertaken prior to admission and documented in their appropriate records.

For details of which aspects of the physical examination can be undertaken by the relevant staff and recommended blood investigations for specific services see appendices A and B. Guidance for nursing staff on standard examinations and required actions can be found in appendix D.

The medical equipment recommended to carry out the assessment and examination is listed in appendix A.

The use of Oxevision can be used to supplement physical health observations taken in line with this policy, not as an alternative to the standard practice for assessing physical health observations where indicated.

All physical observations taken at the time of admission must be recorded on the trust physical observation and neurological observations charts in the baseline column.

When undertaking a physical examination the individual patient’s needs are to be considered in respect of where and how the physical examination is conducted.

Where it is not possible to complete the physical assessment and examination at the time of admission, this should be recorded in the patient’s clinical record.

If the patient refuses to consent to a physical assessment and examination this should be recorded in their clinical record. The admitting clinician should still make a record of basic observable physical signs, such as levels of consciousness, respiratory rate, skin colouring or condition etc.

Consideration must be given whether the patient has the capacity to make the decision: to agree or refuse a physical assessment and examination. If the patient lacks capacity to consent to a physical assessment and examination, follow the principles of the Mental Capacity Act 2005 and ensure that a decision is made in the person’s best interests. If the patient has the mental capacity to consent to undergo a physical health assessment but refuses, document this then and try again as soon as practicable.

In the event that a patient is admitted from another hospital or the accident and emergency department, (A and E department) and a physical assessment and examination was conducted there, a copy of this will be filed or scanned in the patient’s clinical record.

In cases where the patient has a pre-existing physical condition for which they are receiving treatment, the admitting clinician will liaise with the patient’s general practitioner or specialist service to gather additional information where shared electronic records are unable to safely provide this. If such liaison is not immediately possible for out-of-hours admissions, this will need to be completed within the working hours of the service being contacted. If this pre-existing condition impacts on the patient’s physical observations a normal parameter exception care plan must be completed. This should also inform prescribing and reduce the risk of deterioration in health due to incorrect or inaccurate prescribing of such medications as anticonvulsants, anticoagulants, opiates leading to withdrawal symptoms.

In cases where the patient is a current smoker, they should be informed of the trust’s smoke free policy and offered nicotine replacement therapy within 72 hours of admission in accordance with the RDaSH guidelines for nicotine replacement therapy (NRT). If an in-house smoking cessation service is available, the referral should be made within 24 hours of admission. If there is no established internal smoking cessation service in place, smokers should be provided with NRT and e-cigarettes free of charge throughout of the duration of their in-patient stay and referred to the community smoking cessation services on discharge.

Patients with SMI should still have an annual PHC completed by inpatient staff, captured on the appropriate template on SystmOne, if due whilst an inpatient.

5.2.2 During the hospital stay

Staff must ascertain if there is an existing ‘physical health plan’ in place by either checking the shared record or contacting the GP. If a plan is available it must be utilised for the period of admission.

Side effects of antipsychotic medication are reviewed using the Glasgow antipsychotic side effect scale (GASS) (available in the EPR) or the side effects neuroleptic medication rating scale, easy read version as per the safe and secure handling of medicines policy.

5.2.3 How appropriate follow-up of physical symptoms takes place

Where any ongoing need has been identified in respect of a patient’s physical health, a care plan is to be put in place which must clearly state:

what the identified need is
how this identified need is to be met
signs of deterioration and action to be taken by staff
what information is to be provided to the patient?
who to contact should further advice be required

The care plan will then be reviewed and evaluated within the Multidisciplinary team (MDT) or ward review meetings with the patient and carers (with patient consent).

If a patient requires a referral to another department or hospital for review or treatment the referring clinician must record in the clinical records:

date of referral
who the referral was made to and contact details
date for when they will review the progress of the referral

It is the responsibility of the referrer to ensure that any referral they make is received and acted on.

5.2.4 Transfers between mental health inpatients settings and physical heath hospitals

For patients requiring transfer to, and readmission from, a physical health hospital, there should be a comprehensive clinical summary prepared to accompany the patient which includes, but is not limited to:

physical and mental health condition(s)
current physical and mental health care plans
physical and mental health medications and allergies
monitoring and escalation plans
a mental health capacity assessment and the status of mental health legislation (if applicable)

5.2.5 Ongoing physical health monitoring

All health needs should be incorporated into the care plan with clear actions, review dates and responsibilities.

