DML Integrated
Minimum Data Set
Resident Assessment Instruments (RAIs),
Resident Assessment Protocols (RAPs)
&
Personalised Care Planning
DML Services for Older Persons
&
Nursing and Midwifery Planning and Development
April 2010
Foreword
Services for Older people who live in residential care in Ireland are directed by a number
of strategies emanating from the Department of Health and Children, from the
Corporate Plan of the Health Service Executive and more latterly by the Health
Information and Quality Authority (HIQA) through their “National Quality Standards for
Residential Care Settings for Older People in Ireland” (HIQA 2009). The provision of care
based on an individualised assessment and the development of a personalised care plan
is central to these standards.
The Nursing & Midwifery Planning and Development Unit in Palmerstown, in
conjunction with HSE, DML Services for Older Persons is very pleased to publish this
evidence based document which outlines a minimum dataset and supporting
documentation tools for use in residential care settings. The minimum dataset comprises
Resident Assessment Protocols and Personalised care planning – based on protocols of
care and sample care plans. It also includes Resident Assessment Instruments which are
included in the appendices.
These documents provide nursing staff who work in residential care settings with a
comprehensive range of evidence based tools to support them in all aspects of resident
assessment and care planning. They assist in the standardisation of documentation
across all Health Service Executive residential settings in Dublin Mid-Leinster.
I wish to sincerely express our appreciation to the documentation group for their
expertise, time and effort over the last eighteen months in the development of this
document. Special thanks are extended to Ms Linda McDermott Scales, Chairperson of
the DML Documentation Group, - DML Services for Older Persons and Ms Angela Ring
former Project Officer; Older Persons services – NMPD for their commitment and drive
for the project, thereby ensuring its successful completion.
Liz Roche
Director
NMPD – Palmerstown
April 2010
1
Table of Contents
Disclaimer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Section 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Section 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2.1 Personalised Care Planning using the DML Integrated Minimum Data Set . . . . 6
2.2 Resident Assessment Instruments (RAIs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2.3 Resident Assessment Protocols (RAPs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2.4 Lay out of the RAPs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2.4.1 Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.4.2 RAI Identifiers of Potential Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.4.3 Risk Factors (intrinsic & extrinsic) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.4.4 Further Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.4.5 Referrals Required . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.5 Personalised Care Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.6 Documenting Personalised Care Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.6.1 Topic Heading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.6.2 Problem/Need Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.6.3 Goal specification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.6.4 Specific Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.6.5 Evaluation of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.7 Protocol of Expected Standards for Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.8 Sample Care Plan Generic or Personalised . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Section 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Resident Assessment Protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
RAP 1: Communication, Vision and Hearing . . . . . . . . . . . . . . . . . . . . . . . . . 17
RAP 2: Mood and Behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
RAP 3: Cognition and Acute Confusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
RAP 4: Breathing and Circulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
RAP 5: Nutritional Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
RAP 6: Dehydration and Fluid Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . 65
RAP 7: Urinary Incontinence and Continence Promotion . . . . . . . . . . . . . . . 73
RAP 8: Faecal Incontinence and Continence Promotion . . . . . . . . . . . . . . . . 81
RAP 9: Constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
RAP 10: Falls Prevention and Risk Reduction . . . . . . . . . . . . . . . . . . . . . . . . 100
RAP 11: Impaired Ability for Personal Care . . . . . . . . . . . . . . . . . . . . . . . . . 107
RAP 12: Pressure Ulcer Prevention and Management . . . . . . . . . . . . . . . . . 115
RAP 13: Skin and Wound Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
RAP 14: Psychosocial Welfare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
RAP 15: Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
RAP 16: Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
RAP 17: Disturbed Sleep and Rest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
RAP 18: Psychotropic Drug Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
RAP 19: MRSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
RAP 20: Feeding Tubes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
RAP 21: Palliative Care for All . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
RAP 22: End of Life Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Section 4 Appendices
Appendix 1 Integrated Minimum Dataset and Resident Record - Chart Layout . . . . . 232
Appendix 2 Resident Assessment Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
Appendix 3 Documentation Audit Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
Appendix 4 Guidelines for completing "My Day My Way" . . . . . . . . . . . . . . . . . . . . . 306
2
Disclaimer
The Resident Assessment Protocols (RAPs) and the Protocols for the Expected Standards
of Care in Older Persons designated centres as stated in this document, have been
developed based on the best available evidence with expert and peer review. The aim
of these instruments is to assist healthcare professionals, carers, residents and their
significant other(s) in making decisions about appropriate options or treatments for
specific conditions and aspects of care. As with all clinical policies, procedures, protocols
and guidelines, the recommendations provided may not be appropriate for use in all
circumstances. Decisions to adopt any particular recommendation must be made by
the practitioner in the light of:
• The resident’s/significant other(s) circumstances and wishes
• Available resources
• Local services, policies and protocols
• Available personnel and support services
• Clinical judgement and the experience of the practitioner
• Knowledge of more recent research findings
3
DML Integrated Minimum Data Set
Resident Assessment Instruments (RAIs), Resident Assessment
Protocols (RAPs) and Personalised Care Planning
Section 1
1.1 Introduction
The ‘National Quality Standards for Residential Care Settings for Older People in Ireland’
and its supporting legislation, set out the standards of the quality in care that older
people living in designated centres can expect to receive 1, 2, 3. The provision of these
minimum standards in expected care is centred within a model of personalised care
planning which is to be delivered within a home-style setting.
Personalised care planning is fundamentally based in addressing an individual’s full range
of needs and wishes, taking into account their health, personal, social, economic,
educational, mental health, ethnic and cultural background and their circumstances4.
It recognises that there are other issues in addition to medical needs that can impact on
an older person’s total health and well-being. The overarching aims of the care planning
process are to:
• Put the individual, their needs and choices at the centre of the process to support
them in achieving optimal health and well-being
• Focus on goal setting and outcomes that residents, their significant others and
carers want to achieve
• Ensure that there are appropriately planned strategies in place, to address the
resident’s potential or actual problems or needs, and that contingency (or
emergency) plans are available to better manage crisis episodes (for those
with complex needs, such as those with behaviour that challenges)
• Ensure that resident choice and control are promoted by putting the person at
the centre of the process and facilitating better management of risk
• Ensure that people, especially those with more complex needs or those
approaching end of life, receive co-ordinated care, reducing fragmentation
between disciplines and services
• Provide information that is relevant and timely to support residents with decision
making in care and lifestyle choices
• Provide support for self-care, so that residents can self-care/self-manage their
condition(s) and prevent deterioration where possible
• Facilitate multidisciplinary team working and inter agency working
• Result in an overarching, single personalised care plan that is owned by the
resident, but can be accessed by those providing direct care or by other relevant
people as agreed by the resident. For example, if a resident is reviewed by a
member of the multidisciplinary team (MDT) and specific care instructions are
given, the resident’s care plan interventions should be updated to reflect the
changes ordered. This ensures a single overarching plan of care is provided to the
resident.
4
Note: In designated centers for older people that use an integrated resident record
system i.e., where all members of the MDT record in the same resident file, the MDT can
record the specific interventions required for achieving personalised care using the Care
Plan Template. However, in residential facilities that do not use an integrated resident
record system, nurses must update the specific interventions section in the care plan
following MDT review. In updating the interventions required, it is not necessary for
nurses to re-write all the MDT instructions given. However, MDT reviews must be
referenced in the interventions and a copy of the instructions where appropriate should
be attached to the care plan. For example, if a resident is seen by a dietitian and detailed
instructions for care are given, the care plan interventions need simply record ‘refer to
dietitian’s instructions’ and a copy of the dietitian’s instructions should then be
attached to the care plan. This will reduce fragmentation of care and ensure that nurses
assuming the care of a resident, know exactly what the MDT plan of personalised care
is for that specific resident.
It is vital to note, the most important part of care provision is that care planning
discussions with the resident and/or their significant other(s) has taken place, with
an emphasis on goal setting, equal partnership, negotiation and shared decision
making4.
5
Section 2
2.1 Personalised Care Planning using the DML Integrated Minimum Data Set
The DML Integrated Minimum Data Set is made up of Resident Assessment Instruments
(RAIs), Resident Assessment Protocols (RAPs), Personalised Care Planning (based on
Protocols of the Expected Standards in Care) and sample care plans. These instruments
are guided by professional standards of practice, regulatory requirements and clinical
judgement 1, 5, 6, 7, 8 .
2.2 Resident Assessment Instruments (RAIs)
The Resident Assessment Instruments are a minimum data set (MDS)9. They ensure that
staff collects the minimum, necessary, standardised assessment information for each
resident on admission, when the resident’s conditions improves or deteriorates, and at
a minimum three monthly. This allows a personalised care plan to be developed and
reviewed, based on the individual’s needs, strengths and preferences. However, the
Resident Assessment Instruments (RAIs) alone will not provide a comprehensive
assessment of all aspects of a resident’s needs. They can be considered as a preliminary
screening tool in identifying actual or potential needs.
2.3 Resident Assessment Protocols (RAPs)
In certain areas, residents may require further in-depth assessments so that an
appropriate plan of personalised care can be developed according to the resident’s
needs, preferences and strengths. Resident Assessment Protocols (RAPs) have been
designed to meet this need7. They are problem-orientated assessment frameworks which
outline the need for additional assessments7. The RAPs are triggered by the symbol when completing the RAIs. In planning personalised care, it is essential that causes or
unique risk factors for decline or lack of improvement in the individual are identified.
Once identified, the plan of personalised care should address these factors with the goal
of promoting the resident’s highest level of functioning, health and well-being.
6
2.4 Layout of the RAPs
There are 22 RAPs developed which cover the majority of areas likely to be addressed in
a resident’s care plan.
RAP 1:
RAP 2:
Communication, Vision and Hearing
RAP 4:
Cognition and Acute Confusion
RAP 6:
Nutritional Status
RAP 8:
Urinary Incontinence and Continence Promotion
RAP 10:
Constipation
RAP 12:
Impaired Ability for Personal Care
RAP 14:
Skin and Wound Care
RAP 16:
Activities
RAP 18:
Disturbed Sleep and Rest
RAP 20:
MRSA
RAP 22:
Palliative Care for All
RAP 3:
Mood and Behaviour
RAP 5:
Breathing and Circulation
RAP 7:
Dehydration and Fluid Maintenance
RAP 9:
Faecal Incontinence and Continence Promotion
RAP 11:
Falls Prevention and Risk Reduction
RAP 13:
Pressure Ulcer Prevention and Management
RAP 15:
Psychosocial Well-being
RAP 17:
Pain
RAP 19:
Psychotropic Drug Use
RAP 21:
Feeding Tubes
End of Life Care
7
There are 7 parts to the RAP and Personalised Care Planning Instrument:
1. Definition
2. RAI Identifiers of Potential Risk
3. Risk Factors (intrinsic & extrinsic)
4. Further Assessment
5. Referrals Required
6. Personalised Care Planning
7. Protocols of Expected Standards in Care
8. Sample Care Plan
2.4.1 Definition
This provides a definition or description of the identified need, condition, risk or
problem affecting the individual.
2.4.2 RAI Identifiers of Potential Risk
In the RAIs, the symbol (followed by a number) identifies a potential or actual
problem or need that requires further RAP assessment and investigation by the
multidisciplinary team. The multidisciplinary team (MDT) includes the resident and
their significant other(s), carers, nurses, doctors and allied health professionals.
Following RAP assessment, the MDT can determine if a plan of personalised care is
needed or on the most appropriate plan which incorporates the resident’s, needs/
strengths and preferences.
For example; in the RAIs, if 12 is ticked, this indicates that RAP 12: Pressure Ulcer
Prevention and Management has been triggered. The assessor should now refer to this
specific RAP for further assessment protocols required in planning appropriate
multidisciplinary personalised care.
In the RAPs, RAI identifiers of potential risk are listed followed by their corresponding
RAI Section letter and number. This identifies where in the RAI the specific RAP was
triggered. It is important to note the specific resident’s RAI identifier of potential risk that
triggered the RAP in planning personalised care.
For example, in RAP12: Pressure Ulcer Prevention and Management, the ‘RAI Identifiers
of Potential Risk’ lists ‘Total Assistance required in Repositioning J 4’ and an ‘Inability to
Mobilise Independently C11’. This means that when the assessor is completing Section
C- Initial Admission Assessment and number 11 is ticked to indicate the resident is
dependent in mobilising, RAP 12 is triggered.
The assessor should refer to RAP 12 for further assessment protocols while being
cognisant of this specific trigger (resident mobility dependence), so that an appropriate
plan of personalised can be developed. Similarly, if J4 is ticked indicating the resident
requires total assistance in repositioning, RAP 12 is triggered. Again, the assessor should
refer to RAP 12 for further assessment protocols while being cognisant of this specific
trigger (total assistance required in repositioning) in developing a personalised care plan
with the resident and their significant other(s).
8
2.4.3 Risk Factors (intrinsic & extrinsic)
This section provides information for evaluating further risks that are not listed in the RAI
instrument. These risk factors may cause, contribute to, or exacerbate the problem or need
identified. By assessing the risk factors that may contribute to the resident’s problem, the
assessor may identify:
• Associated causes and effects. Sometimes problems (e.g. constipation) may have a
single cause (e.g. inadequate fluid intake). However, more often they have several
causes (e.g. new drug, immobility, lack of privacy concerns, etc)
• Multiple triggered conditions are related e.g. Vision and Falls
• A need for obtaining further information on the resident’s condition from the resident
or their significant other(s) or from the multidisciplinary team
• A need for expert referral (e.g. Clinical Nurse Specialist in Older Persons Care for
Behaviour that Challenges or Psychiatry of Later Life referral)
• The basis for care plan goals and specific interventions required for personalised care
2.4.4 Further Assessment
This section details further assessments that are needed to undertake a comprehensive
assessment of the resident’s needs, which may include multidisciplinary team referral and
review. The information listed in the ‘Further Assessments’ section is used to structure and
guide the assessment process, so that information needed is not missed. When reviewing
the ‘Further Assessments’ section, staff should consider the specific resident’s RAI trigger(s)
that caused the RAP to be reviewed. This focuses the review on pertinent information that
helps the assessor and multidisciplinary team to determine the nature of the problem
identified and to decide if a care plan is necessary or what types of interventions are
appropriate. Staff, together with the resident/significant other(s) where possible, then
decide whether or not the triggered condition affects the resident’s functional ability or
well-being and refer to the Protocols of Expected Standards for Care, if a care plan is
warranted. Staff should document key findings following RAP review in the resident’s
narrative notes.
2.4.5 Referrals Required
Multidisciplinary referrals that may be required in assessing, evaluating and managing
a particular resident problem or need are listed under this heading.
2.5 Personalised Care Planning
The aim of personalised care planning is to develop a single multidisciplinary tailor-made
plan of care to address the individual’s problem(s), concerns or needs and their associated
causes or risks. The multidisciplinary team (MDT) includes the resident/significant other(s),
carers, nurses, doctors and allied health professionals. This section of the RAPs provides
problem-orientated care frameworks for deciding on appropriate personalised interventions
for care. Care plan development is centred on discussion with the resident and/or their
significant other(s) where possible, to determine their preferences and goals; the best
available evidence; MDT review and clinical judgement. Nursing staff should refer to: the
resident/significant other(s), the Protocols of Expected Standards for Care and to the
Multidisciplinary Team’s specific instructions, when planning appropriate personalised care.
This ensures that a single, overarching plan of personalised care is delivered to the resident.
9
2.6 Documenting Personalised Care Planning
A Care Plan Template is provided in The DML Integrated Minimum Data Set and
Resident Care Record for documenting the resident’s plan of personalised care. The
headings on the template include: Topic Heading, Problem/Need Identification, Specific
Interventions and Evaluation of Care.
2.6.1 Topic Heading
The topic heading outlines the resident’s problem or need.
2.6.2 Problem/Need Identification
The resident’s identified problem/need is recorded as an actual or potential
problem/need and its associated or related risk factors are documented.
2.6.3 Goal specification
The MDT goals of care are recorded. It is important that goals are specific, measurable,
achievable, realistic, and time-oriented. The goals of care must reflect the
resident’s/family’s care choices and wishes.
2.6.4 Specific Interventions
The specific interventions needed to address the resident’s problem or need are
recorded under this heading. These specific interventions are based on expected
standards of care, the outcome of the MDT RAP review and discussion and clinical
judgement. In simple terms, the specific interventions section should address:
i. Interventions needed: What we need to do to address the problem, risk or
concern. These should include specific MDT interventions based on
residents/significant other(s) concerns and care choices, where possible
ii. On-going reassessments: What we need to monitor
iii. Communication: What, to whom and when we need to communicate back to
the MDT/resident/significant other[s]
iv. Education: What and who we need to educate/provide information/health
promotion advice to in order to improve the problem/need/concern
When writing specific personalised interventions in the resident’s care plan, the
Protocols of Expected Standards for Care should be reviewed and the following
headings used. (Remember the MDT includes the resident/significant other(s), carers,
nurses, doctors and allied health professionals)
Record:
1. Specific MDT Interventions to address the resident’s/significant other(s)’
concerns, preferences and care choices
2. Specific MDT Interventions to address the problems or risks identified
3. Monitoring and ongoing reassessments
4. Communication required
5. Information/education/health promotion required
10
2.6.5 Evaluation of Care
Personalised care plans should be evaluated when the resident’s condition improves or
deteriorates and at a minimum of 3-monthly. A record should be maintained in the
“Evaluation of Care” section on the Care Plan Template of all MDT reviews that fall
outside the routine 3-monthly reviews, e.g., when the resident’s condition improves
or deteriorates or is re-assessed. The Three Monthly Reassessment Form should be used
when routinely evaluating resident’s MDT personalised care plans. Three monthly
reviews of personalised care plans should be a planned event and where possible an
appointment should be made with the resident/significant other(s), to discuss and
evaluate their personalised care planning and delivery.
2.7 Protocol of Expected Standards for Care
The Protocols of Expected Standards for Care have been developed in a flow chart
format and are based on the best available evidence, expert and peer review. These
Protocols can be used to assist healthcare professionals, carers, residents and their
significant other(s) in making decisions about appropriate treatments for specific
conditions and aspects of care.
2.8 Sample Care Plan Generic or Personalised
Under specific RAP headings, sample care plans are provided. These are presented in
personalised and generic formats.
11
References
1
HIQA (2009) National Quality Standards for Residential Care Settings for Older People
in Ireland
2
Department of Health and Children (2009) Health Act 2007 (CARE AND WELFARE OF
RESIDENTS IN DESIGNATED CENTRES FOR OLDER PEOPLE) REGULATIONS 2009
3
Department of Health and Children (2010) HEALTH Act 2007(CARE AND WELFARE
OF RESIDENTS IN DESIGNATED CENTRES FOR OLDER PEOPLE) (AMENDMENT)
REGULATIONS 2010
4
Department of Health UK (2009) Supporting people with long term conditions:
commissioning personalised care planning - a guide for commissioners.
Accessed on line at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAn
dGuidance/DH_093354
5
An Bord Altranais, (2000) The Code of Professional Conduct for each Nurse and
Midwife, An Bord Altranais, Dublin.
6
An Bord Altranais, (2000) Scope of Nursing and Midwifery Practice Framework, An
Bord Altranais, Dublin.
7
An Bord Altranais, (2002) Recording Clinical Practice Guidance to Nurses and
Midwives, An Bord Altranais, Dublin.
8
An Bord Altranais, (2009) Professional Guidance for Nurses working with Older People,
An Bord Altranais, Dublin
9
Challis., D., Stewart, K., Strudy, D., Worden, A. (2000) UK Long Term Care Resident
Assessment Instrument User’s Manual MDS/RAI UK, interRAI UK, York, UK.
12
Section 3
Resident Assessment Protocols
13
RAP 1:
14
RAP 2:
Communication, Vision and Hearing
RAP 4:
Cognition and Acute Confusion
RAP 6:
Nutritional Status
RAP 8:
Urinary Incontinence and Continence Promotion
RAP 10:
Constipation
RAP 12:
Impaired Ability for Personal Care
RAP 14:
Skin and Wound Care
RAP 16:
Activities
RAP 18:
Disturbed Sleep and Rest
RAP 20:
MRSA
RAP 22:
Palliative Care for All
RAP 3:
Mood and Behaviour
RAP 5:
Breathing and Circulation
RAP 7:
Dehydration and Fluid Maintenance
RAP 9:
Faecal Incontinence and Continence Promotion
RAP 11:
Falls Prevention and Risk Reduction
RAP 13:
Pressure Ulcer Prevention and Management
RAP 15:
Psychosocial Well-being
RAP 17:
Pain
RAP 19:
Psychotropic Drug Use
RAP 21:
Feeding Tubes
End of Life Care
RAPS
Authors
Introduction to the DML MDS
Linda McDermott-Scales, R.G.N., Post
RAP 1: Communication, Vision
and Hearing
RAP 2: Mood and Behaviour
RAP 3: Cognition and Acute
Grad Cert Neurological /Neurosurgical Nursing, H
Dip Tissue Viability, MSc Nursing. DML Services for
Older Persons.
Julie Byrne, R.G.N., R.M., CNM2, Education
Officer, Cherry Orchard Hospital
Edel Carey, RGN, H-Dip L.D., PD / B.C.P, CNS
Behaviours that Challenge, Cherry Orchard
Hospital
Orla Canning, R.G.N., H. Dip Gerontology,
Confusion
RAP 4: Breathing and
Circulation
CNS Dementia, Cherry Orchard Hospital
RAP 5: Nutritional Status
RAP 6: Dehydration and Fluid
Linda McDermott-Scales
Maintenance
RAP 7: Urinary Incontinence
and Continence
Promotion
RAP 8: Faecal Incontinence and
Continence Promotion
RAP 9: Constipation
RAP 10: Falls Prevention and
Risk Reduction
RAP 11: Impaired Ability for
Personal Care
RAP 12: Pressure Ulcer Prevention
and Management
RAP 13: Skin and Wound Care
RAP 14: Psychosocial Well-being
RAP 15: Activities
Anne Marie Payne, R.G.N, Nurse Tutor, St.
Mary’s Hospital, Phoenix Park.
Linda McDermott-Scales
Linda McDermott-Scales
Olivia Flattery, R.G.N, Practice Development,
James Connolly Hospital
Linda McDermott-Scales
Olivia Flattery
Linda McDermott-Scales
Debby Dowd, R.G.N., CNM2, James Connolly
Hospital
Mary Doyle, R.G.N., R.P.N., R.M., H. Dip
Gerontology, CNS Older Persons Peamount
Hospital
Nicole Nolan, R.G.N., DML Services for Older Persons
Linda McDermott-Scales
Linda McDermott-Scales
Carol Byrne, R.G.N., CNM2 Balltinglass
District Hospital
Caroline Doran, R.G.N., CNM3, Meath
Community Unit
Arnel Kidpalos, MSc, H Dip, BSc, R.G.N.,
RAP 16: Pain
RAP 17: Disturbed Sleep and Rest
RAP 18: Psychotropic Drug Use
RAP 19: MRSA
RAP 20: Feeding Tubes
RAP 21: Palliative Care for All
RAP 22: End of Life Care
R.N.T, EdD student, Nurse Tutor- Gerontology, Our
Lady's Hospice Ltd.
Caroline Doran
Luzviminda Montejo, R.G.N., CNM2, Tara
Care Centre, Putland Road, Co. Wicklow.
Arnel Kidpalos
Linda McDermott-Scales
Nicole Nolan
Anne Murphy, R.G.N., H Dip in Wound
Management, H Dip Gerontology, CNS Older
Persons Care, Cherry Orchard Hospital
Nicole Nolan
Nicole Nolan
15
Expert Reviewers
•
Michelle Bonner, CNS Palliative Care, Bray Palliative Care Team
•
Sonia Jeffery, CNS Palliative Care, Bray Palliative Care Team
•
Hazel Bailey, CNS Palliative Care, Bray Palliative Care Team
•
Mary Gregan, CNS Palliative Care, Bray Palliative Care Team
•
Dr. Seamus O’Dea, Medical Superintendent, Cherry Orchard Hospital
•
Dr. Eleanor McNamara, Consultant Microbiologist, Public Health Laboratory, Cherry
Orchard Hospital
•
Laura Dillon CNS Infection Control & The ICS
•
Gillian O’Brien, CNS Tissue Viability, Naas General Hospital
•
Fiona Concannon, CNS Tissue Viability, Dublin North East
•
Mary Doherty, Tissue Viability Nurse, Cherry Orchard Wound Clinic
•
Mairead Murray, TVN, Midlands
•
Mary Kehoe, Senior Dietician DML, Clonskeagh Hospital
•
Grainne Flanagan-Rughoobur, Senior Dietician DML, Mullingar
•
Anne O’Sullivan, CNM2, A & E Department, Royal Victoria Eye & Ear Hospital
•
Maeve Murphy, Chairperson of IASLT
•
Aidan Lawlor ADN, RPN, CBT, St. Loman’s Hospital
•
Jeremey Jeffreys CNS Behaviour
•
Continence Promotion Unit, Dr. Stevens Hospital
•
Lynne Robb, CNS Pain Management and the Pain Nurses at St James’s Hospital
•
Jean Dunne, RGN, Social Worker, Quality Standards and Governance, HSE DML
•
Fiona Lyons, Social Worker, Cherry Orchard Hospital
•
Eimear O’Dwyer, MPSI, Chief II Pharmacist/Supervising Pharmacist, Our Lady’s
Hospice Ltd
16
•
Alma Joyce, Occupational Therapist Manager, Dublin South City
•
Pamela Ennis, Occupational Therapist, Meath Community Unit
RAP 1: Communication, Vision and Hearing
Definitions:
Communication is a process, involving a minimum of two people and encompassing any
means by which individuals relate experiences, ideas, knowledge and feelings.
Communication is the means by which people connect socially, and ensures a person is
not isolated. Communication can be verbal (through words) or non-verbal (e.g.
gestures/sign language). To communicate effectively, your communication partner must
understand your mode of communication.1
Impaired Communication: Decreased, delayed or absent ability to receive, process,
transmit and use a system of symbols.2
Expressive Aphasia: is the loss of ability to verbally, express oneself.3
Receptive Aphasia: is the loss of ability to understand language.3
Dysarthia: is a language disorder in which there is difficulty in articulating words due
to motor speech impairment.3
Visual Impairment: is a change in the amount or patterning of incoming stimuli,
accompanied by a diminished, exaggerated, distorted, or impaired response to such
stimuli.2
Hearing impairment: is a change in the amount or patterning of incoming stimuli
accompanied by a diminished, exaggerated, distorted, or impaired response to such
stimuli.2
Comatosed: Persistent vegative state/no discernable response.
RAI Identifiers of Potential Risk:
Resident requires an interrupter A11, Unable to express wishes A30, A31, Uses
Assistive Devices/Communication Aids - hearing aid A49, I11, Spectacles A50,
Communication Aids D5 Speech incoherent or other speech problems D1, Comprehension difficulties D3, Expressive difficulties D4, Inability to verbalise: pain
D22, feeling hot or cold I11 Impaired hearing D6, D7, H3 Impaired Vision D8, H3
Restless/agitated (unable to communicate unmet need) D13, D14, History of
Behaviour that Challenge (?unable to communicate unmet need) D16, Impaired
Communication Skills M7
Other Risk Factors include:
Sensory challenges involving hearing and/or vision, ear infection, ear wax accumulation,
glaucoma, cataracts, diabetes mellitus, muscular paralysis and weakness, progressive
physical, neurological, and psychiatric disorders. C.V.A, vascular dementia, receptive
aphasia, expressive aphasia, dysarthia, structural problems e.g. tracheostomy, acute
medical conditions e.g. urinary tract infection, pain, medication e.g. psychotropic drugs
and narcotics, cultural differences e.g. (speaks a different language), dyspnoea, fatigue,
fear/shyness, unfamiliar environment and faces.
17
Further Assessments:
Document the following assessment on admission, after 5 days, if the
resident’s condition improves or deteriorates and at least 3 monthly.
NB: Please note: Prior to carrying out these further assessments ask the resident or
their significant other about prior use of assistive devices. Ensure the resident is using
these if applicable and that they are working properly. Assistive devices may include:
spectacles, hearing aids, magnifying glass, writing pad and pencil, picture board and
word/phrase card, assistive technology, including high tech communication devices.
In undertaking further assessments of the resident’s communication ability, reduce
background noise and ensure privacy.
If the resident uses sign language or is an augmentative communication user (e.g. uses
a computer or a picture board), ensure the person assessing him/her can use this system
of communication or involve someone who can in the process (e.g. family member).
Several sources of information should be used in assessing residents with communication
difficulties. The resident should be the primary source of this information. However,
where marked difficulties exist, significant others and carers will often know the most
effective methods of communicating with the resident. Gather and document pertinent
information about the resident’s usual mode of communication; this should include
verbal / non verbal cues which the resident uses to identify their needs/wants.
Assess the Resident’s:
1. Past and present medical history: for any suggestive or actual risk factors for
communication. If the resident has already been seen by a Speech and Language
Therapist (SLT), Audiologist and /or an Optician prior to admission, record the date
of last review and list/attach their recommendations in their personalised plan of
care. Consider the resident’s overall risk context for communication e.g. Physical,
Neurological, or Mental health disorders, Memory loss, decreased attention span,
expressive or receptive aphasia, visual or hearing impairment which may impact on
the resident’s ability to communicate. Consider the resident’s medications for
possible risks of over sedation, or side effects which may cause or exacerbate
communication difficulties4.
2. Level of consciousness: Is the resident alert, orientated, confused, semi-comatose
or comatosed? Review clinical records and activity of daily living assessments.
3. Cognitive patterns: conduct a brief interview for mental status (e.g. the Mini
Mental State Examination [MMSE] )
4. Behavioural patterns: behaviours that challenge are frequently the only way that
residents have in communicating unmet needs5. Refer to RAP 2 for further
assessments required.
5. Hearing: If applicable ensure the resident is using their hearing aid and that it is
working correctly before attempting to assess hearing function. Record the use of
hearing aids during assessment. Interview and observe the resident.
18
Ask the resident about their hearing function. Be alert to how you communicate with the
person in order for them to understand. You may notice that you have to speak louder,
more slowly and distinctly. You may have to use gestures or bring the person to a quieter
environment. These cues should alert you to the resident having a hearing problem.
Select the best description from the list below of the resident’s hearing pattern in the past
five days:
b) Adequate hearing. The resident has no difficulty in normal conversation, social
interaction or in using the telephone.
c) Minimal hearing difficulty. The resident finds it difficult to hear in a noisy
environment.
d) Moderate hearing difficulty. The resident finds it difficult to hear normal
conversation. Their communication partner has to speak louder and more
distinctly.
e) Severe hearing difficulty. The resident demonstrates difficulty in hearing in all
situations with an absence of functional hearing.
f) No functional Hearing.
Document Hearing Assessment findings in the Narrative Notes and
ensure appropriate Multidisciplinary referral.
6. Speech Clarity: Select the best description from the list below to describe the
resident’s speech pattern in the last 5 days.
a) Clear speech. The resident demonstrates distinct intelligible words.
b) Unclear speech. The resident’s speech is slurred or with mumbled words.
c) Speech unintelligible to unfamiliar conversation partners but can
but understood by familiar conversation partners e.g. family/friends
d) Speech unintelligible to all listeners, including familiar partners e.g.
family/friends
e) Speech intelligible in quiet surroundings but poorly intelligible with
background noise
f) No intelligible speech in any environment.
Document Speech Assessment findings in the narrative notes and ensure
appropriate multidisciplinary referral.
7. Expression: Interact with the person, observe and listen to his/her attempts to
communicate. If the person uses communication devices, encourage their use. These
may include: a pad and pen, an alphabet board or a memory book. Record the type
of communication device used during assessment. Note the presence of non verbal
expressions; these may include e.g. blinking, hand squeezing or gesturing. Select the
best description which most closely represents the resident’s ability to make them
self understood over the last 5 days.
a) Communication partner understands resident always, resident expresses ideas
without difficulty
b) Communication partner understands resident usually. Resident has difficulty
finding words/finishing sentences but can achieve more success when prompted
by listener
19
c) Communication partner understands resident sometimes. Resident can make
basic needs known e.g. request a drink, but has difficulty with more complex
language.
d) Resident is rarely/never understood by communication partner.
Document Expressive Assessment findings in the narrative notes and
ensure appropriate multidisciplinary referral.
8. Comprehension: Interact with the person and consult with other members of the
multidisciplinary team and the resident’s significant others. Select the description
which corresponds to the most appropriate response for the resident.
a) Always Understands. The resident clearly understands the speaker’s message.
b) Usually understands. The resident misses some part or intent of the message but
understands most of the conversation by responding in words or actions.
c) Sometimes understands. The person has difficulty integrating information and
responds adequately only to simple direct questions.
d) Rarely/never understands.
Document Comprehension Assessment findings in the Narrative Notes
and ensure appropriate Multidisciplinary referral.
9. Vision: If applicable ensure the resident is using their spectacles before attempting
to assess visual function. Record the use of spectacles during assessment. Introduce
yourself. Provide adequate light. Always tell the resident with whom they are
speaking and when you are moving away, so that they are not speaking to an empty
space. Ask the resident if he/she is able to read newsprint, menus, etc. Be sensitive
to the fact that some people have literacy difficulties or speech difficulties such as
aphasia/dysarthia.
To assess for distance visual acuity ask the resident to put on their distance glasses
(if appropriate) i.e. what the resident wears for watching telly. If available use a
Snellen chart. Check at 6 meters distance, cover one eye and ask the resident to
read from the top. All lines on the chart have a number with 6 being the line a
normal eye can see at 6 meters and 60 being the line a normal eye can see at 60
meters. The result is written as a fraction with the top number being the distance i.e.
6 and the bottom being the number being the line read. Thus if the result is 6/60
their vision is poor while if the result is 6/6 they have normal vision. If they cannot
see the top line you should check if they can count fingers held about 18 inches in
front of them or failing that if they can see the hand moving. If not can they
distinguish a light shone in their eye. All would be sign of serious visual impairment.
To assess near visual acuity, ask the resident to read aloud (if they are able to). Test
one eye at a time (cover one eye). Wearing reading glasses (if appropriate), assess if
the resident can read different levels of print at normal reading distance which is
about 16 inches. Start with the larger print headings and end with the small print.
Select the description which corresponds to the list below.
e) No visual impairment. Resident sees fine detail including regular print in paper.
f) Minimal visual impairment. Resident sees larger print in newspaper
g) Moderate visual impairment. Resident is not able to see newspaper headlines
but can identify objects
20
h) Severe visual impairment. Resident can not identify object in question but
eyes appear to follow objects (especially people walking by).
i) No Vision
Document Visual Assessment findings in the narrative notes and ensure
appropriate multidisciplinary referral. The first point of referral should
be an optician as it may simply be a matter of getting new glasses. If
there is a necessity to refer to an ophthalmologist the optician will
advise.
Referrals required:
Refer the resident to the multidisciplinary team as appropriate to assessment findings.
Referrals should be made as soon as concerns arise e.g. on admission/review. Record all
referrals made on the MDT Referral Record.
•
Refer all residents with communication difficulties to their doctor for assessment and
review of their medical condition and current medications. Discuss with the
Doctor the resident’s current prescribed medications which may be impacting on the
resident’s ability to communicate.
•
Hearing impairment: minimal, moderate, severe hearing impairment
or resident has no functional hearing - check when the resident was last reviewed
by an audiologist. Refer residents who have not been reviewed within 1-2 years.
Lost or malfunctioning hearing aids - Refer the resident to an audiologist.
Some residents who are profoundly deaf may use sign language. It may be necessary
to access a certified sign language expert particularly when attempting to get
informed consent and for the resident to receive or impart other important medical
information.
•
Speech impairment: speech unclear or resident has no speech. Refer the
resident to the Speech and Language Therapist – or make contact with the person’s
Speech and Language Therapist if currently under the care of one.
•
Expressive/comprehension impairments: usually understands,
sometimes understands or rarely/never understands- Refer the resident to the
Speech and Language Therapist – or make contact with the person’s Speech and
Language Therapist if currently under care the of one.
•
Visual impairment: minimal, moderate, severe or vision absent - check
when the resident was last reviewed by an Optician. Refer residents who have not
been reviewed within the last 1-2 years. Lost or malfunctioning spectacles – refer the
resident to an Optician.
•
Behavioural Problems: It is essential that any resident who demonstrates
challenging behaviour is appropriately assessed - Refer to RAP 2 for the appropriate
care and onward referrals required.
•
Cultural: language barriers/foreign language; access a certified Interpreter to
validate information from both sides of dialogue. Interpreters can be sourced
through the Interpreting Services (check with Management for the company used).
21
Personalised Care Planning
The aim of care planning is to develop a single multidisciplinary MDT plan of
personalised care to address the causes or risks of communication difficulties, where
possible. The MDT includes the resident/significant other(s), nurses, doctors, carers, and
allied health professionals.
Problem/Need Identification
Record the actual or potential Communication difficulty and its associated or related risk
factors. For example;
‘Mary is aware that her hearing has recently deteriorated and reports, “Both ears are bad at
the moment. I get this a lot. It’s the wax”. Mary has moderate hearing impairment associated
with cerumen build up.’
Or
‘Mary reports “My eyesight is not what it should be, that’s what diabetes does to you”. Mary
currently has minimal visual impairment and is at risk of further impairment related to
Diabetes associated Macular Degeneration’.
Goal Specification
Record: realistic, measurable and obtainable goals. For example: ‘To dissolve the plug of
ear wax in Mary’s ear and restore her hearing to its normal level within 1 week’
Specific Interventions
These are the specific steps taken based on expected standards of care in addressing
actual or potential communication, vision and hearing problems. Document:
• What we need to do (specific interventions based on residents/significant other(s)
care choices where possible)
• What we need to monitor (on-going reassessments)
• What we need to communicate (back to the MDT)
• What/who we need to educate (to improve the problem)
1. Specific MDT interventions:
a. Document the specific interventions required to address the
resident’s/significant other(s)’ concerns, preferences and care choices
e.g. when communicating with a person in a wheelchair, speak directly with the
resident not the person pushing the wheel chair. If possible get down to the level of
the chair and establish eye contact e.g. by sitting on a chair.
b. Document the MDT specific care instructions. This includes the nursing care
instructions for addressing and managing impaired communication, vision and
hearing and other instructions from the multidisciplinary team, e.g. a speech and
language therapist’s specific instructions for communicating with a resident with
dysthartia. These should be listed here or a photocopy attached to the care plan. It
is important to refer the reader to the attached instructions. The same applies to all
instructions from other members of the multidisciplinary team.
22
For residents with Communication difficulties:
i.
Document the information obtained from the resident/significant others and carers in the
development of personalised care plans for effective communication. Detail the verbal/non
verbal cues which the resident uses to identify their needs/wants e.g. indicators for thirst,
toilet, etc.
ii. Document the calming interventions that carers/significant others found most helpful to the
resident if they became frustrated in attempting to get their needs across. This includes the
sources of comfort/types of reassurance liked.
iii. Encourage the use of charts, models and pictures to illustrate messages if appropriate.
iv. Maintain eye contact with the resident when communicating. Use gestures and facial
expressions to get your message across effectively.
v. Be aware of memory impairments, if memory is impaired constant repetition may be required.
vi. Pay attention to non verbal cues, encourage the resident’s attempts to communicate
vii. Reduce environmental distractions such as TV and radio that compete for attention when
conversing with the resident.
viii. For identified Hearing and Vision impairments. Ensure all residents assistive device needs are
documented to maintain/improve/promote independence e.g. spectacles, hearing aid,
memory boards, picture cards.
ix. In conversation with residents with expressive dysphasia, avoid verbal testing or questioning
beyond the person’s capacity. Give the person ample time to respond. Listen attentively;
clarify your understanding of the resident’s communication with the resident or with their
significant other if difficulty persists.
x. Acknowledge that communication may be a frustrating/difficult experience for both of you.
If you need to, take a break to give both of you a short ‘time out’.
xi. Do not make assumptions that the resident who has difficulties comprehending language
does not understand anything. Explain instructions/ideas simply using jargon free, short
sentences and visual aids such as pictures or diagrams.
xii. Medication: Some medications e.g. aspirin quinidine, some chemotherapeutic agents and the
amino glycosides are known ototoxic agents. If a hearing impairment is noticed after any of
these drugs have been commenced, the doctor should be informed as withdrawal of these
drugs often allows return to full hearing.
2. Monitoring & Ongoing reassessment:
• For residents with cognitive impairment the MMSE should be repeated not less than
3 monthly or if deterioration in the resident’s cognitive status is suspected. Compare
their current MMSE score with previous scores, act on findings which are of concern
e.g., onward referral to doctor for medication review/CNS in Dementia for further
assessment. Refer to Rap 3: Cognition and Acute Confusion.
• Ongoing reassessment using a validated tool e.g. HADS should be recorded at least
3 monthly for residents who show signs of depression, anger or withdrawal as these
are common responses to communication difficulties. Act on findings, refer to doctor
for medication review, CNS in behaviours for further assessment. Refer to Rap 2:
Mood and Behaviour.
• Conduct regular pain assessments using the Abbey /or Universal Pain Scale Tool. Act
on findings. Refer to Rap 16: Pain Assessment and Management
• Enquire about and/or observe for signs of infection e.g. eye lid inflammation
/discharge, earache /discharge, dizziness. Check ears for ear wax accumulation. Act
on findings, refer to doctor.
• Monitor the resident’s compliance with the use of assistive devices.
23
3. Communication:
• Promptly communicate monitoring concerns to the resident’s doctor and
appropriate members of the MDT e.g. SLT, CNS. Update care plan accordingly.
• NOTE: Residents MUST BE referred back to the multi-disciplinary team if there is any
deterioration in their communication ability despite following MDT advice
/instructions.
• Communicate the resident’s personalised care plan to all those involved in the
residents direct care. Ensure that the resident/significant other(s)/visitors are
encouraged to use assistive devices. Ensure the resident /significant other(s) are kept
up to date.
4. Information/Education/Health Promotion for the resident, Significant
other(s) and care staff.
• Educate the resident /care staff on the use and care of assistive devices e.g. hearing
aids. Check for age, condition, functional batteries and wax impaction of the
equipment.
• Provide training for all staff/family members on communicating with people with
aphasia.
• If a resident uses alternative or augmentative communication such as, sign language or
a communication device, make sure staff are all trained in how to communicate
effectively with the person.
• Demonstrate the proper administration of eye/ear drops or ointments. Allow for return
demonstration by resident/care staff.
• Teach standard precautions in infection control in relation to maintaining sterility of all
eye /ear droppers, medication tubes.
• Encourage residents with communication difficulties to socialise with family and friends.
Suggest that care staff, significant other/family and visitors engage the resident for short
periods at a time and continue talking even if the resident does not respond.
• Provide answers and helpful suggestions for what is known while not providing false
assurances.
• Contact the National council for the blind, Whitworth Road, Drumcondra, Dublin 9.
Lo-Call 1850 334353 e-mail info@ncbi.ie or The Irish deaf society, National Association
of the deaf, 30 Blessing ton Street, Dublin 7. Phone: 01 8601878. e-mail
www.deafhear.ie, www.try-it.ie or www.atdementia.org.uk for up to date information
on technical assistive products and services.
Evaluation of care (based on goals specified)
• Communication care plans must be evaluated when the resident’s condition
improves or deteriorates and at least 3 monthly. Evaluate the effectiveness of the
care provided by checking if the goals of care are being met e.g. the resident is
negotiating their environment safely and participating in ADLs to maximum their
potential.
• Ensure the resident can use their assistive devices appropriately and effectively. If
they are not using their assistive device, discuss with them the reasons for this.
• Evaluate if the resident is socialising with family/friends.
Refer to the ‘Protocol of Expected Standards for Care’ flow chart and sample
‘Personalised Care Plans’ in documenting personalised care planning and in
providing care.
24
25
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Nursing Assessment-Document
Past medical history/Co-Morbidities.
Risk Factors.
Communication abilities /deficits
Pain assessment.
Cognitive ability assessment.
Behaviour and Mood pattern.
Expressive language assessment.
Comprehension of language assessment.
Vision assessment (using his/her
spectacles if applicable.
Hearing assessment (using his/her
hearing aid if applicable).
Consider the impact of
Psychotropic/Narcotic medications.
Acute Infections e.g. U.T.I.
Resident’s cultural beliefs.
Resident’s/Significant others main
concerns.
Further Assessments
MDT Assessments.
Referrals required for e.g. Speech &
language therapist, CNS in Dementia/
Behaviour that challenges/ Older Persons
Care, Psychiatrist, Audiologist, Optician,
Doctor.
Assistive device Needs.
Dignity, respect and privacy
requirements.
(On admission, if resident’s condition improves
Or deteriorates and at least 3 monthly)
Nursing Assessment
Reassess when there is
a change in the
resident’s condition
and at a minimum
every 3 months.
No difficulties in
communication
identified
1. Identify cause if
possible & risk level.
2. Develop a MDT
Personalised
communication
care plan.
Difficulty in
communication
identified
Nursing Diagnosis
1. Resident/Significant other discussion in the
care planning process where possible
2. The identified resident’s problem(s) / need(s)
3. The resident’s identified Goals of Care
4. The specific interventions including verbal
and non-verbal cues.
5. The MDT management plan for any risks
identified. Consider MDT referrals required &
made & specific communication instructions.
6. Pain risk, refer to RAP 16
7. Psychotropic drug risk, refer to RAP 18.
8. Cognition deficit or acute confusion, refer to
RAP 3.
9. Behaviours that challenge risk, Refer to RAP 2.
10. Consider environmental distractions and
reduce/remove same.
11. The appropriate assistive devices
identified/required.