The care plan should consider symptoms, progress and treatment for long term physical conditions, for example, diabetes, hypertension, and arthritis. This should be reviewed with the patient and documented by medical staff (frequency of review should be recorded in the care plan).

Weight and blood pressure (BP) should be checked and recorded a minimum of monthly, or more frequently for patients considered at risk.

Patients should be encouraged to access dental care, chiropody, audiology, dietetics, sexual health counselling and optician where appropriate.

If a referral to a primary care provider, for example, dentist is required, the patient should be supported to make an appointment and attend where appropriate.

5.2.6 Ongoing assessment of physical health needs of patients who remain in the inpatient services for a year or longer

Any patient who is within the inpatient service for a year or longer, will be provided with a physical assessment and examination at least annually organised by the consultant in charge of their care. This will normally be delegated to the relevant ward doctor or other appropriately trained clinician.

5.2.7 Chaperones

For any consultation, examination, procedure, treatment or care that is of an intimate nature, a chaperone should be offered. Obvious examples of an intimate examination include examination of the breasts, genitalia and the rectum. The patient should be given the opportunity to state their preferences in relation to the sex of the chaperone. This must be documented in their health records.

This precaution is particularly important where patients are intoxicated with alcohol or other substances or are elated, and as a consequence may be sexually disinhibited or may misconstrue situations.

Details of any examinations or procedures should be recorded in the patient’s clinical record and the presence or absence of a chaperone recorded, including the name of the chaperone.

See chaperoning policy.

5.2.8 Consent

It is important that patients have a clear understanding of the importance and purpose of the physical assessment and examination and are kept informed of the outcomes. See consent to care and treatment policy.

Where there are concerns about a person’s capacity to consent staff should apply the Principles of the Mental Capacity act 2005 (MCA).

See Mental Capacity Act policy.

5.2.9 Discharge from inpatient care

It is the responsibility of the inpatient consultant, supported by the Multidisciplinary team (MDT) to communicate any modified or existing physical health care plan, including any investigations and their outcomes to the patient’s GP and Community team.

5.3 Community teams (adult mental health, older people’s mental health, CAMHS, learning disability, drug and alcohol services)

As part of their mental health review and assessment on SystmOne (formerly known as the full needs assessment) or annual review (whichever is applicable), all patients should be asked about their tobacco and alcohol use. Identified smokers should be given brief advice and referred to a smoking cessation service where appropriate. Patients identified as drinking above low risk levels should be given brief advice or offered a specialist referral.

For many community mental health patients; physical healthcare will be delivered via the GP or other primary care services. The following patients will be offered an annual PHC by RDaSH in the first instance:

those meeting SMI criteria
those who are on the first episode of psychosis pathway

RDaSH should approach the patient’s GP to ascertain if any health checks have already been completed to avoid duplication and any inconvenience for the patient. The assessment must be recorded using the PHC tool in the EPR and the PHWB care plan shared with the GP.

However, patients subject to a shared care agreement for PHCs will have their PHCs completed by their GP; these arrangements are subject to local agreement with the respective integrated care board (ICB). The following principle has been used to inform shared care arrangements for PHCs:

patients who receive secondary care mental health services that fulfil criteria for SMI will be encouraged to register with their GP and advised to make effective use of the primary care physical health review. For patients who are taking antipsychotic medication, RDaSH maintains responsibility for monitoring their physical health and the effects of antipsychotic medication for at least the first 12 months or until the person’s condition has stabilised, whichever is longer. Thereafter, the responsibility for this monitoring may be transferred to primary care under local physical health shared care arrangements

Side effects of medication are reviewed using a validated rating scale, for example, GASS (in the EPR) or the side effects neuroleptic medication rating scale, easy read version.

5.4 Early interventions in psychosis

Early intervention service patients will be offered a specific comprehensive physical health assessment as per NICE standards including:

comprehensive physical health assessment within 12 weeks for adults having treatment for first episode of psychosis
12 month review repeated annually until discharge or transfer of care (NICE, 2015b)

5.5 Learning disability services

Patients with a learning disability access the Learning Disability Health Action team and have an annual health check with their GP. Community nurses will complete a physical health assessment with the patient who will be given the back page which documents the actions required; this is also sent to the GP Practice.