12. Provide education to residents/significant
others & carers on specific communication
instructions & on the use & maintenance of
assistive devices & on accessing further
information from e.g. The National Council
for the blind ,or the National association for
the deaf.
13. Monitor & address residents/Significant
others concerns in relation to
communication difficulties.
Implement a Communication
Care plan Document:
Nursing Care Goals & Planning
Reassess: Refer back
to the MDT should
difficulties in
communication
persist or increase.
Goals unmet or
Condition Changes
Goals met
• Resident/carer aware
of appropriate
communication
measures & involved
in communication
decisions.
• Continue with current
communication care
plan.
Measure outcome
against specified
goals
Nursing Evaluation
Protocol for Expected Standards in Communication in HSE Older Persons Designated Centres
SAMPLE CARE PLAN
Topic Heading: Communication Care Plan
PROBLEM / NEED IDENTIFICATION
Number:
Date
Signature
01/01/10 Mrs Breen’s hearing has recently deteriorated associated with cerumen build up.
Mary reports “I can’t hear what you are saying as my ears are full of wax.”
Patricia
Clarke
GOAL SPECIFICATION
To dissolve the plug of wax in Mary’s ears and thereby restore her ability to understand speech
within 1 week.
GOAL SPECIFICATION
Date
05/01/10
Signature
•
•
•
•
•
•
•
•
•
•
•
Refer Mary to the doctor for assessment to confirm a plug of ear wax has
formed and to prescribe an appropriate ear wax softener.
Explain and discuss the procedure with Mary and get her verbal consent
to the administration of ear wax softener.
Consult her prescription chart and administer the drop(s) as per best
practice guidelines as outlined in the Medication Policy.
Observe Mary for signs of dizziness, and/or disequilibrium after instilling
the ear drops.
Reduce background noise when speaking to Mary.
Speak distinctly adjusting tone appropriately; use touch to indicate your
presence as Mary may not hear you approach.
Mary has been given information on the symptoms of ear infection e.g.
pain, itchiness, and/or purulent discharge and has been requested to
report any symptoms immediately.
Monitor effectiveness of treatment. Ask Mary if she can hear her radio, TV,
etc and adjust the volume as required.
Ask the doctor to re-examine Mary’s ear drum after 5 days to check if the
plug of earwax is dissolving & seek Mary’s opinion on her hearing status
Mary’s Significant/other / Family/ Visitors & Care Staff have been advised
to approach Mary from the front and lightly touch her arm to make her
aware of their presence, reduce background noise, speak slowly & clearly
& let her know when they are moving away so that she doesn’t continue
to speak when they have gone.
Communicate monitoring concerns promptly to the Doctor.
Patricia
Clarke
EVALUATION OF CARE (based on goals specified)
Date
Signature
Discontinued Date: ............../ ............../ 20......... Signature: ................................................
26
Suggested further reading:
HSE, (2009) Regional Guidelines for Communication in Older Persons Residential
Care Facilities in Dublin Mid-Leinster
References
1
Mc Intyre, A. and Atwal, A. (2005) Occupational Therapy and Older People, pages 187192, Blackwell Publishing, Oxford, England.
2
Nanda definition, accessed at
http:www.us.elsevierhealth.com/MERLIN/Gulanik/index.cfm?plan=11
3
Zaretsky, H., Richter, E. and Eisenberg, M. (2005) Medical Aspects of Disability, 3rd Edition,
A Handbook for the Rehabilitation Profession. Pages 292-293, Springer Publishing, New
York.
4
Challis, D., Stewart, K., Sturdy, D., Worden, A., (2000) interRAI UK Long Term Care
Resident Assessment Instrument User’s Manual MDS/RAI UK. The JRW Group, Gatley,
Cheadle, Cheshire SK8 4BE
5
Kitwood, T, (1997), Dementia reconsidered, the person comes first, p.136
27
RAP 2: Mood and Behaviour
Definitions:
Mood is a person’s state of mind or emotion.
Behaviour is the action or reaction of a person to a stimulus.
Stimulus is something that directly or indirectly causes a response in the individual e.g.
stimuli can be internal (pain due to infection) or external such as from sound or touch
(sense organs).
Behaviour that challenges is described as “Behaviour of such an intensity, frequency
or duration that the physical safety of the person or others is likely to be placed in serious
jeopardy, or behaviour which is likely to seriously limit or delay access to and use of
ordinary community facilities”.1
Glossary of terms:2, 3
Functional Analyses (F.A.): Are the observations taken to answer the question, why is
the behaviour that challenges occurring. When obtaining information we look at defining
the specific behaviour occurring, its rate, intensity or duration and establish a baseline
through A-B-C recording (antecedent, behaviour consequence).
Antecedent: is what the resident was doing immediately before the behaviour occurred.
Behaviour: what the problem behaviour is, clearly define the behaviour.
Consequence: what happened immediately after the behaviour occurred? Consider:
how staff responded to the resident, what did the resident do?
Correlation: a mutual relation identified between factors such as the time of day or
specific activities where the incidence of behaviour that challenges occurs.
RAI Identifiers of Potential Risk:
Resident has behaviours that challenge C20, D15-20, Constipation G11, F23, Pain
D22, Depression (mood decline) D11, F23, Altered cognitive state e.g. (confusion,)
D11, D13, D14, Communication impairment, D1, D3, D4, D6, Malnutrition F1, Dehydration, F21 Disturbed Sleep Pattern/ Sleep Deprivation, C14, N8, N9, Psychological factors H5
Risk factors:
Residents who have behaviours that challenge are often perceived by
professionals as challenging. It must be remembered that this may be the
resident’s only way of communicating their unmet needs.
Risks include all the above RAI Identifiers and Organic disease, (Dementia, Infection,
Cancer, Chronic pain), Confusion, Emotional trauma, ABI (acquired brain injury) Mental
Health Problems (Delirium, Psychosis, Depression), Immunocompromised, Loneliness,
Boredom, Response to environment, Communicative act, Interpersonal interactions,
Learnt Behaviours.
Further Assessments:
The following assessments are to be carried out if the resident is identified
as exhibiting behaviour that challenges, if the resident’s behaviour improves
or deteriorates and at least two weekly.
1) Assess the resident’s usual behaviour pattern with their significant other(s) and staff
working in the unit to establish a baseline. Several sources of information should be
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used in assessing residents with behaviours that challenge, with the resident being the
primary source for this information. However, where marked difficulties exist for residents
in communicating their needs, their significant other(s) and carers will often know the most
effective methods of communicating with the resident. Gather and document pertinent
information about the resident’s usual mode of communication; this should include verbal
/ non verbal cues which the resident uses to identify their needs/wants. Refer to RAP 1:
Communication, Vision & Hearing.
2) Assess for an underlying cause(s) for any new presentations of behaviours that challenge
e.g. out rule the presence of:
• Pain, use a validated tool to assess e.g. Abbey Pain scale or Numeric Pain Scale.
Refer to RAP 16: Pain
• Exacerbation of an underlying medical condition causing discomfort/pain e.g.
angina, gastric ulcers, arthritis, etc
• Constipation
• Infection; observe for local/systemic signs and symptoms of infection. Assess vital
signs, urinalysis, presence of a cough, etc. If indicated send appropriate samples
to the lab for Culture and Sensitivity
• Boredom and the need for occupation
3) Assess and observe for signs of agitation, confusion or memory decline using a validated
tool e.g. Cohen Mansfield Agitation Inventory or the Mini Mental State Exam, MMSE.
Refer the resident to the Doctor for further assessment if required and/or to a specialist
in the area e.g. CNS, Psychologist, Psychiatrist as appropriate.
4) Assess nutritional status, refer to RAP 5, hydration status, refer to RAP 6 and
constipation status, refer to RAP 9
5) Assess pertinent blood results. Refer to the doctor to reserve bloods for further
assessment such as FBC, U&E, ESR etc.
6) Assess each episode of behaviour and or mood decline using a validated tool e.g. ABC
Functional Analyses of Behaviour or the Hospital Anxiety and Depression Scale (HADS).
Document each episode of behaviour in the accident / incident reporting form, in
accordance with the designated centre’s policy.
7) Undertake a full risk assessment where indicated by the behaviour exhibited.
Referrals Required:
•
Refer to the resident’s doctor for a medical assessment and full blood screen to assess
for underlying infection and/or dehydration
• Refer to the CNS behaviour (if available) or consider referral to the CNS dementia /
CNS older persons care if present onsite
• Refer the resident to the Occupational Therapist for further cognitive assessment if
deemed appropriate
• Refer the resident to the dietician if they are identified as being at risk of malnutrition
or if malnutrition is evident
• Refer the resident to the Physiotherapist for correct positioning to alleviate pain if
evident
• Refer the resident to the Speech and Language Therapist if communication difficulties
are evident
• Refer the resident to the Occupational Therapist/Activities Co-ordinator to assist in
developing an appropriate, individualised activity/occupation schedule for the resident
If behaviours persist consider making a referral to a consultant psychiatrist
or to a psychologist.
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Personalised Care Planning
The aim of care planning is develop a single multidisciplinary (MDT) plan of personalised
care to address the cause or risks of behaviour where possible. The MDT includes the
resident / significant other(s), carers, nurses, doctors and allied health professionals.
Problem/Need Identification
Record the actual or potential behavioural problem and its associated or related risk
factors. For example; “Mary has the potential to display episodes of verbal
aggression related to an acquired brain injury or agitation associated with
constipation”.
Goal Specification
Record: realistic, measurable and obtainable goals. For example: “To reduce the
number of episodes of verbal aggression exhibited by Mary within a two-week
period”.
Specific Interventions
These are the specific steps taken based on expected standards of care in addressing
actual or potential behaviours that challenge. Document:
• What we need to do (specific interventions based on residents/significant other(s)
care choices where possible)
• What we need to monitor (on-going reassessments)
• What we need to communicate (back to the MDT)
• What/who we need to educate (to improve the problem)
Note: The resident’s needs may be physical and/or psychological in nature and if unmet
can result in the resident exhibiting the behaviour that challenges. The aim of care is
evaluate the RAI Identifiers of Potential Risk that have been triggered during assessment
and to consider other risk factors that might be causing the behaviours, so that successful
interventions can be identified, implemented and alternate positive behaviours
reinforced.
Non-pharmacological interventions should be used first before medication
in cases of behaviours that challenge4
1. Specific MDT interventions: Record:
a) Accurate Assessment of behaviours that challenge:
• Record and monitor resident’s behaviour using the ABC functional analyses
(antecedent, behaviour, consequence) or the Cohen Mansfield Agitation Inventory.
Document the time, location, triggers if noted and the type of behaviour
exhibited. Analyse the information to ascertain if any precipitating factors exist,
such as a correlation / emerging pattern between the times of day, certain activities,
particular staff, etc when an incidence of behaviour that challenges occurs.
• Consider: Many residents who experience altered cognitive state may have
communication difficulties, thus exhibiting behaviours such as screaming or
aggression. The behaviours may also be influenced by the interaction skills of staff
• Risk assess the behaviour and implement appropriate risk management strategies
e,g. Crisis Prevention Interventions techniques
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b) Meet with the MDT (Doctor, Psychiatrist, Nurse, CNS, O.T., Physio, Social worker,
Activity team, Dietician, Art therapist, Music therapist, Speech and Language
therapist) resident and family to develop a multidisciplinary approach and
personalised plan of care.
c) Treat any identified underlying causes to behaviours such as infection, pain, etc, as
directed by the Doctor. Monitor the effects of treatment on the outcome of
behaviour.
d) Implement a personalised activity schedule based on the information obtained in the
meaningful activities assessment.
e) Staff should familiarise themselves with the resident as a person, using the
information obtained from ‘A Key to Me’, ‘My Day, My Way’ and the resident’s ‘Personal
Calendar of Important Events’. Particular emphasis should be noted on the resident’s
interests, likes and dislikes. This information may assist staff in de-escalating episodes
of behaviours that challenges.
2. Monitoring & ongoing reassessment
a) Continue to observe and monitor behaviour to establish a pattern, observing for any
new behaviours presenting. Report findings to the MDT
b) Document and monitor each episode of behaviours that challenge on the functional
analyses form (See Appendix 1).
c) Report behaviours that challenge on the Accident / Incident reporting form as
appropriate and in accordance with the designated centre’s policy.
d) Monitor interventions closely for effectiveness
e) Monitor for any underlying causes to behaviour presenting and the treatment outcome.
3. Communication
a) Promptly communicate any monitoring concerns to the resident’s doctor and MDT as
appropriate. Discuss the issues arising or the need for new interventions. Update and
implement personalised care plans accordingly.
b) Note: residents MUST BE referred back to the multi-disciplinary team if there is
deterioration in their Behaviour despite following behavioural interventions
implemented by the MD team.
c) Inform all staff of the incidence of behaviour at the commencement of each shift,
including agency and relief staff. Ensure staff are aware of resident’s personalised care
plan and are informed of any changes in the residents care at the commencement of
each shift.
d) Communicate with the resident’s significant others / visitors about the resident’s
personalised plan of care and inform them of any changes and encourage their
involvement.
4. Information / Education / Health promotion for Resident, Significant
Other(s) and Carers
a) Educate staff around behaviours that challenge. Identify to staff that these behaviours
do serve a purpose to the resident who is exhibiting them. This will allow staff to gain
an understanding and insight into the behaviour, thus assisting in the treatment
outcome.
b) Educate the resident’s significant other(s) to allow them to gain an understanding which
may in turn alleviate anxiety or fears they may have about their loved one and encourage
their involvement. Provide specific written information for them as appropriate.
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c) Inform staff about the importance to always re-establish communication with the
resident after behaviours that challenge are exhibited in a calm reassuring way.
d) Educate staff to avoid revisiting the event with the resident, as the resident is
unlikely to remember what has happened. This serves no useful purpose.
Evaluation of Care, (based on goals specified)
a) ‘Behaviour that challenges’ care plans must be evaluated at two weekly intervals.
Evaluate the effectiveness of the interventions implemented (care provided) by assessing
to see if the goals specified are being met e.g. reduction in the incidences of behaviour
that challenge, improved interactions with fellow residents and staff, improved
participation in activities of daily living, improvement in the resident’s or their significant
other(‘s) self reported quality of life.
b) When behaviours that challenge have faded out, observe for replacement behaviours
and reinforce alternate positive behaviours.
c) If the behaviour has not faded out, meet with the Consultant / Psychiatrist or Doctor to
discuss the implementation of Psychotropic / Neuroleptic medication in conjunction
with a personalised plan of care. Monitor closely for effects and side effects of medication
used. Evaluate as required; “Each resident should benefit from their medication to
increase the quality or duration of their life. They should not suffer unnecessarily
from illness caused by the excessive, inappropriate or inadequate consumption of
medicines”.5
Refer to the ‘Protocol of Expected Standards for Care’ flow chart and sample
‘Personalised Care Plans’ in documenting personalised care planning and in
providing care.
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33
• Past & present medical history including
suggestive evidence of behaviours that
challenge.
• Commence Functional Analyses to
determine & assess RAI identifiers / risk
factors to behaviour exhibited.
• Outrule acute confusional state, mood
decline and any RAI identifiers, risk
factors identified using a validated tool,
continue with F.A. recording.
• When / if identified treat causes e.g.,
pain, UTI. Monitor closely for treatment
outcome.
• Continue with F.A recording, analyse
information to ascertain any
precipitating factors, obtain information
from resident and or significant other.
• Continue to observe and assess
behaviour, meet with MDT and family to
develop a personalised plan of care
incorporating a desired activity schedule,
monitor closely.
• Undertake a full risk assessment where
indicated by the behaviour exhibited.
Nursing Assessment-Document
(On admission, if the resident’s condition improves
or deteriorates and at two weekly intervals)
Nursing Assessment
Record: realistic,
measurable &
obtainable goals. For
example: to reduce
the number of
episodes of verbal
aggression exhibited
within a Two-weekly
period.
Nursing Goal
The resident
demonstrates
behaviour that
challenges e.g. verbal
aggression such as
shouting & name
calling in a threatening
manner.
Nursing Diagnosis
• Accurate assessment: document time,
location triggers if noted, type of behaviour.
• Close observation of the behaviour is required
while also observing for any trigger evident
prior to the behaviour by using ABC
functional analyses.
• Inform all staff of the incidence of behaviour
at the commencement of each shift.
• Continuous monitoring of the behaviour and
document clearly on the FA form and/or the
Accident / Incident form in accordance with
local policy. Analyse information.
• Report findings to the multi-disciplinary team.
• Obtain information from the resident /their
significant other (s).
• Ensure staff, familiarise themselves with the
resident (use ‘A Key to Me’, ‘My Day, My Way’,
‘Personal Calendar of Important events’ )
• Meet with the MDT to develop a
personalised plan of care incorporating a
desired activity schedule, including
information obtained.
• Implement plan and monitor closely.
• Educate staff and the resident’s significant
other(s) on their personalised plan of care.
• Note: residents must be referred back to the
MDT before their scheduled evaluation date
should there be a deterioration in their
behaviour despite following interventions
implemented by the MDT.
Care Planning
• Behaviour that challenge
care plans must be
evaluated at two weekly
intervals.
• Evaluate the effectiveness of
the interventions
implemented, (care
provided) by assessing to
see if the goal(s) specified
are being met e.g. number
of incidences reduced,
improved social interactions,
self reported improvement
in quality of life.
• When behaviours that
challenge have faded out
observe for replacement
behaviours and reinforce
alternate positive
behaviours.
• If the behaviour has not
faded out meet with
consultant / psychiatrist or
GP to discuss the use of
psychotropic / Neuroleptic
medication in conjunction
with personalised plan of
care, Monitor closely for
effects and side effects of
drug (s) used, evaluate as
required.
Evaluation
Protocol for Care for Behaviours that Challenge in HSE Older Persons Designated Centres
SAMPLE CARE PLAN
(to be reviewed in 3 months and re-written in 6 months)
Topic Heading: Sample (Behaviour) Care Plan
PROBLEM / NEED IDENTIFICATION
Number:
Date
Signature
01/01/10 Mary displays verbal aggression related to acquired brain injury
GOAL SPECIFICATION
To reduce and / or fade out Mary’s episodes of verbal aggression by 2 weeks
SPECIFIC INTERVENTIONS
Date
05/01/10
Signature
•
•
•
•
•
•
•
•
•
•
•
•
•
•
All staff must use the same firm approach with Mary when aggressive
behaviour is exhibited.
Do not respond back to any verbally aggressive statements/behaviours
exhibited by Mary.
Staff will react in a calm voice and attempt to redirect the conversation,
(Use the information obtained in the “A key to Me” to redirect the
conversation).
Do not revisit the behavioural event, as Mary is unlikely to remember
what has happened. This serves no useful purpose.
Staff should re-establish communication with Mary after each episode
has resolved
Always explain to Mary any procedures staff wish to carry out.
If Mary becomes agitated when staff are attempting to carry out a
procedure walk away and approach again later if safe to do so.
(within hour)
Ensure routine medications are administered at the correct times.
Refer to Mary’s preferred activities see Meaning Activities Care Plan. Mary
particularly likes the rummage box and her life story being read to her.
Allow time for the Mary to express herself e.g. anxieties, fears. Offer Mary
reassurance and encouragement at all times.
Monitor / observe and document any verbal/ non-verbal signs of
aggression e.g. rigid body, clenched fists or verbally aggressive behaviour
using a ABC Functional analyses form. Note any triggers evident prior to
the behaviour.
Document clearly any incidence of behaviours that challenge in incident
/ accident report book in accordance with hospital policy
Refer Mary back to the MDT before her scheduled evaluation date should
there be a deterioration in behaviour despite following interventions
implemented by the MDT.
Educate resident, significant other and family on interventions
implemented
Patricia
Clarke
EVALUATION OF CARE (based on goals specified)
Date
Time
Signature
Discontinued Date: ............../ ............../ 20......... Signature: ................................................
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Appendix 1: ABC Functional analyses record form
Target Behaviour: please complete each time the resident engages in a target behaviour
i.e. (the specific behaviour). For example each time the resident is hitting out
Time/
Date
Antecedents
(before)
What did the
resident do?
Name of staff/other
residents involved?
Target Behaviour
Consequences
(What is the
(After)
problem behaviour- What did you do?
describe)
What did you say to
the resident? What
did the resident do?
Staff please
sign and print
name
35
References
36
1
Emerson et al, (2000) “treatment and management of behaviours that challenge in
residential”, journal of applied research in intellectual disabilities;13;197-215
2
Newman et al, (2003) Behaviour speak, A glossary of terms in applied behaviour
analyses; 114-118
3
Miltenberger, R.,G, (2004), third edition, behaviour modification, principles and
procedures; 4:71
4
National institute for clinical excellence and social care institute for excellence, (2006)
Dementia: supporting people with dementia & their carers in health and social care
5
Health Information and Quality Authority, (2009) National quality standards for
residential care settings for older people in Ireland
RAP 3: Cognition and Acute Confusion
Definitions:
Cognition is defined as “the collection of mental processes and activities used in perceiving,
remembering, thinking, and understanding, as well as the act of using these processes.” 1
Acute confusion, also known as delirium, is generally a sudden onset of confusion or
sudden worsening of a person’s existing confusional state.
Delirium is defined as “a transient disorder of cognition and attention accompanied by the
sleep-wake cycle and psychomotor behaviour”2
Many residents with acute confusion may have associated cognitive deficits such as altered
perception (including hallucinations, illusions and delusions); sleep disturbances; memory
loss; language deficits; inattention; altered level of consciousness, disorientation/disorganised
thinking; difficulty with calculations, abstraction, insight, judgement and mood disorders
e.g. fear, elation, anxiety or depression.
Residents with dementia such as vascular, lewy-body, frontal temporal (Picks) and mixed
(vascular and Alzheimer’s) dementia may also present with acute confusion. Vascular
dementia that presents with a sudden onset of acute confusion, may be associated with a
further vascular event occurring. With lewy-body, frontal temporal and mixed dementia, the
resident may have a fluctuating decline in cognition and confusion.
It is essential not to treat signs of acute confusion as a natural progression of
the resident’s dementia. Delirium/acute confusion is a medical emergency.
RAI Identifiers of Potential Risks:
■ Constipation G11 ■ Cognitive impairment D3, D4, D11, D13, D14, ■
Hallucinations/delusions D21, ■ Depression N8, ■ Dehydration F21, ■ Malnutrition
F1, ■ Vomiting and/or diarrhoea F23, ■ Communication impairment D3, D4 ■ Pain
D22 ■ Disturbed Sleep Pattern/Sleep deprivation N9.
Other Risks include:
■ Hypoxia, ■ Infection/pyrexia, ■ hyper/hypo glycaemia, ■ Physical restraints, ■
Psychological factors ■ Urinary/chest infection ■ Advanced age ■ Dementia ■
New/unfamiliar environment ■ Alcohol addiction ■ over medication/drug toxicity ■
mental health illness ■ Reduced renal function ■ Post surgery ■ Trauma i.e. head
injury following fall ■ Acute stress ■ Immuno-compromised ■ Sensory overload/
deprivation ■ Isolation ■ Relocation ■ Recent loss/bereavement
Risk factors for some residents may be compounded further by their inability
to give an accurate account of their symptoms associated with their memory
problems or cognitive impairment. Therefore it is important for nurses to
carefully observe for all triggers and risk factors.
Further assessments
If a resident is identified as being acutely confused, the following assessments
should be carried out. The resident should be reassessed when their confusion
improves or deteriorates, and at least once weekly.
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1. Carry out a health and safety risk assessment to identify any potential risks posed
to the acutely confused resident, other residents and staff members.
2. Assess the resident’s falls risk using a validated tool e.g. FRASE (refer to Rap 10: Falls
Prevention and Risk Reduction).
3. Assess the resident’s cognition using a validated tool e.g. MMSE
4. Establish the resident’s baseline cognitive status by obtaining information from
people who are familiar with the resident e.g. the resident’s significant other(s),
carers and staff.
5. Assess for signs and symptoms of infection e.g. urinalysis, assess vital signs and
temperature four hourly.
6. Assess the resident’s pressure ulcer risk using a validated tool e.g. Braden (Refer to Rap
12: Pressure Ulcer Prevention and Management).
7. Assess for signs and symptoms of constipation (refer to RAP 9: Constipation).
8. Assess for signs and symptoms of dehydration (refer to Rap 6: Dehydration and Fluid
Maintenance)
9. Assess for signs and symptoms of malnutrition (refer to Rap 5: Nutritional Status)
10. Assess for swallowing difficulties which may pose a risk for aspiration.
11. Assess for signs and symptoms of pain (refer to Rap 16: Pain).
12. Assess current medications with the doctor and/or pharmacist as a contributory factor
to the resident’s acute confusion (refer to Rap 18: Psychotropic Drugs).
13. Assess each episode of acute confusion using a validated behaviour assessment tool and
record e.g. using a mood and behaviour assessment tool (refer to Rap 2: Mood and
Behaviour).
Referrals required:
Referrals should be made as appropriate to assessment findings
• Refer to the Doctor promptly for a general physical examination to outrule an
underlying pathological cause for the resident’s acute confusion
• An onward referral may be required for a psychiatry review if the resident is
depressed or anxious and/or has had a recent bereavement
• Refer to the doctor and pharmacist for a medication review
• Refer to the dietetic services if the resident is at risk of/or has malnutrition
• Refer to the physiotherapist if the resident is hypoxic; for recommendations on
correct positioning if pain is present and/or for a mobility/gait assessment
• Refer to the speech and language therapist for a swallow/communication assessment
as appropriate
• Refer to Activities for recreational activities
• Refer to the Occupational Therapist if the resident has any additional seating/comfort
requirements
• Refer to the Social Work Department if the resident has had a recent bereavement
or loss and/or is struggling to come to terms with their environment
• Refer to CNS’s (if available) for education and advice on appropriate management
according to current best practice
Personalised Care Planning
The aim of care planning is to develop a single, multidisciplinary (MDT) plan of personalised
care to address the cause or risks of acute confusion where possible. The MDT includes the
resident and significant other(s), carers, nurses, doctors, and allied health professionals.
38
Problem/ Need identification
Record the actual and /or potential problem and its associated or related risk factors, e.g.
Mary has a urinary tract infection and is acutely confused, possibly related to an inadequate oral
fluid intake
Goal specification
Record realistic, measurable and obtainable MDT goals e.g. Mary will drink at least 1.5 litres
of oral fluids daily. Mary’s UTI will be resolved within 7 days. Mary’s MMSE score will return to
her baseline of 18/30
Specific Interventions
These are the specific steps taken based on expected standards of care in addressing actual
or potential cognition and acute confusion problems. Document:
• What we need to do (specific interventions based on residents/significant other(s) care
choices where possible)
• What we need to monitor (on-going reassessments)
• What we need to communicate (back to the MDT)
• What/who we need to educate (to improve the problem)
1. Specific MDT interventions
a) The specific interventions to address the resident’s /significant others
concerns, preferences and care choices e.g. A significant other’s concern for the
resident’s acute confusion can be addressed by effectively communicating and
incorporating their input into the care planning process.
b) Specific MDT care instructions: This includes nursing care instructions and other
care instructions from members of the MDT e.g. doctors instructions; dietician’s specific
instructions on diet and fluids; physiotherapist instructions; CNS instructions. These
instructions should be listed here or a photocopy attached to the care plan. It is
important to refer the reader to the attached instructions. The specific MDT instructions
required will be specific to the underlying cause of the acute confusional state.
General interventions include:
• Document all incidents of acute confusion using a behaviour diary. Complete an
Incident/Accident report form, if required.
• Gently orientate the resident to time, place and person, incorporating information
obtained from ‘A Key to Me’.
• Implement CPI training techniques as deemed appropriate, for the management of
agitation and aggressive outbursts.
2. Monitoring and ongoing reassessment:
• Monitor the resident’s vital signs at least four hourly
• Monitor and reassess the resident’s confusion, mood and behaviour on a Mood and
Behaviour Diary.
• Continue to monitor and record the resident’s cognition once a week using a validated
tool e.g. MMSE.
• Monitor for signs of UTI each time the resident passes urine. Note the urine colour,
approx volume, presence of malodour, and pain on urination. Check urinalysis and send
a urine specimen to the lab for culture & sensitivity if appropriate.
39
•
•
Monitor for signs and symptoms of dehydration. Maintain a fluid intake and output
chart for at least 7 days.
Monitor for signs and symptoms of malnutrition and implement interventions as
appropriate (Refer to RAP 5- Nutritional Status)
3. Communication:
• Communicate any monitoring concerns to the MDT e.g. if the resident’s confusion is
worsening.
• Communicate the resident’s personalised care plan with all those involved in the
resident’s direct care. Ensure the resident and their significant other is kept up to date
with the resident’s personalised care plan and with any improvement/deterioration in
the resident’s confusion. Ensure that the significant other(s) are involved in and are in
agreement with the resident’s plan of care.
• Residents must be referred back to the MDT if there is any deterioration in the resident’s
acute confusion despite following MDT advice/instructions.
4. Information/ Education/ Health Promotion for resident, significant
other and carers
• Provide information/education to the resident/significant other(s) and carers on the
cause of the resident’s acute confusion, their plan of care and on appropriate strategies
in dealing with acute confusion
Evaluation of care (based on goals specified)
• The personalised plan of care for the resident with acute confusion must be evaluated
when the residents confusion improves or deteriorates, and at least once weekly.
Evaluate the effectiveness of the interventions provided by assessing to see if the goals
of care are being met e.g. is confusion level minimising? Is the MMSE score increasing?
Is the resident drinking at least 1.5 litres of fluids daily? Are we providing a safe
environment for the resident?
• If the resident’s confusion levels are not resolving, refer back to the doctor for further
diagnostic assessment and to other members of the MDT, as appropriate.
Refer to the ‘Protocol of Expected Standards for Care’ flow chart and sample
‘Personalised Care Plans’ in documenting personalised care planning and in
providing care.
40
41
• Past & present medical history including
suggestive evidence of previous
episodes of acute confusion
• Assess the resident’s cognition using a
validated tool. Check usual pattern of
cognition / confusion with resident’s
next of kin, significant other(s) to obtain
a base line
• Outrule mood decline and treat any RAI
identifiers of Potential Risk or other risk
factors
• Assess for an underlying cause e.g.
infection, pain, constipation,
dehydration use a validated tool where
appropriate
• Carry out a health & safety risk
assessment to identify any potential risks
posed to the acutely confused resident,
other residents, visitors & staff
• Assess the residents falls risk using a
validated tool
• Assess current medications with the
Doctor and / or the pharmacist which
may be a contributory factor to the
acute confusion
• Assess each episode of acute confusion
using a validated tool
Nursing Assessment-Document
(On admission, if resident’s condition improves
Or deteriorates and at once weekly intervals)
Nursing Assessment
Record:
Realistic, measurable &
obtainable goals.
Nursing Goal
Record the identified
problem, e.g. acute
confusion related to a
UTI
Nursing Diagnosis
Document:
• The specific interventions required in the
treatment and management of the underlying
cause of the acute confusion
• Record all incidents of acute confusion using a
Behaviour Diary. Complete an
Incident/Accident form if appropriate
• Document appropriate risk management
strategies
• Gently orientate the individual to person,
place & time. Use the information obtained in
the ‘Key to Me’ or the resident’s ‘Life Story’ to
assist in re-orientating
• Explain any procedures before carrying them
out
• Monitor vital signs & temperature four hourly
• Monitor and reassess the resident’s confusion,
mood & behaviour
• Monitor for signs and symptoms of local/
systemic infections
• Monitor urinary output on an intake/ output
chart
• Monitor bowel elimination
• Monitor for signs & symptoms of dehydration
• Monitor for malnutrition
• Monitor risks for resident/visitors and staff
• Communicate promptly any monitoring
concerns to the MDT
• Inform the resident/significant other of any
proposed changes to their individualised care
plan & keep of any improvement and / or
deterioration in confusion levels
Care Planning
• Acute confusion care
plans must be evaluated
at once weekly intervals
• Evaluate the effectiveness
of the interventions
implemented
• If the residents confusion
levels are not resolving,
refer back to the Doctor
for further diagnostic
assessment
• Refer back to the MDT as
appropriate
Evaluation
Protocol for Care for Acute Confusion in HSE Older Persons Designated Centres
SAMPLE CARE PLAN
Topic Heading: Acute Confusion Care Plan
PROBLEM / NEED IDENTIFICATION
Number:
Date
Signature
21/01/10 Mary has a urinary tract infection and is acutely confused, possibly
related to an inadequate fluid intake.
GOAL SPECIFICATION
Mary will be provided with at least 1.5litres of fluids daily. Mary’s UTI will be resolved within 7 days.
Mary’s MMSE score will return to her baseline of 18/30.
SPECIFIC INTERVENTIONS
Date
21/01/10
Signature
•
•
•
•
•
•
•
•
•
Administer Ipral 200mgs at 08:00hrs and 18.00hrs daily for 7 days as
prescribed.
Encourage Mary to drink at least 1.5litres of oral fluids every 24hrs.
Maintain a fluid balance chart for 7 days, record the drinks
offered/refused and those taken. Mary only likes to drink tea and warm
7UP.
Monitor Mary’s urinary output each time she passes urine (note the
colour, volume, malodour and assess Mary for any pain on voiding).
Document all incidents of acute confusion on a Mood and Behaviour
Diary and complete an Incident/Near-miss report form, if required.
Record Mary’s vital signs and temperature at least 4 hourly.
Gently re-orientate Mary to time, place and person when she is confused.
Use the information obtained in the ‘A Key to Me’ document to assist in
re-orientating and in communicating with Mary when she is confused.
Mary particularly likes talking about her family and looking at their
photographs.
Always explain any events/interventions/procedures to Mary prior to
carrying them out
Communicate any concerns regarding Mary’s care promptly to the
doctor and other relevant members of the MDT.
Inform Mary and/or significant other of any changes to Mary’s
individualised plan of care and of any improvement and/or deterioration
in confusion levels.
Patricia
Clarke
EVALUATION OF CARE (based on goals specified)
Date
Time
Signature
Discontinued Date: ............../ ............../ 20......... Signature: ................................................
42
References
1
Ashcroft, M, H (2006) Cognition. Fourth Edition: 11.
2
WebMD, (2008) Confusional states and acute memory Disorders.
http: // emedicine.medscape.com/article/1135767-overview
43
RAP 4: Breathing and Circulation
Definitions:
The Cardiovascular System includes the heart together with two networks of blood
vessels; these are the systemic circulation and the pulmonary circulation. The cardiovascular
system effects the circulation of the blood around the body, which brings about transport of
nutrients and oxygen to the tissues and the removal of waste products via arteries and veins.
Diseases affecting the cardiovascular system are many and can cause significant morbidity and
mortality particularly for older people. Cardiovascular disease (CVD) including coronary heart
disease (CHD), Heart failure (HF), stroke (CVA), Peripheral Vascular Disease (PVD) and other
circulatory diseases accounts for the most common cause of death in Ireland.2 Because CVD
is frequently associated with life-style related atherosclerotic changes, much emphasis is now
placed on preventing its occurrence and progression. The aim of which is to modify risk
factors, such as: in the treatment of hypertension, controlling cholesterol levels through
healthy eating, exercise and/or medication, avoidance of smoking and stress reduction.3
The Respiratory system involves the combination of organs and tissues associated with
breathing. It includes the nasal cavity, pharynx, trachea, bronchi, bronchioles, lungs, pleural
cavity and the diaphragm, nerves and other muscles associated with breathing movements.4
Diseases affecting the respiratory system range from mild and self-limiting such as a common
cold (Respiratory Tract Infection), to life-limiting conditions such as Chronic Obstructive
Pulmonary Disease (COPD) or Restrictive Lung Diseases, to life-threatening conditions such
as bacterial pneumonia. Modifiable risk factors in the prevention and treatment include:
healthy eating, exercise, avoidance of smoking and vaccination (pneumonia/flu).
COPD: is a group of respiratory diseases characterised by airway obstruction. The main
obstructive airways diseases include: Chronic bronchitis and its subgroup bronchiolitis;
Bronchiectasis; Asthma; and Emphysema.
Restrictive Lung Diseases: are a group of lung diseases that restrict lung expansion
resulting in a decreased lung volume, an increased work of breathing, and inadequate
ventilation and/or oxygenation.5
RAI Identifiers of Potential Risks:
■ Has not received Flu / Pneumococcal vaccines A61, A62, ■ Pursed Lipped Breathing
E1, ■ Abdominal Breathing E1, ■ Changes in Breathing Pattern E2, ■ Difficulty
associated with Breathing C19, E4, ■ History of smoking E7, ■ Trachyeostomy E5■
Cough Present E8, ■ Lower Extremity Oedema E9, ■ Differences in Temperature in
Lower Extremities E9, ■ Palliative Care Symptoms of Dyspnoea, Cough, Noisy
Breathing, Fatigue O6, ■ End of Life Care Symptoms of Dyspnoea, Cough, Noisy
Breathing, Fatigue P5.
Other Risk Factors include:
1. Risk Factors and Causes of Respiratory Disease include:
a) COPD this includes:
•
•
44
Chronic bronchitis (associated with hyperplasia and hypersecretion of mucus glands)
caused by tobacco smoking and/or air pollutants.
Bronchiolitis (associated with inflammatory scarring and bronchiole obliteration) caused
by tobacco smoking and/or air pollutants.
•
•
•
Emphysema (associated with airspace enlargement and wall destruction) mainly
caused by tobacco smoking.
Asthma (associated with smooth muscle hyperplasia, excessive mucus and
inflammation) results from immunologic or idiopathic causes.
Bronchiectasis (dilation and scarring of airways) results from persistent severe
infections.
b) Restrictive Lung Diseases
Causes/risks include
1. Pulmonary fibrosis and hypersensitivity pneumonitis caused by inhalation of
environmental or occupational pollutants/allergens e.g.
•
•
•
•
•
•
•
•
Asbestosis (asbestos dust).
Silicosis (silica dust [pottery]).
Silo-filler’s disease (toxic gas inhalation).
Farmer’s Lung (inhalation of thermophilic actinomycetes from fresh-cut hay).
Bird Fancier’s Lung (inhalation of avian proteins from bird droppings or feathers).
Mushroom Worker’s Lung (inhalation of thermophilic actinomycetes from
Mushroom compost).
Peat moss worker's lung (caused by Monocillium sp. and Penicillium citreonigrum
found in peat moss).
Chemical Worker's lung (caused by Trimellitic anhydride found in plastics, resins,
and paints).
2.
3.
4.
5.
6.
Acute Respiratory Distress Syndrome.
Inflammatory Diseases such as sarcoidosis, rheumatoid arthritis.
Radiation fibrosis.
Certain drugs such as amiodrone, methotrexate, opiates.
Neuromuscular disease such as quadriplegia, multiple sclerosis, motor neuron
disease, polio and post polio syndrome.
7. Musculoskeletal and chest wall deformities such as kyphosis, severe scoliosis,
kyphoscoliosis, kyphosis, fractured ribs.
8. Idiopathic causes.
Other risks include: tracheostomy, impaired swallow and aspiration risk (dysphagia/
impaired cough/gag reflex) and bed bound residents.
c) Signs and Symptoms of Respiratory Disease
These differ depending on the disease. Common symptoms include:
•
•
•
•
•
•
General malaise.
Shortness of breath or dysponea which usually occurs with exercise and can interfere
with daily activities. In severe cases, shortness of breath can occur while resting
(Orthopnea).
Cyanosis, a bluish discoloration of the lips, tongue or fingers.
Abnormal pulse oximetry, peak flow recordings.
Cough with or without the production of sputum.
Coughing blood (haemoptysis).
45
•
•
•
•
•
•
Chest pain. This may or may not be pleuritic chest pain (that is, pain that worsens
with the movements of breathing).
Noisy breathing, either wheeze or stridor.
Fatigue.
Loss of appetite.
Weight loss.
Cachexia.
In some cases respiratory disease is diagnosed without symptoms in the investigation of
another disease or through a routine check.
2. Risk Factors for Cardiovascular Disease include:
There are many risk factors associated with cardiovascular disease. The major risk factors
include: tobacco use, alcohol use, high blood pressure (hypertension), high cholesterol,
obesity, diabetes, physical inactivity and unhealthy diets. Old age, gender (men), family history
of CVD, ethnic origin (African or Asian ancestry are at higher risks of developing cardiovascular
disease than other racial groups), poverty, chronic stress, social isolation, anxiety and
depression increases the risk of CVD. Certain medicines such the contraceptive pill and
hormone replacement therapy may also increase risks.6
Lower Extremity Peripheral Vascular Disease (PVD) Risk Factors:
a) Risk factors for Peripheral Arterial Disease (PAD) include diabetes, hypertension,
hyperlipedemia, stroke, transient ischaemia attack, myocardial infarction, angina,
intermittent claudication, smoking, a history of arterial surgery and previous or present
leg ulceration.
b) Risk factors for venous hypertension include multiple pregnancies, Deep Venous
Thrombosis, obesity, occupation (standing for long periods), a history of varicose veins,
phlebitis, vein surgery or sclerotherapy, fracture, immobility and a family history of leg
ulcers or previous/present leg ulceration. Other risks include a history of Intravenous Drug
Abuse.7, 8
Cardiovascular Disease Signs and Symptoms9
1. Signs and Symptoms of Coronary Artery Disease
•
•
•
•
•
•
•
46
Angina (may be described as a discomfort, heaviness, pressure, aching, burning,
fullness, squeezing, or painful feeling in the chest, shoulders, arms, neck, throat, jaw,
or back. Pain may mimic heartburn.; fullness, indigestion, or choking feeling).
Dyspnoea.
Palpitations, arrhythmias and ECG abnormalities.
Tachycardia.
Weakness or dizziness.
Nausea.
Sweating.
2. Symptoms of a Myocardial Infarction (MI)
Symptoms of a MI typically last 30 minutes or longer and are not relieved by rest or oral
medications, these may include:
•
•
•
•
•
•
•
Chest pain- usually with same distribution as angina above. Atypical pain can also
be a feature.
Acute shortness of breath, abnormal pulse oximetry recordings.
Sweating, nausea, vomiting, or dizziness.
Extreme weakness, anxiety, or a sense of impending doom and a feeling of being
acutely ill.
Tachycardia, arrhythmias and ECG abnormalities.
Loss of consciousness.
Some people have no signs or symptoms- silent MI.
3. Symptoms of Heart Valve Disease
Symptoms may include:
•
•
•
•
Dysponea which increases with exercise or when lying flat (Orthopnea), abnormal
pulse oximetry recordings.
Weakness, dizziness or confusion.
Chest discomfort with activity or when going out in cold air often described as a
feeling of pressure or weight.
Palpitations.
Valve disease can cause heart failure
4. Symptoms of Heart Failure
Symptoms of heart failure can include:
•
•
•
•
•
•
•
•
•
•
Dysponea-shortness of breath noted during activity (most commonly) or at rest,
especially when lying flat (Orthopnea) or paroxysmal nocturnal dysponea (a sudden
night-time attack of severe breathlessness, usually several hours after going to sleep
also known as ‘Cardiac Asthma’). Cyanosis in late stages due to left-sided heart failure
and pulmonary oedema. Abnormal pulse oximetry recordings.
Cough that is productive of a white mucus.
Quick weight gain due to fluid retention (a weight gain of two or three pounds in
one day is possible).
Oedema (peripheral-ankles, legs, and ascites-abdomen) associated with right-side
heart failure. Nocturia may be a feature due to fluid returning from the legs when
elevated.
Cool extremities at rest due to inadequate systemic perfusion.
Dizziness, confusion due to inadequate systemic perfusion.
Fatigue and weakness.
Palpitations/Arrhythmias.
Other symptoms include nausea, palpitations, and chest pain.
Some people may have little or no symptoms yet have a severely damaged heart.
47
5. Symptoms of Heart Muscle Disease (Cardiomyopathy)
Symptoms of cardiomyopathy can occur at any age and may include:
•
•
•
•
•
•
Chest pain or pressure (occurs usually with exercise or physical activity, but can also
occur with rest or after meals).
Heart failure symptoms (see above).
Oedema (lower extremities).
Fatigue.
Fainting.
Palpitations/Arrhythmias/ECG abnormalities
6. Symptoms of Pericarditis
When present, symptoms of pericarditis may include:
•
•
•
•
•
Chest pain. This pain is different from angina. It may be sharp and located in the
centre of the chest. The pain may radiate to the neck and occasionally, the arms and
back. It is made worse when lying down, taking a deep breath in, coughing, or
swallowing and relieved by sitting forward.
Dry cough.
Fatigue and anxiety.
Low-grade fever.
Tachycardia.
Further assessments
Document the following Assessments on admission, if the resident’s condition
improves or deteriorates and at least every three months.
1. Consider the resident’s specific risk factors, modifiable risks and previous
cardio/pulmonary history.
2. Assess vital signs, weight, BMI and urinalysis and Finger stick blood sugar (document on
the Vital Signs, Blood Sugar, Weight, BMI and Urinalysis Chart).
3. Assess if and when Influenza and Pneumococcal vaccine have been administered.
4. Breathing Assessments:
• Observe for shortness of breath, wheeze/ stridor or pain while:
– Speaking
– Eating
– Drinking
– Exertion
– Mobilising
– Sleeping / lying flat
• Observe the character/type of resident’s breathing pattern.
• Assess for the presence of a cough/sputum.
• Measure Peak Flow to establish a baseline of the person’s peak expiratory flow rate.
• Measure Pulse Oximetry on room air to establish a baseline. Acceptable normal ranges
are from 95 to 100 percent. N.B: the limitations of pulse oximetry must be
noted. These include:
48
•
➢ Inaccurate recordings due to:
– Probe movement e.g. resident shivering or tremor present.