5.6 Older people’s mental health services

Older adults, frail adults and adults with dementia, referred into a community team service for older people’s mental health provision will have an initial physical health history and physical examination by their GP and Primary Care team, which is shared with RDaSH in the patient’s referral.

Primary care would be expected to undertake physical health checks where it forms part of an annual shared care monitoring arrangement. Secondary care services are responsible for physical health monitoring where it does not fall under a shared care agreement and is condition or medication specific.

5.7 Drug and alcohol services

Though the PHC assessment tool on the EPR is not currently used by the service, patients will have assessments that review:

registration with GP
physical health history, including any current illnesses, long term conditions and disabilities
risks to health from current and past substance use will be assessed, for example, overdose, blood-borne viruses (BBVs), injecting related problems, severity of dependence and withdrawal
disability issues that may affect engagement, for example, mobility problems, eyesight problems, hearing loss
smoking
pregnancy
contraception
sexual health risks
dental and oral health problems

Tests or investigations (if relevant to the individual) may include:

urine drug testing
breathalyser
BBVs (with appropriate pre-test discussion)
LFTs

Patients undergoing only psychological or psychosocial treatment will not routinely receive further medical or nursing assessment.

5.8 CAMHS

Children and young people with bipolar disorder, psychosis or schizophrenia should be given healthy lifestyle advice at diagnosis and at annual review. They should also have their treatment monitored for side effects (with baseline physical health investigations, 12 weeks after starting treatment and every 6 months; NICE 2015c).

Physical health assessments are currently undertaken by way of a focussed history enquiring about the child’s medical history and any family history of physical illness. Further physical health checks and assessments are determined by any prescribed medication and associated monitoring.

Children under community eating disorder services have the following undertaken as part of their initial assessment:

height, weight, percentage median BMI
blood pressure and pulse (sitting and standing for both)
bloods investigations: full blood count, urea and electrolytes, blood glucose, lipid profile, magnesium, bone profile, liver function test, thyroid function test, vitamin B12, folate, ferritin, amylase
ECG

Blood investigations are repeated as clinically indicated. At the start of treatment, weight and sitting and standing blood pressure is checked weekly. Further monitoring is determined by clinical progress. An ultrasound scan of the pelvis and DEXA bone scan may be considered dependent upon clinical factors.

6 Training implications

6.1 How the organisation assesses the competency of all staff involved in the physical assessment and examination of patients

In order for practitioners to be competent to safely carry out the required investigations the RDaSH clinical skills team have provided educational programmes, clinical skills packages based on The Royal Marsden’s Hospital manual of clinical nursing procedures, training resources and assessment tools to support proficiency in each essential skill.

6.2 Training needs and responsibilities

Whilst there are no specific training needs identified in relation to this policy, inpatient clinical staff will be made aware of their individual responsibilities in the following ways:

at induction for trainee doctors and newly qualified nurses
details of the policy review will be published in the trust’s daily emails
staff attendance at the physical health and wellbeing training

Training and awareness sessions include:

trust induction (health and wellbeing session)
life support training (as specified by the staff training matrix)
clinical skills training
recognising and assessing medical problems in psychiatric settings (RAMPPS)

Other requirements identified by the member of staff and manager may include:

wellness and recovery action planning (WRAP)
making every contact count (MECC)
medicines management
dysphagia
falls
behaviour change and motivational interviewing
smoking cessation (very brief advice)
malnutrition universal screening tool (MUST) training
pressure sores
frailty

7 Monitoring arrangements

7.1 Physical assessment of patients when they are admitted to a service, including time frames

How: Clinical audit.
Who by: Clinical audit department.
Reported to: Quality committee.
Frequency: Annually.

7.2 How appropriate follow-up of physical symptoms take place

How: Clinical audit.
Who by: Clinical audit department.
Reported to: Quality committee.
Frequency: Annually.

7.3 Ongoing physical assessment of physical needs for all patients, including timeframes

How: Clinical audit.
Who by: Clinical audit department.
Reported to: Quality committee.
Frequency: Annually.

7.4 Availability of medical examination equipment on inpatient wards

How: Clinical audit.
Who by: Clinical audit department.
Reported to: Quality committee.
Frequency: Annually.

7.5 How the trust assesses the competency of all staff involved in the physical assessment and examination of patients

How:
- clinical audit
- staff training attendance
- monitoring complaints
- discussion and review of patients care in clinical supervision
Who by:
- clinical audit department
- consultants
Reported to: Quality team.
Frequency: Annually plus ongoing.