– Nail varnish obliterating probe from detecting a pulse.
– Room temperature and resident temperature: An environment that is too
cold will cause the arterioles to constrict and decrease the blood flow through
the digits.
– To correct, ensure the resident is warm and any nail varnish removed or rotate
the finger probe so that it does not cover the nail. Prevent the resident’s digit
from moving during recordings.
➢ Hypoventilation and oxygen therapy; a person suffering from hypoventilation
(i.e. poor gas exchange in the lungs) given 100% oxygen can have excellent blood
oxygen levels while still suffering from respiratory acidosis due to excessive carbon
dioxide.
➢ Insufficient blood flow/anaemia:
– If there insufficient haemoglobin in the blood (anaemia), tissues can suffer
hypoxia despite high oxygen saturation in the blood.
– If there is insufficient blood flow e.g. very ill residents with low BP and poor
peripheral perfusion, the finger probe frequently will not pick up a pulse and
oximetry reading cannot be recorded.
➢ High blood levels of methemoglobin. Methemoglobin is a form of
haemoglobin that cannot carry oxygen. Normally one to two percent of
people's haemoglobin is methemoglobin; a higher percentage than this can be
genetic or caused by exposure to various chemicals and depending on the level
can cause health problems known as methemoglobinemia. A higher level of
methemoglobin will tend to cause a pulse oximeter to read closer to 85%
regardless of the true level of oxygen saturation.10
Observe the resident’s mucous membranes and nail beds for signs of cyanosis
(blueness/greyness).
5. Circulatory Assessments:
a) Observe for shortness of breath dysponea, orthopnea, paroxysmal nocturnal
dysponea, presence of cyanosis, fatigue, dizziness, confusion. Measure pulse
oximetry.
b) Observe for dry cough, white sputum.
c) Assess for the presence of chest pain, type and characteristics (Refer to RAP 10: Pain).
d) Observe pulse for arrhythmias, note: rate, rhythm & volume.
e) Assess for presence of palpitations, oedema (peripheral or systemic). In heart failure
peripheral oedema is bilateral.
6. Lower Extremity Circulatory Assessments:11
• Assess the resident’s lower extremities for signs and symptoms that are indicative of
peripheral arterial disease (PAD):
– Observe resident’s extremities note their colour, shape and their temperature.
Consider if the temperature is equal between the two extremities. Ensure that
both the resident and their environment are warm; a cold environment can
cause vasoconstriction in the lower extremities. Note whether feet are cold,
pale or blue.
49
– Assess the skin; is it shiny and taut? Note if there are areas of
hyperpigmentation (brown staining), presence of varicose veins, and/or
eczema.
– Assess for blackened or gangrenous toes.
– Assess capillary refill in the toes by pressing gently on the nail beds and
releasing. Nails beds turn white or blanch when pressure is exerted and
resume their normal pink colour within 3 seconds (capillary refill).
– Palpate pedal pulses.
– Assess for signs of oedema. Note if oedema is bilateral or unilateral.
– Calf measurements.
– Assess for pain- note the type and nature of the resident’s pain.
•
Pain Indicative of Arterial disease:
• Intermittent claudication on exercise (complaints of pain on walking usually
located in the back of the calf muscles, thigh muscles or buttocks, relieved
in seconds by ceasing walking).
• Relieved by rest.
• Rest pain, relieved when foot is placed on the floor (dependent).
•
Pain Indicative of Venous Disease:
• Pain at ulcer site.
• Aching or heavy legs.
• Night cramps.
Indicative of PAD, findings may include:
• A pale, cool foot with shiny, hairless skin, thickened toenails and an absence of palpable
pedal pulses, delayed capillary refill greater than 3 seconds, intermittent claudication or
rest pain and a positive Buerger's Test. To assess using the Buerger’s Test the resident
must be supine. Note the colour of the feet/soles. They should be pink. Then elevate
both legs to 45 degrees for more than 1 minute. Observe the soles. If there is marked
pallor (whiteness), ischemia should be suspected. Next check for rubor on dependency.
Sit the resident upright and observe the feet. In normal circulation, the feet quickly turn
pink; with arterial insufficiency dependent rubor occurs, this is where the limb presents
as ruby red in a sitting position.
Indicative of Venous disease, findings may include:
• The presence of: varicose veins, brown skin staining, eczema, lipodermatosclerosis
(presence of hard woody-type tissue), leg shape (leg of mutton / inverted champagne
bottle, shaped leg), ankle flare, atrophe blanche (white spots/areas of avascularisation),
oedema, foot pulses present and complaints of night cramps or restless legs.
Indicative of Mixed Arterial/Venous lower extremity disease a combination of
the sign and symptoms of both arterial and venous disease are present.
Oedema Measurements
50
2mm or less = 1+
Oedema
2-4mm= 2+ Oedema
✓ Slight pitting
✓ No visible distortion
✓ Disappears rapidly
✓ Slightly deeper pit
✓ No readable detectable
distortion
✓ Disappears in 10-15
seconds
4-6mm = 3+ Oedema
✓ Pit is noticeably deep
✓ May last more than 1
minute
✓ Extremity looks fuller &
swollen
6-8mm = 4+ Oedema
✓ Pit very deep
✓ Last as long as 2-5
minutes
✓ Extremity is grossly
distorted
Referrals required:
Refer to the Multidisciplinary Team as appropriate to the Assessment findings:
• Doctor: referral is required for baseline assessment and for ongoing concerns e.g.
abnormal vital sign measurements, abnormal blood sugars, abnormal character of
breathing, shortness of breath, cough, cyanosis, signs/symptoms of Respiratory Disease,
CVD, PVD, oedema, unequal calf-measurements, management of pain and for the
presence of a leg ulcer.
• Physiotherapy: e.g. Cough, decrease endurance, dizziness.
• An urgent vascular referral is required for all residents presenting with rest pain or
uncontrolled pain and gangrene.
• A prompt vascular referral is required for all residents who present with
signs/symptoms of PVD. All residents with PAD should be considered for
revascularisation devices such as stents, irrespective of their age and co-morbidities.
• All residents with lower extremity ulceration should be referred for a leg ulcer
assessment by appropriately trained healthcare professionals (Refer to Rap
13: Skin and Wound Care).
• Dietician referral may be required to optimise nutritional intake and to advise on
appropriate diet e.g. cardiac diet, diabetic diet.
• Podiatrist/chiropodist referral will be required for providing nail and foot care
for residents with arterial disease.
Personalised Care Planning
The aim of care planning is to develop a single multidisciplinary (MDT) plan of
personalised care that is specific to the person’s difficulty with breathing and /or
circulation. The MDT includes the resident/significant other(s), carers, nurses, doctors
and allied health professionals.
Need / Problem Identification
Record the specific breathing/circulation problem that has been highlighted following a
thorough assessment. This should be written as to address the person’s needs
For example: Mrs Peacock states she can only walk a couple of yards and has to stop because
of the pain in her right calf muscle. She also reports that her pain is getting progressively worse
and that she now has intolerable pain in her right leg at night when she is in bed. Mrs Peacock
has signs and symptoms of intermittent claudication, rest pain and progressive peripheral arterial
disease.
Goal specification
Goal: state the desired resident outcome from the nursing interventions. The goal must be
measurable, obtainable and reflect the resident’s/families’ desires as much as possible.
For example: Mrs Peacock’s leg pain will be controlled to an acceptable level as identified
through self reports. Mrs Peacock will have an urgent vascular referral within 1 week to determine
her suitability for revascularisation options such as stenting.
Specific Interventions
These are the specific steps taken based on expected standards of care in addressing actual
or potential cardiovascular / respiratory problems. Document:
51
•
•
•
•
What we need to do (specific interventions based on residents/significant other(s)
care choices where possible)
What we need to monitor (on-going reassessments)
What we need to communicate (back to the MDT)
What/who we need to educate (to improve the problem)
1. Specific MDT interventions
a) Specific interventions to address residents/significant other(s) concerns,
preferences and care choices e.g. ‘a fear of breathlessness’. This can be addressed
by providing psychological support and through education on appropriate MDT
management strategies in improving/maximising respiratory status.
b) MDT specific care instructions. This includes nursing care instructions for addressing
the actual or potential cardiovascular / respiratory problem(s) and other care instructions
from members of the MDT. For example: a doctor’s specific instructions for the
management of the cardiovascular or respiratory problem. A physiotherapist’s
instructions on improving lung capacity and/or the management of the resident’s
symptoms. These should be listed here or a photocopy attached to the care plan. It is
important to refer the reader to the attached instructions.
2. Monitoring and ongoing reassessment:
The monitoring interventions required will be specific to the cardiovascular or respiratory
problem identified. Monitoring is aimed at assessing the effectiveness of the
treatment/management strategies and in identifying signs of disease progression and its
impact on the resident’s life.
3. Communication:
• Promptly communicate monitoring concerns to the resident’s doctor and appropriate
members of the MDT team. Update care plans accordingly
• NOTE: Residents MUST BE referred back to the multi-disciplinary team if there is
deterioration in their cardiovascular / respiratory status despite following MDT
advice/instructions.
• Communicate the residents personalised care plan to all those involved in the resident’s
direct care. Ensure the resident’s and their significant others (if the resident so wishes)
are aware of the resident’s plan of personalised care and are kept up to date.
4. Information/ Education/ Health Promotion for resident, significant
other and carers
• Educate residents/significant other(s) on the resident’s specific type of cardiovascular /
respiratory problem and their personalised plan of care. Provide written information
where possible and/or provide information in a format that suits the resident’s
communication requirements. Refer to RAP 1: Communication, Vision and Hearing.
Evaluation of care (based on goals specified)
• Cardiovascular / Respiratory Care plans must be evaluated when the resident’s condition
improves or deteriorates and at least 3 monthly. Evaluate the effectiveness of the care
provided by checking to see if the goals of care are being met. e.g. improvement in self
reported symptoms and in resident’s self reported quality of life.
Refer to the protocols of ‘Expected Standards for Care Flow Chart’ and sample
‘Personalised Care Plan’ in documenting personalised care planning and in
providing care.
52
Protocol for the Expected Standards of Care in the
Assessment of Breathing and Circulation in Older Persons
Designated Centres
Does this person have a history breathing and or
circulatory problems/ difficulties?
Complete admission
assessment
No
Yes
Baseline
assessment
within normal
limits
No
The person has
difficulties with:
Yes
Circulation
Both
Breathing
Assess
Assess
Assess for modifiable Risk Factors. Assess if &
when flu/Pneumococcal Vaccines were given.
Further assess:
Smoking History
Signs &
Symptoms
of CVD
Lower
extremities
for
Signs &
Symptoms
of PVD
Continue to monitor.
Requires monthly
Observations
Yes
No. per day
Expresses
wishes to quit
smoking
Write a care plan focusing on
the specific problem assessed
with circulation and address
modifiable risk factors
Quit
No
No. of
years ago
Wishes to continue
smoking- risk
assess, offer
options for
smoking cessation
Colour of
Nail beds,
Mucous
membranes
& skin
Write a Plan of Care for the
management of smoking/
smoking Cessation
Changes
in
breathing
pattern
with
activities
of living
Difficulty
with
inspiration,
exertion,
expiration,
lying down
Character
of Cough
&
Pain
Write a care plan focusing on the specific
problem assessed with Breathing and address
modifiable risk factors where possible
Document implementation of the interventions on the appropriate Flow Chart or in the Narrative Notes
Evaluate the effectiveness of your interventions by referring to the Goal set in the care plan. If the goal is being met
continue the care as planned. If the problem is resolved discontinue the care plan, write a narrative note when the care
plan is discontinued
If the goal has not been met, establish new interventions based on evidence- based, best practice
53
SAMPLE CARE PLAN
Topic Heading: Lower Extremity Circulation
PROBLEM / NEED IDENTIFICATION
Number:
Date
Signature
01/04/10 Mrs Peacock states she can only walk a couple of yards and has to stop
because of the pain in her right calf muscle. She also reports that her
pain is getting progressively worse and that she now has intolerable
pain in her right leg at night when she is in bed. Mrs Peacock has signs
and symptoms of intermittent claudication, rest pain, delayed capillary
refill and progressive peripheral arterial disease.
Jane
Murphy
GOAL SPECIFICATION
Mrs Peacock’s leg pain will be controlled to an acceptable level as identified through self reports.
Mrs Peacock will have an urgent vascular referral within 1 week to determine her suitability for
revascularisation options such as stenting.
SPECIFIC INTERVENTIONS
Date
01/04/10
Signature
•
•
•
•
•
•
•
•
•
Mrs Peacock was seen by Doctor O’Brien on admission & commenced
on prophylactic Statins therapy (Pravastatin 20ms daily) and antiplatelet
therapy (low dose Asprin 75mg daily) according to best practice.
Analgesia charted. Administer medication as prescribed..
Dr O’Brien sent an urgent vascular referral and a dietetics referral. While
awaiting referral DO NOT apply elastic compression hosiery such as TED
Stockings, as these will further reduce Mrs Peacocks arterial circulation
Mrs Peacock is at high risk of foot and heel pressure ulcers. Use Heelift
boots® while in the bed. Inspect feet daily for signs of pressure ulcer
damage and record. Discourage Mrs Peacock from crossing her legs.
Encourage Mrs Peacock to wear her soft zip-up slippers while mobilising.
Discourage her from wearing her hard leather shoes as these are likely to
cause a pressure ulcer. Encourage Mrs Peacock to mobilise as much as
possible.
Do Not elevate Mrs Peacocks’ legs while in the bed as this will reduce
her circulation further and cause pain. If Mrs Peacock complains of right
leg pain while in the bed, encourage her to hang her leg out of the bed,
so that gravity can assist with her circulation. Review analgesia should this
occur.
Monitor and record the intensity of Mrs Peacock’s pain using the
Numeric Rating Scale 0-10 (with 10 being the worst pain experienced)
before and approx 30 minutes after drug administration.
Monitor Mrs Peacocks lower extremities at each shift. Note: skin
integrity, colour/warmth and capillary refill & document findings
Communication: Promptly report monitoring concerns to the
Doctor/MDT.
Information: Provide information sessions to Mrs Peacock/Significant
Others on the Plan of Care to address this problem.
Jane
Murphy
EVALUATION OF CARE (based on goals specified)
Date
Time
Signature
Discontinued Date: ............../ ............../ 20......... Signature: ................................................
54
References
2
Irish Heart Foundation (2010), Facts on Heart Disease and Stroke
http://www.irishheart.ie/iopen24/facts-heart-disease-stroke-t-7_18.html
3
Mackay, J., Mensah, G. (2004) Atlas of Heart Disease and Stroke. World Health
Organization. Geneva
4
Oxford Medical Dictionary (2005) 7th Edition
5
Kanaparthi, L., Lessnau, K., Sharma, S. (2009), Restrictive Lung Disease,
http://emedicine.medscape.com/article/301760-overview
6
J Mackay, G Mensah, (2004) Atlas of Heart Disease and Stroke. World Health
Organization. Geneva
7
Meissner, M., Eklof, B., Smith, P., Dalsing, M., DePalma, R., Gloviczki, P., Moneta, G.,
Neglen, P., O' Donnell, T., Partsch, H., Raju, S. (2007) Secondary chronic venous
disorders. Journal of Vascular Surgery, 46 Supplement:S68-S83.
8
Grey, E., Harding, K., (2006) ABC of Wound Healing, BMJ Books, Blackwell Publishing
9
WebMD (2009) Heart Disease Guide http://www.webmd.com/heartdisease/guide/heart-disease-symptoms?page=3
10
Denshaw-Burke, M., Savior, D., Schoffstall, J (2009) Methemoglobinemia, emedicine:
http://emedicine.medscape.com/article/204178-overview
11
Kandarpa, K., (2007) Peripheral Vascular Interventions, Lippincott Williams &
Wilkins, U.S.A.
55
RAP 5: Nutritional Status
Definitions:
Nutritional status is the state of a person’s health in terms of the nutrients in his or her diet.1
Malnutrition is a bodily state in which there is a deficiency of nutrients that causes
measurable adverse effects on body composition, function or clinical outcome. The term
includes under nutrition and over nutrition2, 3. The risk of under nutrition rather than over
nutrition is the main cause of concern for older people in residential care.4 Malnutrition has
a detrimental impact on a resident’s health and wellbeing, however once identified, it can be
effectively treated.5
Body Mass Index (BMI): A measure of body weight relative to height used to determine
whether people are underweight, at a healthy weight, overweight or obese.6
RAI Identifiers of Potential Risks:
BMI less than 20 C1, Difficulties associated with eating C7, Communication
Difficulties C6, D3, D4, Recent unexplained weight loss C9, F1, Modified Diet F5,
Difficulties in Swallowing F22, Nausea/vomiting/diarrhoea F23, Presence of
Wounds C10, J1, J7, Dietary restrictions C16, Functionally dependent F17, Breathing difficulties C19, E2, Dehydration F21, Potential risk of pressure ulcers J2,
Palliative Care Symptoms present- sore mouth, nausea, vomiting, weight loss and
anorexia O6, End of Life Palliative Care Symptoms- sore mouth, nausea, vomiting,
weight loss and anorexia P5
Other Risk Factors include:
•
•
•
Pre-admission risks such as living alone, low income, limited mobility, lack of
cooking/shopping ability and a lack of social support.7 On admission to residential
care approximately 1 in 3 residents (30%) are at risk of malnutrition.8
Co-morbidities risks may include; behavioural problems, paranoia, depression,
oral health problems, medication side effects/sedation and certain underlying
medical conditions e.g. Parkinsons disease, dementia, Feeding, Eating, Drinking and
Swallowing Disorders (dysphagia), CVA, episode(s) of acute illness (vomiting,
diarrhoea, fever), neoplastic and respiratory disease.9
Post-admission risks may include; psychosocial causes e.g. resident’s individual
food preferences, palatability (e.g. texture modified diets) and visual presentation of
food offered, residents feeling rushed, cultural and religious factors. Biomedical risks
include an exacerbation of the resident’s medical conditions and functional decline.
Other post-admission risks may include inadequate care practices e.g. a lack of staff
awareness of the need for nutritional assessments, poor/inadequate monitoring and
documentation of those at risk/or with malnutrition, inflexible timing of meals, lack
of assistance while eating.10, 11, 12
Further assessments
Document the following assessments on admission, if the resident’s condition
improves or deteriorates and at least three monthly:
1. Assess the resident’s past and present medical history for any suggestive or actual risk
factors/co-morbidities for malnutrition and for Feeding, Eating, Drinking, and
Swallowing Disorders (FEDS disorders/dysphagia). Several sources of information should
be used in information/history gathering e.g. discussion with the resident significant
56
2.
3.
4.
5.
6.
7.
8.
others, transfer letters, contact with/and discussion with the multidisciplinary team. This
is especially important for residents with communication or cognitive difficulties. If the
resident has already been seen by a Speech and Language Therapist (SLT) and/or a
dietitian prior to admission, record the date of last review and list/attach their
recommendations in the nursing care plan. Consider the resident’s medications for
possible risks of over sedation or side effects which may cause or exacerbate malnutrition.
Assess the resident’s dietary likes/dislikes, preferred portion size, dietary modifications and
fluid consistency. Assess if the resident has any cultural or religious practices that might
impact on dietary intake.
Assess the resident for signs and symptoms of malnutrition e.g. thin/obese, weight loss,
loose clothes, loose rings, muscle wasting, prominent bones, poor appetite, feeling cold,
low energy levels.
Assess and observe the resident for signs and symptoms of FEDS Disorders/dysphagia
and associated anxiety/depression13 e.g. reported swallowing problems, drooling,
coughing, choking and/or throat clearing when eating /drinking, wet voice after
swallowing, recurrent chest infections, pocketing of food in the mouth, unexplained
weight loss. Note: Up to 80% of older people may not seek treatment advice for
dysphagia prior to admission.14, 15 This highlights the importance of observation in
assessing residents.
Assess the resident’s; functional ability to self feed, level of assistance required,
appropriateness of usual position for eating, need for modified utensils to
improve/maintain independence. If a resident is already using modified equipment,
record the type used, in the assessment (RAI) and in their care plan.
Complete a nutritional risk assessment using a validated tool e.g. MUST or MNA, Record
the residents’ weight and BMI.
If the resident is at risk or identified with malnutrition they are further at high risk of
developing pressure ulcers. Assess the resident’s skin, checking pressure areas. Complete
a pressure ulcer risk assessment. Refer to RAP 12: Pressure Ulcer Prevention and
Management.
Complete an oral cavity assessment and record the date of their last dental check-up.
Referrals required:
•
•
Refer the resident to the multidisciplinary team (MDT), as appropriate to their
assessment findings e.g. Doctor referral for those identified with/or at risk of
malnutrition/FEDS Disorders, Dietetic referral [see protocol below], SLT referral
required for those identified with/or suspected of FEDS Disorders, OT/Physiotherapist
referral required when advice on correct positioning for feeding/seating assessments
are required and Dental referral may be required for oral health needs. Referrals should
be made as soon as concerns arise e.g. on admission/review. Record all referrals made
on the MDT Referral Record
In facilities with no/limited access to SLT, consider the risk of aspiration and urgency
for swallow assessment (for residents with suspected FEDS Disorders/Dysphagia). In
HSE Units, contact: Resident’s Doctor /Senior Nursing Management/SLT Area
Manager/Local Health Manager to arrange an urgent review or to decide on the
transfer of the resident to an acute hospital if an urgent review is not possible. In private
designated centres contact: Irish Association of Speech and Language Therapists in
private practice (IASLTPP) 01-8787959 or IASLT at 085 – 7068707
57
•
In facilities with no/limited access to dietetic services, consider the resident’s risk level
and urgency of review required. In HSE Units, contact: Resident’s Doctor / Senior
Nursing Management/Local HSE Dietitian or Dietetics Area Manager/Local Health
Manager to arrange an urgent review if required. In private Units contact: The Irish
Nutrition & Dietetic Institute (INDI) on www.indi.ie for a private appointment.
Protocol for Dietetic referrals: to be sent when a resident is/has;
• At risk/identified with malnutrition (MUST/MNA) or has a BMI < 20kg/m2 or >25kg/m2
• Unintentional weight loss of 10% of body weight since last recorded weight or within
3-6 months. This includes residents whose current BMI falls within 20kg/m2 or
>25kg/m2 (normal healthy range)
• A diagnosis of Dementia, Feeding, Eating, Drinking and Swallowing Disorders (FEDS
disorders/Dysphagia) or whose current co-morbidities place the individual at risk of
malnutrition (Carcinoma, COPD, etc)
• Currently on a medical diet e.g. diabetic, renal or cardiac diets or is receiving oral or
enteral nutritional support i.e. PEG, NG, NJ, JEJ feeding
• Wound(s) present e.g. leg/foot ulcers, pressure ulcers including residents with
exudating varicose eczema. Refer to RAP 13 - Skin and Wound Care
Personalised Care Planning
The aim of care planning is to develop a single multidisciplinary (MDT) plan of
personalised care to address the cause or risks of malnutrition where possible. The MDT
includes the resident/significant other(s), carers, nurses, doctors and allied health
professionals.
Problem/Need Identification
Record the actual or potential nutritional problem and its associated or related risk factors.
For example; ‘Mary reports a difficulty in swallowing and is at risk of malnutrition associated with
dysphagia’ or ‘Mary is at risk of malnutrition related to her cognitive impairment and dementia ’.
Goal specification
Record: realistic, measurable and obtainable MDT goals. For example: ‘Mary will increase her
nutritional intake by eating fortified foods. Mary’s weight and BMI will be maintained or improved
on monthly reassessment’.
Specific Interventions
These are the specific steps taken based on expected standards of care in addressing actual
or potential nutritional problems. Document:
• What we need to do (specific interventions based on residents/significant other(s)
care choices where possible)
• What we need to monitor (on-going reassessments)
• What we need to communicate (back to the MDT)
• What/who we need to educate (to improve the problem)
58
1. Specific MDT interventions: Record:
a) Specific interventions to address resident’s/significant other(s’) concerns,
preferences, care choices and religious/cultural requirements e.g. fear of
choking for those with dysphagia. This can be addressed by providing psychological
support and through education on SLT strategies to prevent choking. See section below.
b) MDT specific care instructions. This includes nursing care instructions for
addressing malnutrition risk or management and other care instructions from
members of the MDT. For example: a dietitian’s specific instructions for
treatment of malnutrition. These should be listed here or a photocopy attached to
the care plan. It is important to refer the reader to the attached instructions. The
same applies for Speech and Language (SLT) instructions on dietary
consistency for safe swallowing and the resident’s position required for
safe swallowing.
• In facilities with limited access to dietetic services, nurses should implement and
document a food fortification plan of care as a first step for residents with / or at risk of
malnutrition, unless contraindicated by the resident’s co-morbidities such as residents
on medical diets e.g. diabetes, renal disease, etc. If these medical conditions are present
consult a dietitian prior to commencing food fortification. Food fortification is the
process of increasing the nutrient content of a resident’s diet without increasing the
portion size. This includes the addition; of cream, butter, honey or skimmed milk
powder to meals where appropriate, and by providing additional nutritious snacks.
Refer to the regional guidelines on nutrition and hydration for further information.
For residents with dysphagia consider:
i. The risks of aspiration and the resident’s position required for safe swallowing
e.g. chin tilt, 90° upright and maintain upright for 30minutes after eating/drinking.
Ensure the resident is alert to eat.
ii. Ensure strategies for safe swallowing which have been provided for an
individual resident by the SLT are implemented (e.g. swallow twice, slow down, put
your chin down etc).
iii. Residents with dysphagia who are prescribed modified consistency diets by
a SLT should be provided with clear guidelines on the type of consistency required
for safe swallowing e.g. soft, minced and moist, smooth pureed or liquidised.
iv. The palatability and visual appearance of food offered. For example, pureed
food is more appealing when prepared in food moulds and served in individual
portions on the same plate. Residents are likely to eat more if they can taste
different flavours, never mash different foods into a bowl. When some vegetables
are pureed such as carrots, water separates out onto the plate. The addition of
thickener e.g. Thick & Easy®/Nutils® to vegetables before serving can prevent
this.
v. It may be necessary to avoid food that is difficult to swallow e.g. dry/crumbly
foods (toast, brown bread, sponges- moisten first with e.g. syrup/sauces/gravies),
mixed consistency foods (e.g. lumpy soups, cornflakes & milk- provide uniform
consistency foods e.g. blended soup, porridge etc), stringy vegetables (e.g.,
green beans), vegetable or fruit with skins (e.g. peas, grapes-remove skins
first), foods that can cause choking (e.g. peanuts, popcorn, boiled sweets,
sweet corn). Please note: each person with dysphagia must be assessed by a
SLT for individual recommendations on safe swallowing.
59
vi. Ensure that any oral nutritional supplements recommended by the
dietitian are of the consistency recommended by the SLT.
vii. Ensure the resident’s specific equipment needs are documented to
maintain/improve/promote independence e.g. beaker/volume control beaker
/straw/napkin to protect clothing. Allow sufficient time and support for eating
and drinking.
viii. Discourage talking while eating or drinking and minimise distractions.
ix. Document oral hygiene requirements to prevent the risk of aspiration pneumonia.
x. Medication: some medication can help improve swallowing e.g. anti-Parkinsonian
medication for those with Parkinson’s disease. Medications prescribed 30-60mins
before meals can optimise swallowing and eating. Other medications can make
swallowing worse e.g., antipsychotic medication. If swallowing deteriorates when
antipsychotic medication is commenced or increased this should be promptly
communicated to the resident’s doctor.
2. Monitoring and ongoing reassessment:
• Weights should be recorded at least monthly, but may require more frequent
monitoring in specific cases. Maintain a weights chart in the Nursing Assessment Tools
section. Compare current weight to previous weight and baseline weight. Act on
findings which are of concern e.g. onward referral to doctor/dietitian for weight loss.
Note: weight loss can be very gradual, therefore the importance of baseline
comparisons.
• Nutritional Risk reassessments (MUST/MNA) should be recorded at least 3 monthly and
BMI indices compared.
• Enteral feeding, maintain and monitor a daily intake/output chart. Monitor and record
urine colour. Refer to RAP 20- Feeding Tubes.
• Accurate food charts/Food diaries should be maintained using agreed descriptions of
portion sizes for those at risk/or identified with malnutrition. The duration of this specific
record keeping should be agreed with the dietician at local level. If dehydration is present
refer to RAP 6- Dehydration and Fluid Maintenance.
• Monitor blood reports.
• Monitor daily intake of diet using the Daily Record of Care flow chart. The amount taken
at each meal is recorded as a %.
• Monitor and record daily skin inspections for pressure ulcer development using the Daily
Record of Care flow chart.
• Monitor for signs/or worsening of dysphagia. If signs of aspiration are observed,
document what the person was eating or drinking at the time and promptly
communicate findings to the MDT. Further monitor for any evidence of deterioration
in respiratory status e.g. recurrent pneumonias and promptly record and report findings
to the MDT.
3. Communication:
• Promptly communicate monitoring concerns to the resident’s doctor / dietitian / SLT.
Update care plans accordingly
• NOTE: Residents MUST BE referred back to the multi-disciplinary team if there is
deterioration in their nutritional status despite following MDT advice/instructions.
• Communicate the resident’s personalised care plan to all those involved in the resident’s
direct care. Ensure the resident’s significant others/visitors are aware of any swallowing
difficulties. Ensure the resident/significant other is kept up to date.
60
4. Information/Education/Health Promotion for Resident, Significant
Other(s) and Carers
• Educate residents and relatives on the importance of nutrition and the prevention of
malnutrition and associated risks if present with FEDS/dysphagia. Provide written
information where possible and/or provide information in a format that suits the
resident’s communication requirements. Refer to RAP 1 Communication, Vision and
Hearing.16
Evaluation of care (based on goals specified)
• Nutritional Care plans must be evaluated when the resident’s condition improves or
deteriorates and at least 3 monthly. Evaluate the effectiveness of the care provided by
checking to see if the goals of care are being met e.g. weight gain, improvement in
BMI, improved dietary intake, improvement in biochemical parameters, maintaining
skin integrity, improvement in the resident’s self reported quality of life.
Refer to the protocols of ‘Expected Standards for Care Flow Chart’ and sample
‘Personalised Care Plan’ in documenting personalised care planning and in
providing care.
61
62
• Past & present medical history. Note
suggestive or actual risk factors/comorbidities for; malnutrition & FEDS
disorders (dysphagia). If resident has
already been seen by a SLT and or a
dietitian prior to admission, record date
of last review & recommendations in the
nursing care plan.
• Resident’s dietary likes/dislikes- preferred
portion size, dietary modifications, fluid
consistency, level of assistance required
& need for modified utensils.
• Weigh resident.
• Nutritional Screening using MUST or
MNA Tool. Record BMI.
• Assess resident’s oral health & record last
dental check-up.
• Assess resident for signs and symptoms
of malnutrition e.g. weight loss, loose
clothes, thin/obese, poor appetite,
consider MUST/MNA findings.
• Assess resident for signs & symptoms of
dysphagia e.g. reported swallowing
problems, drooling, coughing, choking
and/or throat clearing when eating
/drinking, wet voice after swallowing,
recurrent chest infections, pocketing of
food in mouth, unexplained weight loss.
• Assess resident’s / significant other(s)
concerns in relation to prevention and
management of malnutrition.
Nursing Assessment-Document
(On admission, if resident’s condition improves
or deteriorates and at least 3 monthly)
Nursing Assessment
At Low Risk
Reassess when there is
a change in the
resident’s condition
and as per local policy
(monthly weights &
nutritional screening at
least 3 monthly).
Consider overall
weight loss/gain &
refer to the Multidisciplinary Team as
appropriate.
At Medium-High
risk Malnutrition
• Identify risk level.
• Identify factors for
Malnutrition and or
Dysphagia (FEDS)
disorders
Nursing Diagnosis
• Refer resident to MDT i.e. Doctor, Dietitian, SLT(If FEDS disorders) & OT for advice on
equipment/ positioning.
• In units with limited dietetic access, nurses
should implement a ‘Foods first, First step approach food fortification plan for those with /
or at risk of malnutrition, unless contraindicated
by the resident’s co-morbidities. Add cream,
butter, honey, skimmed milk powder to meals
& provide additional nutritious snacks e.g. Petit
Filous, full fat cheese/yogurt, etc.
• For units with limited/no access to SLT consider:
aspiration risks & urgency for swallow
assessment (FEDS Disorders /dysphagia). In HSE
Units, contact: GP /Senior Nursing
Management /SLT Area Manager/LHM to
arrange an urgent review or/ decision to transfer
to acute services. In private units contact:
IASLTPP 01-8787959 (Private appointment)
• Develop & implement a personalised nutritional
plan of care, in conjunction with the wishes of
the resident/significant other & MDT.
• Maintain accurate food/fluid charts using
agreed descriptions of portion sizes & monitor
intake.
• Monitor weights (e.g. weekly), blood results (as
necessary) & check skin integrity daily.
• Monitor for signs/or worsening of dysphagia/
FEDS e.g. respiratory symptoms
Goal- To prevent / manage Risks, FEDS
Disorders &/or Malnutrition
Nursing Goal & Care planning
Malnutrition / FEDS
WorseningRefer resident to multidisciplinary team.
Malnutrition /FEDS
Improving• Continue with care plan.
• Continue to monitor
intake, weights and BMI.
.
At Risk or Suffering
from Malnutrition /
FEDS.
• Reassess resident’s
progress against care
plan goals e.g.
improvement in intake,
BMI, weight,
biochemical parameters,
skin integrity
maintained.
• Document nursing
evaluations based on
above outcome criteria.
Nursing Evaluation
Protocol for Care for Nutritional Status in HSE Older Persons Designated Centres
SAMPLE CARE PLAN
Topic Heading: Sample Nutritional Care Plan
PROBLEM / NEED IDENTIFICATION
Number:
Date
01/01/10 Cissy reports a difficulty in swallowing (FEDS Disorder/Dysphagia) and is
at risk of malnutrition associated with this.
Signature
Jane
Murphy
GOAL SPECIFICATION
Cissy wishes to remain as independent as possible and to choose what she would like to eat and
drink, while being cognisant of preventing aspiration. Cissy’s weight will be maintained or improved
in monthly reassessments.
SPECIFIC INTERVENTIONS
Date
11/01/10
Signature
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Cissy was reviewed by the dietitian and SLT in St. James’s on
04/01/2010 refer to dietary consistency and food fortification
recommendations attached overleaf (or list recommendations here).
Cissy must be sitting upright at a 90°angle when eating or drinking
and this position should be maintained for at least 30mins afterwards, to
prevent aspiration. Mealtimes must be supervised.
Ensure Cissy is alert for eating and drinking & do not ask Cissy
questions while eating to prevent aspiration.
Ensure Cissy has her dentures, modified cutlery, a non-slip mat, clothes
protection and plate guard for meals (needs).
Provide a choice of menu/drinks and allow Cissy choose.
Cissy likes ‘small meal’ portions, ensure food is presented attractively
and in the correct consistency.
Commence a Food Chart & record for XX days. (State Number)
Monitor & record Cissy’s Weight (specify frequency)
Monitor & record BMI (specify frequency).
Monitor for signs and symptoms of FEDS disorder worsening e.g., silent
aspiration (pyrexia, respiratory symptoms).
Record Nutritional Risk Assessment (specify frequency)
Monitor dietary intake on the Daily Flow Chart of Care.
Communicate monitoring concerns promptly to the MDT.
Cissy and her family have been given information and advice on the
importance of a healthy diet and dysphagia management. Ongoing
information is to be provided.
Jane
Murphy
EVALUATION OF CARE (based on goals specified)
Date
Signature
Discontinued Date: ............../ ............../ 20......... Signature: ................................................
63
Suggested further reading:
HSE (2008) Regional PPGs Older Persons ROP066 Nutritional and Hydration Care in
HSE Older Persons Residential Care Facilities
http://hsenet.hse.ie/Hospital Staff Hub/mullingar/Policies, Procedures Guidelines Midland
Area/Care of the Older Persons/Regional PPG's/ROP066 Guideline -Nutritional and
Hydration Care in HSE Older Persons.pdf
References
64
1
National Cancer Institute (2009) Dictionary of Cancer Terms- Nutritional status
http://www.cancer.gov/Templates/db_alpha.aspx?CdrID=463734
2
National Institute for Health and Clinical Excellence (2006) Nutrition support in adults
NICE Clinical Guideline no 32. www.nice.org.uk/CGO32
3
Elia, M., Stratton, R., Russell, C., Green, C., Pang, F. (2005) The cost of disease-related
malnutrition in the UK and economic considerations for the use of oral nutritional
supplements (ONS) in adults. A Report by The Health Economic Group of the British
Association for Parenteral and Enteral Nutrition (BAPEN).
4
Milne, A., Potter, J., Vivanti, A., Avenell, A. (2009) Protein and energy supplementation
in elderly people at risk from malnutrition. Cochrane Database of Systematic Reviews
2009, Issue 2. Art. No.: CD003288. DOI: 10.1002/14651858.CD003288.pub3.
5
Royal College of Nursing (2009) 10 key characteristics of good nutritional care. Royal
College of Nursing www.rcn.org.uk
6
National Institute for Health and Clinical Excellence (2006) Nutrition support in adults
NICE Clinical Guideline no 32. www.nice.org.uk/CGO32
7
Loser, C., Lubbers, H., Mahlke, R., Lankisch, P. (2007) The involuntary weight loss of the
elderly. Der ungewollte Gewichtsverlust des alten menschen, 104(49) A3411-A3420.
8
Russell, C., Elia, M. (2007) Nutrition screening survey and audit of adults on admission to
hospitals, care homes and mental health units. Redditch:BAPEN; 2007.
9
Alibhai, S., Greenwood, C., and Payette, H. (2005) An approach to the management of
unintentional weight loss in elderly people. Canadian Medical Association Journal, 172
(6):773-80.
10
Caroline Walker Trust (2004) Eating Well for older people. www.cwt.org.uk
11
Suominen, M., Muurinen, S., Routasalo, P., Soini, H., Suur-Uski, I., Peiponen, A., FinneSoveri, H., Pitkala, K. (2005) Malnutrition and associated factors among aged residents
in all nursing homes in Helsinki. European Journal of Clinical Nutrition. 59(4):578-583.
12
Voices (1998) Eating well for older people with dementia. Wordworks, London.
13
Eslick G., Talley N. (2008) Dysphagia: Epidemiology, risk factors and impact on quality
of life - A population-based study, Alimentary Pharmacology and Therapeutics.
27(10)(pp 971-979).
14
Turley, R., Cohen, S. (2009) Impact of voice and swallowing problems in the elderly
Otolaryngology - Head & Neck Surgery. 140(1):33-36.
15
Wilkins T., Gillies R.A., Thomas A.M., Wagner P.J. (2007) The prevalence of dysphagia in
primary care patients: A HamesNet research network study. Journal of the American Board
of Family Medicine. 20(2)(pp 144-150)
16
HIQA (2009) National Quality Standards for Residential Care Settings for Older People in
Ireland
RAP 6: Dehydration and Fluid Maintenance
Definitions:
Dehydration is an abnormal depletion of body fluids.1 It can occur as a result of decreased
fluid intake or increased fluid losses or as a combination of both. Dehydration in older adults
can result in; constipation, faecal impaction, increased incidence of pressure ulcers,
hypotension, increased risk of falls, decreased functional and mental capacity, delirium and
infections.2 If untreated dehydration can result in renal failure, shock, seizures, brain damage
and death.3
RAI Identifiers of Potential Risks:
Drinking difficulties C8 Communication/Comprehension difficulties D3, D4 Functionally dependent F17, Requires thickened fluids F8 Difficulty in swallowing
F22 Modified diet F5 Urinary Incontinence G2 Signs & symptoms of dehydration
present F21, Nausea, vomiting, diarrhoea F23
Other Risk Factors include:
•
•
Intrinsic risks; e.g. psychological fear of incontinence, diminished sense of thirst,
diminished appetite/refusal of food and fluids, excessive output from stoma, medical
co-morbidities e.g. dementia, Feeding, Eating, Drinking and Swallowing disorders
(FEDS Disorders/Dysphagia), uncontrolled diabetes mellitus, pituitary adenomas and
adrenal gland disorders causing diabetes insipidus, internal/external haemorrhage
and any acute episode of illness which results in pyrexia, excessive sweating,
diarrhoea or vomiting.
Extrinsic risks; e.g. medications (over use of sedation/psychotropic drugs /
laxatives, drug side effects e.g. nausea, vomiting and diuretic medications).
Inadequate care practices such as; inadequate monitoring, documentation and
management of residents intake and output for those at risk; inadequate monitoring,
documentation and management of residents on fluid restrictions for medical
reasons (e.g. renal or heart failure); inaccessibility of fluids for residents or inadequate
provision of sufficient fluids.4
Further assessments
Document the following assessments on admission, when the resident’s
condition improves or deteriorates and at least three monthly. Assess for:
1. The resident’s overall risk context: Bio/psycho/social risks e.g. co-morbidities, medications,
malnutrition and pressure ulcer risk, limitations in functional activities, psychosocial,
religious and cultural issues6. Several sources of information should be used in
information/history gathering e.g. discussion with the resident, significant others, transfer
letters, contact with/and discussion with the multidisciplinary team e.g. resident’s doctor,
nurses, carers. This is especially important for residents with communication or cognitive
difficulties.
2. The cause of dehydration such as infection, fluid refusal, etc. For example: if a resident
is repeatedly refusing drinks offered, the reason for this refusal should be explored.
Ascertain if the refusal stems from physical conditions such as a sore mouth (e.g. thrush),
dental caries, nausea due to fever/viral infections/medication side effects, cognitive
difficulties (e.g. dementia), psychological factors (e.g. fluid preferences, depression,
behavioural problems, paranoia) or social causes (resident not afforded dignity, feeling
rushed, cultural/religious requirements).
65
3. Signs and symptoms of dehydration: dry furrowed tongue and mucous membranes,
sunken eyes, dark concentrated/decreased/absent urinary output, increased urine
specific gravity, elevated blood urea nitrogen (BUN) to creatinine ratio, increased
frequency of urinary tract infections, constipation, confusion, lethargy, muscle cramps,
hypotension or othostatic hypotension and tachycardia.5, 6
• Note: Assessment of skin turgor is not a reliable indicator of dehydration in older
people due to age related skin changes and a loss of skin elasticity.5
4. Pressure ulcer risk using a validated tool e.g. Waterlow, Braden tools. Refer to RAP 12Pressure Ulcer Prevention and Management.
5. Malnutrition risk using a validated tool e.g. MUST or MNA tools (Refer to RAP 5
Nutritional Status).
Referrals required:
•
•
•
Promptly refer the resident to his/her doctor if signs or symptoms of dehydration are
noted. A prompt referral is further required to a dysphagia trained Speech and
Language Therapist (SLT) if a resident is suspected of having FEDS disorders /
dysphagia (high risk of aspiration) for swallow assessment. A dietetic referral is
required for all residents with FEDS disorders /dysphagia. An Occupational Therapy
referral may be required for advice on equipment and positioning in maintaining a
resident’s independence. Record referrals made on the MDT Referral Record and
document the reason/outcome of the referral in the narrative notes.
In facilities with no/limited access to SLT, consider the risk of aspiration and urgency for
swallow assessment (for residents with suspected FEDS Disorders/Dysphagia). In HSE
Units, contact: Resident’s Doctor /Senior Nursing Management/SLT Area
Manager/Local Health Manager to arrange an urgent review or to decide on the
transfer of the resident to an acute hospital if an urgent review is not possible. In private
designated centres contact: Irish Association of Speech and Language Therapists in
Private practice (IASLTPP) 01-8787959 or IASLT at 085 – 7068707.
In facilities with no/limited access to dietetic services, consider the resident’s risk level
and the urgency of the review required. In HSE Units, contact: Resident’s Doctor /
Senior Nursing Management/Local HSE Dietitian or Dietetics Area Manager/Local
Health Manager to arrange an urgent review if required. In private Units contact: The
Irish Nutrition & Dietetic Institute (INDI) on www.indi.ie for a private appointment.
Personalised Care Planning
The aim of care planning is to develop a single multidisciplinary (MDT) plan of
personalised care to address the cause or risks where possible. The MDT includes the
resident/significant other(s), carers, nurses, doctors and allied health professionals.
Need / Problem Identification
Record the actual or potential fluid maintenance problem and its associated or related risk
factors. For example; ‘Mary reports a difficulty in swallowing and is at risk of dehydration
associated with dysphagia’ or ‘Mary has evidence of dehydration related to acute respiratory
tract infection’.
Goal specification
Record: realistic, measurable and obtainable MDT goals. For example: ‘Mary will increase her
intake of oral fluids to (specify in millilitres/litres in 24 hours)’.
66
Specific Interventions
These are the specific steps taken based on expected standards of care in addressing actual
or potential hydration problems. Document:
• What we need to do (specific interventions based on residents/significant other(s)
care choices where possible)
• What we need to monitor (on-going reassessments)
• What we need to communicate (back to the MDT)
• What/who we need to educate (to improve the problem)
1. Specific MDT interventions: Record:
a) Specific MDT interventions to address resident’s/significant other(s’)
concerns, preferences and care choices. For example many older people
have a fading sense of thirst and forget to drink or they may be unable to consume
adequate fluids due to medical co-morbidities such as MS, CVA and end stage
dementia. Others may simply be frightened to drink because of the fear of
incontinence. Individual considerations should be addressed in the care plan such
as by; Providing psychological care/support to address the resident’s;
• Fears: e.g. of incontinence, through continence promotion strategies. Refer
to RAP 7- Urinary Incontinence and Continence Promotion.