7.6 Physical health assessments for community patient

How: Audit via SystmOne (EPR).
Who by: Clinical audit department.
Reported to: Quality committee.
Frequency: Annually.

7.7 Implementation of serious incident action plans that include physical health care

How: Review of action plans.
Who by: Care group directors.
Frequency: Quarterly.

8 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

8.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’. Consequently, the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity, and respect, (when appropriate this should also include how same sex accommodation is provided).

8.1.1 Indicate how this will be met

No issues have been identified in relation to this policy.

8.2 Mental capacity act

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individual’s capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all colleagues working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason, all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005)to ensure that the rights of individual are protected, and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

8.2.1 Indicate how this will be achieved

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005) (section 1).

9 Associated documents

10 References

11 Appendices

11.1 Appendix A Medical equipment

Adequate physical assessment requires appropriate and fully functioning medical equipment to be available within all inpatient services. The equipment recommended to undertake the examinations outlined in this policy include:

examination couch
ophthalmoscope
auroscope
stethoscope
sphygmomanometer
thermometer
tendon hammer
height measure
weighing scales
urinalysis sticks
tuning forks (128 Hz)
neuro-tips
disposable gloves

The availability and maintenance of this equipment is the responsibility of the modern matrons and service manager in conjunction with the ward manager and should be listed on the ward’s medical devices inventory.

See medical devices management policy.

11.2 Appendix B Medical and nursing assessment responsibilities

Aspects of the physical assessment or examination which can be carried out by either medical or nursing staff.

These include:

weight
height
body mass index (BMI), calculated from the patient’s weight and height
pulse
blood pressure
level of consciousness, using the Glasgow coma scale (if indicated) (doctor only), nursing staff to use AVPU (alert, verbal, pain, unresponsive)
completion of medication reconciliation
urine testing
respiration rate
smoking history
all staff who note bruising on admission, transfer or discharge to and from an inpatient setting must record this on a body map on the electronic patient record. Also record of skin condition, including any cuts other wounds and details as to how these occurred
oxygen saturation levels
ECG, all inpatients should be offered an ECG on admission (Royal College of Psychiatrists, 2017). This should be completed within 24 hours of admission.
temperature
VTE assessment within 14 hours (see VTE policy)
nutritional status, malnutrition universal screening tool (MUST) within 24 hours (see nutrition policy)
falls risk assessment within 12 hours (see falls risk assessment and management policy)
tissue viability assessment within 6 hours, may be extended up to 12 hours if the service user’s mental health state will not allow it to be undertaken within 6 hours (see tissue viability and wound care manual)
hydration status and fluid balance
Dysphagia, if the admission process (history and examination) as completed within 24 hours identifies adverse signs that may indicate dysphagia, complete a referral to the Speech and Language Therapy team (see dysphagia management policy)
recording of NEWS2 (see resuscitation manual)

Nursing staff can undertake observations for the following:

neurological examinations following neurological observations documentation
basic extrapyramidal system examination
observation of the motor system
sensory system

See appendix D for further guidance for nurses on the standard physical examinations and required actions.

Aspects of the physical assessment or examination which can be carried out by medical staff (or other appropriately trained staff) only.

These include:

cardiovascular examination
gastrointestinal examination
respiratory system examination
standard neurological examination
examination of the sensory system
motor system examination (includes extrapyramidal system)
reflexes

11.3 Appendix C Service specific investigations

11.3.1 For older people’s mental health inpatient services

Blood tests, these will usually be performed prior to admission. Where this has not occurred, the admitting clinician may wish to consider the following as a minimum within 24 hours of admission to screen for organic conditions and as a baseline:

full blood count
urea and electrolytes
thyroid function test
liver function test
glycosylated haemoglobin (HbA1c)
B12 and folate
calcium profile

Results should be checked, and an appropriate outcome recorded within 24 hours of the investigation.

11.3.2 For patients admitted for a detoxification programme

Blood tests, the minimum requirement for patients admitted for a detoxification programme are:

full blood count
liver function test
urea and electrolytes
clotting screen

11.3.3 For adult mental health inpatient services

Patients should have the following investigations as a minimum within 24 hours of admission to screen for organic conditions and as a baseline, unless they were completed recently (the period of recency will be determined on the patient’s individual circumstances and needs):

full blood count
urea and electrolytes
thyroid function test
liver function test
glycosylated haemoglobin (HbA1c)
lipids
B12 and folate
calcium profile

Results should be checked, and an appropriate outcome recorded within 24 hours of the investigation.