• Refusal to take fluids: e.g. residents with dementia who repeatedly refuse
drinks from staff will sometimes take it from their loved ones. The importance
of touch in this group can further focus a resident’s attention on drinking.
Holding hands, giving reassuring touches, singing softly and continuity of care
have been found to help overcome resistance to drinking and eating.7
• Fluid maintenance and ethical care choices: The provision of hydration
support is not always appropriate. MDT decisions regarding the withholding or
withdrawing of nutritional or hydration support require legal and ethical
consideration.8 Refer to the Regional Nutritional and Hydration Guidelines.
b) MDT specific care instructions. This includes nursing care instructions for
addressing dehydration risk or management and other care instructions from
members of the MDT e.g. doctor’s specific instructions for increased fluid intake.
• Fluid maintenance/ management Record specific MDT instructions to
maintain/improve hydration. International consensus is that older adults require
1.5 to 2 litres/day or 6 to 8 cups of fluid daily, unless a fluid restriction has been
imposed for medical reasons (e.g. renal or heart failure). Residents who are at
medium to high risk of dehydration require 30-35mls/kg of body weight.9
i. Encourage, remind or assist residents to drink small amounts of fluids hourly.
Refer to the residents’ specific preferences (likes/dislikes). Residents who are
unable to consume adequate oral fluids should be considered for
subcutaneous fluids (short term period) or enteral fluids (long term).
ii. Ensure fluids are within easy reach of residents and provide a choice of
beverages e.g., milk, tea, fruit or vegetable juices, smoothies, soups. Decrease
coffee, alcohol and carbonated intake which can contribute to dehydration.
iii. Ensure adequate fluid intake for residents on high fibre diets.
iv. Ensure the resident is positioned upright and their specific equipment needs
are
documented
to
maintain/improve
independence
e.g.
beaker/straw/napkin to protect clothing or for those with dysphagia a volume
control beaker (5ml/10ml) can limit how much the person swallows per
mouthful. Allow sufficient time and support for eating and drinking.
67
v. Residents with dysphagia who are prescribed modified consistency fluids by
their medical practitioner should further be provided with clear guidelines on
the daily fluid intake goal (in litres) and the type of consistency required for
safe swallowing e.g. syrup/custard/set consistency.
For residents with dysphagia consider:
vi. The risks of aspiration and position required for safe swallowing e.g. chin tilt,
90° upright & maintain upright for 30minutes post eating/drinking. Ensure
strategies for safe swallowing which have been provided for an individual
resident by the SLT are implemented (e.g. swallow twice, slow down, put
your chin down, etc)
vii. The palatability of the fluids offered. For example, warm thickened drinks that
are left to stand can be very unpalatable. When thickening tea/coffee, add
the milk to the tea to bring the fluid to 200ml and then add the thickener.
Thicken minerals, favourite fluids and fruit juices e.g. cranberry, apple and
orange are good choices and hold their flavour well. Add squash /fruit juice
to water before thickening to increase palatability.
viii. The addition of high water foods e.g. soups, jelly, custard and ice cream can
further improve hydration levels.
2. Monitoring & ongoing reassessment
• At high risk or/with dehydration, measure and document a daily fluid intake/output
chart. Record the frequency and types of fluids offered, the amount taken and fluid
losses incurred (urine, vomitus, etc). Monitor and record urine colour.
• At risk of dehydration, record and monitor urine colour on the Daily Record of Care
(use colour code on the flow chart).
• Enteral feeding, maintain and monitor a daily intake/output chart. Refer to RAP 20.
Monitor and record the urine colour.
• Monitor closely any resident who is on thickened fluids or fluid restrictions.
• Monitor for worsening of dysphagia/FEDS disorders if present. Monitor signs and
symptoms of aspiration, deterioration in respiratory status e.g. recurrent pneumonias
• Monitor BUN to Creatinine Ratio and other pertinent lab values (e.g. U & E).
• Pressure ulcer risk present refer the reader to the Pressure Ulcer Prevention
(Management) Care plan.
• Malnutrition (actual or potential problem) refer the reader to Nutritional Care Plan
• Pertinent Lab results e.g. U & E, BUN to Creatinine Ratio.
3. Communication
• Promptly communicate monitoring concerns to the resident’s doctor / dietitian /
SLT. Update care plans accordingly
• Communicate the residents personalised care plan to all those involved in the
resident’s direct care. Ensure the resident/significant other is kept up to date
4. Information/Education/Health Promotion for Resident, Significant
Other(s) and Carers
• Educate the resident and their relatives on the importance of hydration and the
prevention of dehydration and risks associated with FEDS disorders/dysphagia if present.
Provide written information where possible and/or provide information in a format that
suits the resident’s communication requirements. Refer to RAP 1 Communication, Vision
and Hearing.10
68
Evaluation of care (based on goals specified)
• MDT Dehydration / Fluid Maintenance Care plans must be evaluated when the
resident’s condition improves or deteriorates and at least 3 monthly. Evaluate the
effectiveness of the care provided by checking to see if the goals of care are being met
Refer to the ‘Protocols of the Expected Standards for Care’ flow chart and
sample ‘Personalised Care Plan’ in documenting personalised care planning
and in providing care.
69
70
Nursing Assessment-Document
• Past & present medical history. Note
suggestive or actual risk factors/comorbidities for; dehydration, & FEDS
disorders (dysphagia). If resident has
already been seen by a SLT prior to
admission, record date of last review &
Fluid consistency recommendations in
the personalised (nursing) care plan.
• Assess resident for signs & symptoms of
dehydration e.g. dry furrowed tongue,
dry mucous membranes, sunken eyes,
constipation, concentrated/decreased
urinary output, hypotension, tachycardia
etc.
• Assess resident for signs & symptoms of
Dysphagia e.g. reported swallowing
problems, drooling, coughing, choking
and/or throat clearing when eating
/drinking, wet voice after swallowing,
recurrent chest infections, pocketing of
food in mouth, unexplained weight loss.
• Resident’s drinks likes/dislikes- level of
assistance required and need for
modified utensils (beakers, straws, etc).
• Nutritional Screening using MUST or
MNA Tool. Record BMI.
• Pressure Ulcer Risk assessment using a
validated tool e.g. Braden, Waterlow.
• Assess resident’s oral health and need for
oral care. Record last dental check-up.
• Assess resident’s/significant other(‘s)
concerns in relation to prevention and
management of dehydration.
(On admission, if resident’s condition improves
or deteriorates and at least 3 monthly)
Nursing Assessment
At Low Risk
• Reassess when there
is a change in the
resident’s condition.
• Monitor the colour
of urinary output
daily (if incontinent
check incontinence
pad or ask the
resident)
• Monitor for signs
and symptoms of
dehydration daily.
At High Risk / has
Dehydration
• Identify risk factors
related to
dehydration.
• Identify cause(s)
associated with
dehydration.
Nursing Diagnosis
• Promptly refer resident to MDT i.e. Doctor,
SLT-(If FEDS disorders [Dysphagia]
suspected/present) & OT for advice on
drinking utensils/ positioning & maintaining
or improving resident’s independence.
Dietitian referral is required for all residents
with dysphagia.
• In units with limited/no access to SLT
consider aspiration risks & urgency for
swallow assessment (FEDS Disorders). In HSE
Units, contact: GP /Senior Nursing
Management /SLT Area Manager/LHM to
arrange an urgent review or/ decision to
transfer to acute services. In private units
contact: IASLTPP 01-8787959 (Private
appointment)
• Develop & implement a personalised fluid
maintenance plan of care, in conjunction
with the resident’s / significant other’s wishes
& MDT.
• Maintain accurate fluid charts using agreed
descriptors (e.g. cup=150mls,
beaker=200mls) & monitor intake and
output. Record urine colour.
• Monitor relevant lab values
• Check skin integrity daily.
• Provide education/information &
psychological support to residents /
significant others
Goal to Prevent/Manage Risks, Dehydration
or FEDS Disorders
Nursing Goal & Care planning
Dehydration
WorseningPromptly refer resident to
his/her doctor.
Hydration levels
Improving• Continue with care plan.
• Continue to monitor
intake/output, urine
colour & lab values
.
At Risk or Suffering
from Dehydration /
FEDS.
• Reassess resident’s
progress against care
plan goals e.g.
improvement in fluid
intake, improvement in
biochemical parameters,
maintaining skin
integrity.
• Document nursing
evaluations based on
above outcome criteria.
Nursing Evaluation
Protocol for the Expected Standards for Care in Dehydration and Fluid Maintenance in HSE Older Designated Centres
SAMPLE PERSONALISED CARE PLAN
Topic Heading: Dehydration and Fluid Maintenance
PROBLEM / NEED IDENTIFICATION
Number:
Date
01/01/10 Cissy is at high risk of dehydration associated with a gradual decline in
oral intake related to dementia.
Signature
Jane
Murphy
GOAL SPECIFICATION
Cissy’s oral intake will increase to 1.5 litres/24 hrs.
SPECIFIC INTERVENTIONS
Date
11/01/10
Signature
•
•
•
•
•
•
Reviewed by Dr Johnson today, no evidence of swallowing problems or
acute illness. Advised to increase intake to 1.5 litres in 24hrs. Dietetic
referral/bloods sent.
Encourage Cissy to take at least 100mls of fluids hourly. Cissy likes:
pineapple juice, Lilt, 7UP, & Sweet Coffee alternate these drinks & avoid
tea, milk, water which she dislikes.
Use gentle touch and simple verbal instructions. Let Cissy know
that you are about to give her a drink and instruct saying ‘Open your
mouth’ ‘swallow’. Cissy likes sweet foods; give high water content foods
e.g. soup (add two teaspoons of sugar) & Ice cream / custard. Encourage
extra drinks with meals.
Monitor & maintain intake/ output chart. Record drinks offered and
amount taken. Record urine colour (check Cissy’s incontinence wear).
Record if incontinence wear is wet or dry at changes. Monitor blood
results.
Communicate monitoring concerns promptly to the MDT
Information re: prevention and management of dehydration discussed
with Cissy’s family, who will further encourage Cissy to take drinks &
record amounts taken. Family are to be provided with opportunities to
discuss diagnosis and management options.
Jane
Murphy
EVALUATION OF CARE (based on goals specified)
Date
Time
12/01/10
13.20
Cissy has only taken 900mls of fluid in 24hrs despite best
efforts. Doctor contacted, for review this afternoon
Signature
Jane
Murphy
Discontinued Date: ............../ ............../ 20......... Signature: ................................................
71
Suggested further reading:
HSE (2008) Regional PPGs Older Persons ROP066 Nutritional and Hydration Care in
HSE Older Persons Residential Care Facilities
http://hsenet.hse.ie/Hospital Staff Hub/mullingar/Policies, Procedures Guidelines
Midland Area/Care of the Older Persons/Regional PPG's/ROP066 Guideline - Nutritional
and Hydration Care in HSE Older Persons.pdf
References
72
1
Medline (2008) Dehydration. Medical Dictionary. Accessed on line at
http://www2.merriam-webster.com/cgiin/mwmednlm?book=Medical&va=dehydration
2
Grandjean, A., Grandjean, N. (2007) Dehydration and cognitive performance. Journal of
the American College of Nutrition. 26(5 Suppl):549S-554S.
3
Mentes, J. (2006) Maintaining Oral Hydration in Older Adults: Greater awareness is
needed in preventing, recognizing, and treating dehydration. Americian Journal of
Nursing, 106(6), 40-50.
4
Allison, S., Lobo, D. (2004) Fluid and electrolytes in the elderly. Current Opinion in Clinical
Nutrition & Metabolic Care 7(1):27-33.
5
Pinto, S. (2008) Hydration: Maintaining Oral Hydration in Older Adults, Evidence-Based
Care Sheet, Cinahl Informayion Systems, USA
6
Hodgkinson, B., Evans, D., Wood, J. (2005) Maintaining oral hydration in older people: a
systematic review, Database of Abstracts of Reviews of Effects, Centre for Reviews and
Dissemination -: Systematic reviews
7
Voices (1998) Eating well for older people with dementia. Wordworks, London
8
HSE (2008) Regional PPGs Older Persons ROP066 Nutritional and Hydration Care in HSE
Older Persons Residential Care Facilities
9
National Institute for Health and Clinical Excellence (2006) Nutrition support in adults
NICE Clinical Guideline no 32. www.nice.org.uk/CGO32
10
HIQA (2009) National Quality Standards for Residential Care Settings for Older People in
Ireland
RAP 7: Urinary Incontinence and Continence Promotion
Definitions:
Urinary incontinence is defined as: ‘The complaint of any involuntary urinary leakage’.1
Types:
•
•
•
•
•
•
Urge Incontinence/Overactive Bladder: Commonest cause in older persons
care. The bladder muscles are overactive and cause a strong sudden urge to void.
Urine loss may be equivalent to a full void. Other characteristics include frequency
and nocturia.2
Stress incontinence: Small amounts of urine leak through the urethra on effort of
exertion or sneezing or coughing.2
Mixed Incontinence: A combination of urge and stress incontinence.
Urinary Retention/ Overflow Incontinence: There is dribbling or leaking of
urine because the bladder does not empty. Symptoms include frequency, nocturia,
reports of dribbling or leaking, and the sensation that the bladder has not emptied.
Urine loss is in frequent small amounts.2
Functional Incontinence: This is directly related to the resident’s ability to access
the toilet. This ability may be impeded due to physical or cognitive causes.
Acute or transient incontinence: Incontinence with a sudden onset often
associated with a medical and/or surgical problem, usually resolving with treatment
of the underlying problem.3
RAI Identifiers of Potential Risks:
■ Difficulties with urinary management C17, ■ Communication Difficulties D3,
D4, ■ Dehydration F21 ■ Urinary Incontinence G2, ■ Constipation G11 ■
Assistance required with Mobility H1
Other Risk Factors include:
•
Urge Incontinence risks: Diuretic medication, dehydration, glucosuria, or dietary
irritants, such as caffeine, fizzy drinks, smoking. Neuropathic causes include CVA,
Parkinson’s and multiple sclerosis.4, 2
•
Stress Incontinence risks: Pelvic relaxation, obesity, ageing, prostatectomy,
chronic cough, multiple pregnancies, menopause and impaired pelvic floor
innervations.4
•
Mixed Incontinence risks: Combination of risk factors for Stress and Urge
Incontinence
•
Urinary Retention/ Overflow Incontinence risks: Benign prostatic hyperplasia,
urethral stenosis / strictures, constipation, neurological conditions such as spinal injury,
multiple sclerosis and stroke, diabetic neuropathy, certain medications (anticholinergics,
antidepressants, antipsychotics, sedatives, narcotics, alpha-adrenergic agonists, betaadrenergic agonists, calcium channel blockers).5
•
Functional Incontinence risks: Physical, cognitive, or motivational impairment,
inaccessible toilet or caregiver, inappropriate use of incontinence containment
products, drugs e.g. sedatives.3
73
•
Transient Incontinence risks: The mnemonic DISAPPEAR identifies the recognised
transient causes of incontinence, which are Delirium, Infection, Stool impaction
(constipation), Atrophic vaginitis, Pharmaceuticals, Psychological/psychiatric, Excess
fluid, Abnormal laboratory values, Restricted mobility.6
Further assessments
Document the following assessments on admission, if the resident’s
condition improves or deteriorates and at least 3 monthly. Assess For:
1. Asses the resident’s overall risk context (See RAI identifier factors and compare
medical history). Several sources of information should be used in information/history
gathering e.g. discussion with the resident, significant others, transfer letters, contact
with/and discussion with the multidisciplinary team e.g. resident’s doctor, nurses &
carers, examination and observation.
2. For residents who are able to communicate use focused questions to establish the
type urinary incontinence.
• Ask the resident to describe how they pass urine, is it; a steady dribble (retention
with overflow); spurts out (stress incontinence); sudden flow (urgency); little,
often and sore (dysuria).
• Ask the resident how many times do you go to the toilet in 24-hour period?
• How often do you wake to go to the toilet during the night?
• How often do you feel a strong and sudden urge to urinate during the day?
• If you fail to get to the toilet in time, how much urine do you usually leak?
• Do you leak urine when you laugh, cough, jump, or run?
3. A physical examination (including a abdomen/pelvis/perineum and focused
neurological examination (S2-S4) should be undertaken by the resident’s doctor
4. Laboratory investigations include: renal function, calcium, glucose, PSA, urinalysis
and urine culture if indicated
5. Assess the resident’s skin condition in groins (vulva) and anal region to establish
baseline data on skin condition and out rule the presence of moisture lesions.
6. Complete an incontinence assessment tool e.g. HSE Continence Promotion Unit
Continence Assessment Form for Nursing and Residential Homes
7. Look for signs and symptoms of constipation and urinary tract infections or other
causes of transient incontinence. If found treat as necessary, and refer the resident to
the multidisciplinary team.
8. Record a frequency volume chart. This should be completed for a minimum of 3
days.
9. Complete a fluid balance chart if it is suspected that the resident is dehydrated.
Dehydration contributes to Urge Incontinence.
10. If incomplete bladder emptying is suspected, measurement of post-void residual
volume may be required. This should be checked by a bladder scan in preference to
catheterization due to the lower incidence of adverse events associated with scans.
11. If conservative treatment has failed further urology referral may be required.
Referrals required:
Refer to multidisciplinary team as appropriate to assessment findings.
A doctor referral is required for baseline assessment and on going management
concerns e.g. dehydration, infection, urinary retention/overflow, constipation/faecal
impaction, glucosuria, depression and for review of medications associated with
incontinence.
74
OT/ Physiotherapist referral may be required for decreased mobility, dexterity
problems or for pelvic floor exercises. Optician or Audiology referral may be
required if eye sight or hearing impairment is impacting on continence. A Continence
Nurse Specialist referral may be required for personalised care planning advice for
those with urge, stress, mixed or overflow incontinence (e.g. HSE Continence Promotion
Unit phone number: 01-6352775). A consultant urology/specialist referral is
required if symptoms do not respond to treatment within 2-3 months, or where
haematuria is present without infection on urinalysis, or where symptoms are suggestive
of poor bladder emptying (hesitancy, poor stream, terminal dribbling) or where there is
evidence of unexplained neurological or metabolic disease.
Personalised Care Planning
The aim of care planning is to develop a single multidisciplinary (MDT) plan of
personalised care that is specific to the resident and to the type of urinary incontinence
being treated. The MDT includes the resident/significant other(s), carers, nurses, doctors
and allied health professionals.
Need / Problem Identification
Record the specific urinary incontinence problem (refer to the Protocols of Care for Urinary
Incontinence) and its associated or related risk factors. For example; ‘Mary is incontinent of
urine when she laughs, coughs or moves during the day and is continent at night. Mary has
stress incontinence associated with a history of multiple pregnancies’.
Goal specification
Record: specific (to the type of incontinence), realistic, and measurable Urinary Incontinence
and Continence Promotion MDT goals. For example: ‘In 3 months time Mary will have a
reduced number of incontinent episodes by using continence promotion strategies’.
Specific Interventions
These are the specific steps taken based on expected standards of care in addressing actual
or potential urinary incontinence problems. Document:
• What we need to do (specific interventions based on residents/significant other(s)
care choices where possible)
• What we need to monitor (on-going reassessments)
• What we need to communicate (back to the MDT)
• What/who we need to educate (to improve the problem)
1. Specific MDT interventions: Record:
a) Specific interventions to address residents/significant(s) concerns,
preferences and care choices e.g. educate residents that urinary incontinence
is not a normal process of aging and that an overactive bladder is a common and
treatable medical condition. Encourage residents to talk about their fears/concerns.
If the resident expresses a reluctance to take fluids, provide information on the
importance of hydration and on how dehydration can contribute to incontinence.
Malodours can be a further cause for concern; provide information/ psychological
support on good hygiene practices, continence promotion strategies and on
appropriate incontinence products.
75
b) MDT specific care instructions. This includes nursing care instructions/programmes
for promoting continence and managing incontinence and other MDT specific care
instructions e.g. a doctor’s specific instructions for the treatment of urinary incontinence
e.g. specific instructions for faecal impaction treatment or a physiotherapist’s instructions
on pelvic floor exercises should be listed here.
• Specific Interventions (Programmes) for promoting continence and
managing incontinence include:
i. Bladder Retraining Programme: This is used to treat Urge Incontinence. It
actively involves the individual in attempting to increase the interval between the
desire to void and the actual void. A schedule of voiding is strictly adhered to,
with a gradual increase in the intervals between voiding. This schedule is based
on the results of their frequency volume chart. Bladder training lasting for a
minimum of 6 weeks should be offered as first-line treatment to women with urge
or mixed incontinence.7
ii. Pelvic Floor Muscle Training Programmes: A trial of supervised Pelvic Floor
muscle training of at least 3 months’ duration should be offered as 1st line
treatment for stress or mixed incontinence.7 These exercises are initiated by staff
who are trained in Pelvic Floor Muscle exercises.
iii. Habit Training and Prompted Voiding Programme: These are techniques
for restoring continence in residents with Cognitive impairment. The resident is
taken to or reminded to void at certain times in order to re-establish and/ or
reinforce the habit of voiding. Positive reinforcement techniques are used by staff
for the resident on achieving appropriate toileting e.g. by giving praise and
positive attention.3, 7
iv. Timed voiding: Promotes conditioned reflexes for residents with neurogenic
bladder. Fixed voiding schedule that is unaltered. Times must be adhered to.
v. Incontinence Containment Products should only be used when indicated
by a comprehensive assessment. Containment products may be necessary either
during ongoing treatment or when continence cannot be achieved.8 Refer to
local guidelines for choosing the correct type, size and absorbency of incontinence
containment products. Document the specific products required.
• Specific Interventions for Skin Protection: Following incontinent episodes,
cleanse skin with (state product e.g., Clinisan/Water & Silcocks Base). Apply barrier
creams sparingly (state product e.g. Petroleum jelly and do not use
Sudocrem®/Talc or Powder). Refer to RAP 13: Skin and Wound Care.
2. Monitoring & ongoing reassessment
Record the specific types of ongoing reassessments and monitoring requirements in
managing the resident’s incontinence problem/need: Consider:
a) The types of reassessments/monitoring that may be required for the
specific types of incontinence and their associated underlying causes.
For example:
• Urge Incontinence e.g. if associated with dehydration (refer to RAP 6
Dehydration and Fluid maintenance for specific monitoring and assessments
required), glucosuria (monitor blood and urine glucose levels and specify the
frequency) or medications (monitor for specific side affects).
• Stress Incontinence e.g. if associated with obesity will require weight
monitoring (specify frequency) and BMI monitoring (specify frequency).
• Mixed Incontinence will require specific monitoring and ongoing
reassessment of its associated identified risks.
76
•
Urinary Retention/ Overflow Incontinence e.g. if associated with
constipation (monitor bowel motions using the Bristol Stool Chart on the Daily
Flow Chart of Care and refer to RAP 9 Constipation for further assessments).