11.4 Appendix D guidance for nursing staff on standard physical examinations and required actions

11.4.1 Body mass index (BMI)

11.4.1.1 A healthy BMI is one that is between 18.5 and 24.9

The patient should be weighed (in kilograms) and their height (in centimetres) recorded. Their body mass index (BMI) is calculated by: weight in kilograms divided by height in metres squared.

BMI = weight (kg)/height (m)2.

11.4.1.2 BMI below 18.5

Report to Medical team during the next working day as this is a lean BMI which could be an indication of weight loss due to an eating disorder or neglect. If the patient’s BMI is deemed to be so low that their health is at immediate risk of further deterioration then this should be reported to a medic immediately and a discussion should take place to decide how and where the patient should be managed safely.

11.4.1.3 BMI between 25 and 29.9

A BMI in this range is considered to be overweight, and anyone over 27 with co-morbidity (smoker, diabetes etc.) should be offered weight management advice.

11.4.1.4 BMI between 30 and above

A BMI in this range is considered obese.

On admission patients should be screened using must within 24 hours. Staff are then required to implement a “nutritional action plan” according to the patient’s calculated must score.

11.4.2 Pulse rate

A normal pulse rate is between 60 and 100 beats per minute (bpm).

If it is below 60bpm, or above 100bpm, medical staff should be notified as an ECG may be indicated. Qualified staff should take into consideration the patients mental state and repeat a pulse rate if the patient is presenting with high levels of anxiety once relaxation techniques have been undertaken).

11.4.3 Blood pressure (BP)

If this is recorded as 160 over 100 or higher, refer to the medical team for further investigation.

11.4.4 Temperature

37 is normal for an adult therefore any reading 36 or below, or above 37 needs to be reported to the Medical team. A temperature that scores on the EWS, which is accompanied by a fluctuating blood pressure, needs to be reported urgently (a fluctuating BP would require a number of readings over a short period of time likely to be undertaken when a concern regarding someone’s physical health is raised).

11.4.5 Things to note when doing skin observations

All staff who note bruising on admission, transfer or discharge to and from an inpatient setting must record this on a body map on the electronic patient record.
Condition and colour of the skin.
Make a full record of any wounds, or scars and document how these were sustained.
Any evidence of self-harm

11.4.6 Neurological examination

When undertaking a neurological examination you are testing and making a record of the following:

level of consciousness
orientation
memory
speech

11.4.7 Basic extrapyramidal system examination

This will be undertaken by observing and making a record of the following:

the patient’s movements and, in particular any abnormal movements and poverty of movement
observe how they walk

11.4.8 Observation of the motor system

When examining the motor system, attention should be paid to the pattern of any weakness, as opposed to its extent or severity, as this is more likely to indicate the origin of the weakness.

There are three essential patterns to note:

weakness to one side of the body (hemiplegia), which is indicative of contralateral brain damage (damage to the opposite side of the brain)
weakness of both legs (paraparesis), which is suggestive of spinal cord damage
weakness which is limited to the distal portions (towards extremities) of the limbs which is a feature of damage to the peripheral nervous system rather than the central nervous system

If any of these are evident in a patient, who has no previous history, nursing staff should ask a member of the medical team immediately for advice.

11.4.9 The sensory system

An examination of the sensory system requires the cooperation of the patient, and depends mainly on their report rather than actual observation. Staff will need to ask specific questions about the patients:

sight
hearing
sense of smell
sense of taste
any itching or other sensations they may be experiencing

If there is anything which a member of nursing staff is unsure of or concerned about, they must contact a member of the Medical team immediately for advice.

Document control

Version: 4.5.
Unique reference number: 399.
Approved by: Clinical policies review and approval group.
Date approved: 12 November 2024.
Name of originator or author: Deputy medical director.
Name of responsible individual: Chief nurse.
Date issued: 20 November 2024.
Review date: 30 April 2025.
Target audience: All clinical staff in adult, older people’s, child and adolescent mental health services, learning disabilities, forensic and drug and alcohol services (improving access to psychological (IAPT) services is out of scope).

Page last reviewed: December 10, 2024
Next review due: December 10, 2025

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