• Functional Incontinence will require ongoing reassessment and monitoring
of the resident’s cognitive and functional status (refer to RAP 3 Cognition and
Acute Confusion for further reassessment criteria)
• Transient Incontinence will require ongoing reassessment and monitoring
for identified transient causes of incontinence (refer to risk factors)
b) The types of reassessments/monitoring required, to establish the
effectiveness of the MDT Interventions (programmes) in promoting
continence and in managing incontinence;
• Record and monitor an Intake Output Chart (frequency voiding/volume chart)
for residents with urge/stress incontinence. Record for 3-5 days. Document fluid
intake, frequency and volume of urine voided (if possible) or frequency of
wet/dry incontinent pad. Document urinalysis. Interpretation of monitoring:
• Loss of urine during coughing, sneezing or physical exertion is indicative of
Stress – usually small amounts, usually dry at night
• Frequency (8+ voids per day, or twice or more at night ), and urgency is
indicative of Detrusor instability – usually large amounts, usually wet at night
• Post micturition dribble, poor stream, hesitancy, straining to void is indicative
of outflow obstruction
• Continuous wetness may suggest neurogenic/reflex bladder
• Reassess resident’s skin daily (groins, [vulva] and anal region) for the presence of
moisture lesions, if present update care plan. Refer to RAP 13: Skin and Wound
Care.
3. Communication
• Promptly communicate monitoring concerns to the resident’s doctor and other
members of the MDT as appropriate.Update care plans accordingly.
• Communicate the residents personalised care plan to all those involved in the
resident’s direct care. Ensure the resident/significant other is kept up to date.
4. Information/Education/Health Promotion for Resident, Significant
Other(s) and Carers
• Educate residents/significant other(s) on the resident’s specific type of incontinence and
their personalised plan of care. Provide information on the importance of hydration and
on the prevention of dehydration. Provide written information where possible and/or
provide information in a format that suits the resident’s communication requirements.
Refer to RAP 1: Communication, Vision and Hearing.9
Evaluation of care (based on goals specified)
• MDT Urinary Incontinence and Continence Promotion Care plans must be evaluated
when the resident’s condition improves or deteriorates and at least 3 monthly. Evaluate
the effectiveness of the care provided by checking to see if the goals of care are being
met.
Refer to the ‘Protocol for the Expected Standards of Care’ flow chart and
sample ‘Personalised Care Plan’ in documenting personalised care planning
and in providing care.
77
78
Protocols of Care
Ensure adequate hydration
Prevention/treatment of
constipation
Advise resident to avoid
caffeine
Bladder retraining
Administer Antimuscarinic
medication as prescribed
Risk Factors
Diuretic medication
Dehydration
Glucosuria
Caffeine
Neuropathic causes:
CVA, Parkinson’s &
Multiple Sclerosis
Urge
Risk Factors &
Protocols of
Care
Combination of
those for Urge &
Stress
Incontinence
Mixed
Protocols of Care
Pelvic Floor Muscle
Exercises Programme (to be
initiated by staff trained in
PFME only)
Risk Factors
Obesity
Ageing
Multiple
pregnancies
Menopause
Stress
Protocols of Care
Treat underlying cause
Catheterisation
Risk Factors
Certain drugs
Constipation
Benign prostatic
hyperplasia
MS, CVA
Retention
Protocols of Care
Treat underlying cause
Risk Factors
Delerium (drugs & bugs)
Infection
Stool impaction
constipation
Atrophic vaginitis
Pharmaceuticals
Psychological
Excess fluid
Abnormal lab values
Restricted mobility
Risk Factors
Directly related to the
ability to access the
toilet
Protocols of Care
Ensure clear access to
toilet
Ensure adequate
lighting & signage
Assist resident to the
toilet
Use aids such as urinals
& commodes
Use specially designed
clothing for dexterity
problems
Habit training &
Prompted voiding
Transient
Functional
Complete a Urinary Incontinence Assessment Tool.
Assess for signs & symptoms of constipation, urinary tract infection, & other causes of transient incontinence.
If urinary retention is suspected: Assess residual bladder volumes (Palpate bladder).
Assessment
Protocol for the Expected Care Standards for Urinary Incontinence and Continence Promotion in
HSE Older Persons Designated Centres
SAMPLE (Personalised) CARE PLAN
Topic Heading: Urinary Incontinence and
Continence Promotion
PROBLEM / NEED IDENTIFICATION
Number:
Date
01/01/10 Mary is aware that she has “little accidents” (episodes of incontinence) &
states “I hate wearing these bulky pads, but sometimes I forget where the
toilet is and then it’s too late”. Mary has Functional Urinary Incontinence
associated with decreased mobility and mild cognitive impairment
Signature
Jane
Murphy
GOAL SPECIFICATION
To teach Mary ways in achieving continence. To manage incontinence. Mary’s skin will remain intact
and free from incontinence associated dermatitis & moisture lesions. Mary will have reduced episodes
of incontinence in 3 months time.
SPECIFIC INTERVENTIONS
Date
11/01/10 • Provide psychological support by the use of positive coping strategies. These
include: listening to Mary’s concerns, giving information/explanation on
Mary’s specific plan of personalised care, continence products & choice and
information on use, skin care and advice on how to talk (openly) to
family/significant others about urinary incontinence and its management if
Mary wishes.
• Ensure Mary’s privacy and dignity is maintained by ensuring Mary has a call
bell close at hand & by walking Mary to the toilet and ensuring doors are
closed.
• Mary commenced on a Habit Training & Prompted Voiding
Programme: Prompt & remind Mary to use her call bell, if she needs
assistance in using the toilet. Ensure Mary’s Zimmer frame is within easy
reach. Remind Mary of the bathroom location, by pointing out the signage.
Walk Mary to the toilet 2 hourly during the day, with her consent, and
prompt Mary to void urine. Encourage Mary to void urine prior to settling
down for the night. Encourage independent hand hygiene post voiding.
Provide positive reinforcement on achieving appropriate toileting/ having dry
continence wear. Review toileting intervals in 2 weeks to assess effectiveness
• Continence Containment Products: Mary requires: (state product type
& absorbency). Do not use fully enclosed products, Mary does not like these.
• Skin Protection: Following incontinent episodes, cleanse skin with (state
product e.g., Clinisan/Water & Silcocks Base). Apply barrier creams sparingly
(state product e.g. Petroleum jelly).
• Monitor & record: A daily Frequency Voiding Chart for 3 days (baseline
assessment). Record if continence wear is dry/wet & toileting (voided/did
not void). Reassess (ongoing) continence wear requirements and check skin
daily for moisture lesions.
• Monitor Mary’s hydration status daily by observing & recording Mary’s urine
colour, use the colour code on the daily Record of Care (to reduce incidence
of dehydration/constipation/UTI).
• Monitor for constipation & document bowel movements (using Flow
Chart). Constipation can exacerbate urinary incontinence.
Communication: Promptly report monitoring concerns to the Doctor/MDT.
Information: Provide information sessions to Mary/Significant Others
on Mary’s specific type of incontinence, continence promotion strategies &
progress.
Signature
Jane
Murphy
EVALUATION OF CARE (based on goals specified)
Date
Signature
Discontinued Date: ............../ ............../ 20......... Signature: ................................................
79
Suggested further reading:
European Association of Urology (2009) Guidelines on Urinary Incontinence
http://www.uroweb.org/fileadmin/tx eauguidelines/2009/Full/Incontinence.pdf
References
80
1
Abrams P. Car, Cardozo L, Fall M, et al, (2001), The standardisation of terminology of
lower urinary tract function: report from the Standardisation Sub-committee of the
International Continence Society, Neurology and Urodynamics, 21(2): 167-178.
2
Bucci A.T. (2007) Be a Continence Champion: Use the CHAMMP Tool to Individualize
the Plan of Care, Geriatric Nursing, 28(2), 120–124.
3
Thompson D., Smith D. (2002), Continence Nursing: A Whole Person Approach,
Advanced Nursing Practice: On The Front Lines, 16(2), 14–31.
4
Gross J. (2003) Urinary Incontinence after Stroke: Evaluation and Behavioural Treatment,
Lippincott Williams & Wilkins, Inc., 19(1), 43–5
5
Harvey S. (2007) University of Maryland Centre,
http://www.umm.edu/patiented/articles/what overflow incontinence 000050 4.htm
(accessed 13/08/09)
6
Resnick N.M., Yalla S.V. (1985) Management of Urinary Incontinence in the Elderly, New
England Journal of Medicine, 313, 800-804.
7
Zarowitz, B. J., Ouslander, J. G. (2006) Management of Urinary Incontinence in Older
Persons, Geriatric Nursing, 27(5), 265–270
8
Wilson L. (2003) Continence and older people: the importance of functional
assessment, nursing older people, 15(4), 22-28
9
HIQA (2009) National Quality Standards for Residential Care Settings for Older People in
Ireland
RAP 8: Faecal Incontinence and Continence Promotion
Definitions:
Faecal Incontinence is an involuntary loss of solid or liquid faeces.1
RAI Identifiers of Potential Risks:
■ Difficulties with Bowel Management C18, ■ Communication or Cognitive
Difficulties D3, D4, ■ Incontinence of faeces G10 ■ Constipation or Loose Stool
G11 ■ Difficulties with mobilising H1, ■ Bowel Disease G1.
Other Risk Factors include:
Further risks associated with causes include:
• Primary causes: Childbirth, Menopause, Post Surgery (e.g. haemorridectomy and anal
stretch), Trauma (e.g. obstetric), Iatrogenic, Functional bowel disorders, Spinal Injury,
Congenital abnormality, Inflammatory bowel disease, Colorectal cancer, Constipation
with overflow, rectal prolapse, anal or recto-vaginal fistula, haemorrhoids.2
• Secondary causes: Immobility, frailty and dependence, inaccessibility to toilet facilities,
inadequate care/ non available assistance, Mental Health illnesses, Behavioural Problems,
Neurological disorders including cognitive impairment, Diabetes, Intellectual disability,
Communication difficulties, Infections, Pelvic radiation, Diet and Medications with GIT
side effects and excessive use of laxatives.4
NOTE: Faecal incontinence is a sign or a symptom frequently related to several contributory
factors, which requires a multidisciplinary approach to individualised assessment and
management.1, 3
Further Assessments:
Document following assessments on admission, if the residents’ condition
improves or deteriorates and at least 3 monthly.
1. Assess the resident’s medical history for possible contributory factors e.g. severe cognitive
impairment, terminal illness, communication problems, mobility problems (check RAI
Identifiers and risk factors). Several sources of information should be used in
information/history gathering e.g. discussion with the resident, significant others, transfer
letters, contact with/and discussion with the multidisciplinary team e.g. resident’s doctor,
nurses, carers, examination and observation. This is especially important for residents
with communication or cognitive difficulties.
2. For residents who are able to communicate assess bowel habit problems by the use of
focused questioning:
Questions to establish bowel habit history, signs & symptoms:
• How long have you had problems with bowel control? Is there any pattern to this or any
factors that provoke it?
• Has there been any bleeding or mucous from the back passage?
• Do the bowel motions vary in consistency and how frequent are they? (use the Bristol
stool chart to help residents describe their stool [Figure1])
• Do you have to strain to pass stool?
• Are you able to tell the difference between passing wind and a bowel motion?
• Do you have a feeling of incomplete emptying after an attempted bowel motion?
• Do you experience any bloating or abdominal pain before passing a bowel motion?
• Do you ever assist the passage of stool with your finger?
81
•
•
•
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Are you able to clean yourself after passing stool?
Do you have to clean yourself several times after passing stool?
Do you ever leak stool without being aware of it? How much leaks? What is the
consistency of leaks? Do you get the sensation of the need to empty your bowel
before you leak? Is the sensation an urgent need (urge faecal incontinence)? Does
soiling occur after a bowel motion has been passed (post defecation soiling)? Do you
wear pads (or something else) in your underwear? If so, are they effective in
preventing soiling of clothes/furnishings/surroundings?4
Assess the resident for actual or potential risk of dehydration and malnutrition.
Assess for signs and symptoms of faecal loading; continuous faecal staining; small
bowel motions and for signs/symptoms of constipation, distended abdomen, faeces
palpable on abdominal palpation. Measure abdominal girth.
Assess the resident’s medications with their doctor and pharmacist and determine if
the resident is taking any drugs that might exacerbate faecal incontinence (refer to
Table 1)
Assess the resident’s diet for foods which might exacerbate faecal incontinence (refer
to Table 2)
Assess the resident’s skin for excoriation: Ask the resident do you have any itching or
soreness around the back passage? Ask permission to examine the skin
Assess the impact of faecal incontinence on lifestyle / Quality of life. Enquire sensitively
if faecal incontinence impacts on general lifestyle, activities, emotions, self image
Assess the resident’s ability to use the toilet. This includes; their mobility, ability to
adjust clothing and ability to wash after using the toilet
Undertake a cognitive and behavioural assessment if indicated. Refer to RAP 2 Mood
and Behaviour and RAP 3 Cognition and Acute Confusion.
A general physical examination, including an abdominal assessment and an anorectal
examination (Visual inspection of the anus, assessment of perineal descent, digital
examination of anal tone; resident should be able to squeeze anal sphincter
voluntarily, assessment of faecal loading) should be undertaken by the resident’s
doctor. Other assessments that may be required include a vaginal and perineal
assessment.
If symptoms of faecal incontinence persist after initial management, the resident may
require further specialized medical/ surgical assessment e.g. anorectal physiology
studies, endoanal ultrasound, MRI, proctography, transit Xray as indicated.
Referrals required:
Refer to multidisciplinary team as appropriate to assessment findings.
• Doctor review will be required for all residents with faecal incontinence for baseline
assessment and management. An urgent referral will be required if there is blood or
mucus in the stool, recent and significant bowel habit changes or abdominal pain.
• Pharmacist and doctor review of medications, refer to Table 1
• Dietician Referral: is required if faecal incontinence is associated with dietary intake or
medical conditions e.g. diet related; diarrhoea / constipation / malnutrition / Enteral
feeding or co-morbidities such as irritable bowel, inflammatory bowel disease, etc.
• Physiotherapy Referral: may be required for faecal incontinence exacerbated by mobility
problems and for pelvic floor muscle training, electrical stimulation and biofeedback.
• OT referral may be required for faecal incontinence associated with dexterity problems.
82
•
•
•
Continence Specialist Service referral; may be required for specialised management
options such as pelvic floor muscle training, bowel retraining, specialised dietary
assessment and management, rectal irrigation, advice on anal plugs, collection
devices and skin excoriation
Behaviour therapy referral e.g. Psychiatry of Later Life or CNS Behavioural Therapy
(if available) may be required if faecal incontinence is associated with behavioural
problems
Medical/ surgical consultant referrals may be required for specialised further
assessments
Personalised Care Planning
The aim of care planning is to develop a single multidisciplinary (MDT) plan of personalised
care that is specific to the resident and to their preferences. The primary aim is to treat the
underlying cause of faecal incontinence where possible. The following conditions will
require condition-specific interventions: Faecal loading; potentially treatable causes of
diarrhoea e.g. infective, inflammatory bowel disease, irritable bowel syndrome; warning
signs for lower gastrointestinal cancer; rectal prolapse or third-degree haemorrhoids; acute
anal sphincter injury including obstetric and other trauma, acute disc prolapse/cauda
equine syndrome.
Problem/Need Identification
Record the specific faecal incontinence problem (refer to the Protocols of Care for Faecal
Incontinence Management) and its associated or related risk factors. For example; ‘Mary
states that since she has become immobile she feels she can never completely empty her bowel
and has continuous staining which is very upsetting. Mary has faecal Incontinence associated with
faecal loading and immobility’.
Goal Specification
Record: specific, realistic, and measurable Faecal Incontinence and Continence Promotion
MDT goals. For example: ‘Mary will establish a predictable bowel pattern with an ideal
consistency stool (Type 3-4 on the Bristol Stool Scale)’ within one week.
Specific Interventions
These are the specific steps taken based on expected standards of care in addressing actual
or potential faecal incontinence problems. Document:
• What we need to do (specific interventions based on residents/significant other(s)
care choices where possible)
• What we need to monitor (on-going reassessments)
• What we need to communicate (back to the MDT)
• What/who we need to educate (to improve the problem)
1. Specific MDT interventions: Record:
a) Specific interventions to address residents/significant(s) concerns,
preferences and care choices e.g. educate the resident that faecal incontinence
is a common problem and that much can be done to treat and manage this
condition. Encourage the resident to express their fears/concerns. Provide
emotional / psychological support and information on positive coping/continence
promotion strategies.
83
Positive coping strategies include: giving information/explanation: on the specific
plan of personalised care; continence products & choice and information on use;
skin care and odour control; counselling services if needed through the social work
department and advice on how to talk openly to family/significant others about
faecal incontinence and its management (if the resident wishes this).
b) MDT specific care instructions. This includes nursing care instructions/
programmes for promoting continence and managing faecal incontinence and
includes MDT specific care instructions aimed at treating the underlying cause and
symptom management e.g. a doctor’s specific instructions for the treatment of
faecal impaction should be listed here; or a physiotherapist recommendations for
improving mobility/pelvic floor exercises. For a dietitian’s instructions for treating
constipation/diarrhoea, refer the reader to the Nutritional Plan of Personalised Care.
• Specific Initial Interventions for promoting continence and managing
incontinence should be based on baseline assessment findings and
tailored to the individual’s preferences and circumstances. Include:
• Bowel Retraining Programme: Assist or encourage the resident to use the toilet
after meals to empty their bowel (to utilise the gastrocolic response which according
to Gallagher, et al, [2008] is more pronounced after breakfast). Ensure toilet facilities
are accessible, private, and comfortable and can be used safely with sufficient time
allowed. Encourage the resident to adopt a sitting or squatting position where
possible while emptying the bowel and to avoid straining. Ensure resident is aware
of toilet locations and signage. Encourage the resident to use easily removable
clothing to reduce the time needed for access. For mobility dependent residents,
ensure a call bell is within easy reach.
• Incontinence containment products should only be used as indicated by a
comprehensive assessment. Containment products may be necessary either during
ongoing treatment or when continence cannot be achieved.5 Refer to local
guidelines for choosing the correct type, size and absorbency of incontinence
containment products.
• Skin Care: Encourage resident to/or provide skin care post defecation. Cleanse skin
well in the anal region to prevent excoriation (moisture lesions) and record name of
products to be used e.g. Clinisan®. Apply barrier products (state products e.g.
Vaseline, etc.) Refer to RAP 13: Skin and Wound Care. For residents with moderatesevere anal excoriation, fissures or cracks, consider the addition of a soothing
haemorrhoidal preparation (e.g. Hemocane®, Lanacane® cream) apply as directed
by the doctor. Use following defecation and cleansing and apply a barrier product
over the haemorrhoidal preparation to protect the skin.
• Medication management: Review medications with the doctor and pharmacist to
identify any drugs which might be causing/exacerbating the problem (Table1).
Administer anti-diarrhoeal drugs for loose stools as prescribed (anti-diarrhoeal drugs
should only be prescribed once other causes of faecal incontinence have been
excluded e.g. excessive laxative use, dietary factors and other medication. The antidiarrhoeal drug of first choice should be loperamide hydrochloride, given in a very
low dose to start and gradually increasing until the desired stool consistency is
achieved. Loperamide hydrochloride should not be offered to residents with: hard
or infrequent stools, acute diarrhoea without a diagnosed cause or an acute flare-up
of ulcerative colitis. People unable to tolerate loperamide hydrochloride should be
offered codeine phosphate, or co-phenotrope.
84
2. Monitoring & ongoing reassessment
Record the specific types of ongoing reassessments and monitoring required in
managing the resident’s specific faecal incontinence problem/need: Consider
requirements in relation to the identified cause and those required to establish the
effectiveness of interventions.
• Monitor and record a bowel chart/diary and maintain for one week to provide a
baseline of current bowel function. Record the frequency of faecal incontinence,
consistency of voided stool (using the Bristol stool chart), presence of
mucous/blood.2 ( Note: A bowel chart/diary is a separate document to the Daily
Flow Record of Care)
• Monitor and record a food and fluid diary/ intake output chart to establish baseline
data. Advise resident to modify one food item at a time if attempting to identify
potentially contributory factors to their symptoms. See Table 2.
• Monitor dehydration/ malnutrition if present refer the reader to the resident’s
personalised Dehydration and Fluid Maintenance and Nutritional Care plan.
• Monitoring the progress of pelvic floor muscle training requires digital assessment
by an appropriately trained healthcare professional who is supervising the
treatment.
3. Communication
• Promptly communicate monitoring concerns to the resident’s doctor and other
members of the MDT as appropriate. Update care plans accordingly
• Communicate the resident’s personalised care plan to all those involved in the
resident’s direct care. Ensure the resident/significant other is kept up to date
4. Information/Education/Health Promotion for Resident, Significant
Other(s) and Carers
• Educate the resident and their significant other(s) on the resident’s specific type of faecal
incontinence and their personalised plan of care. Provide written information where
possible and/or provide information in a format that suits the resident’s communication
requirements. Refer to RAP 1 Communication, Vision and Hearing.6
Evaluation of care (based on goals specified)
• MDT Faecal Incontinence and Continence Promotion Care plans must be evaluated
when the resident’s condition improves or deteriorates and at least 3 monthly. Evaluate
the effectiveness of the care provided by checking to see if the goals of care are being
met.
Refer to the ‘Protocol for the Expected Standards of Care’ flow chart and
sample ‘Personalised Care Plan’ in documenting personalised care planning
and in providing care.
85
86
Bowel Habit:
• Encourage bowel emptying after
a meal
• Ensure toilet facilities are
accessible, private, &
comfortable & can be used safely
with sufficient time allowed
• Encourage resident to adopt a
sitting or squatting position
where possible while emptying
the bowel & to avoid straining
• Use of easily
removable clothing
for dexterity problems
• Assist the resident to
the bathroom. Use
aids such as
commodes
Toilet Access:
• Ensure clear access to
bathroom
Medication Management
• Liaise with medical team
and pharmacist regarding
medication contributing to
faecal incontinence (see
Table 1)
• Administer anti-diarrhoeal
drugs as prescribed e.g.
Loperamide hydrochloride,
codeine phosphate
Coping Strategies
• Offer the resident
emotional /
Psychological
support
• Use of incontinence
containment
products
• Observe and
maintain skin
integrity
Referral to Specialist Continence Service for
• Pelvic floor muscle training
• Bowel retraining
• Specialised dietary assessment & management
• Biofeedback
• Electrical Stimulation
Referral to a Specialist Surgeon for
• Specialised assessment e.g. anorectal
physiology studies
• Surgery
If faecal incontinence persists after Initial Management, Resident should be considered for Specialised Management, which may involve
Diet:
• Assess for malnutrition
• Ensure overall diet is balanced
• Use a fluid/ food diary/chart.
Modify one food at a time
• Ensure residents with hard stools
&/or dehydration aim for at least
1.5 L daily (unless contraindicated)
• Liaise with Medical Team &
Dietician regarding modifying type
& timing of enteral feed
Initial Management
Treat: Potential reversible causes of faecal incontinence: faecal loading, treatable causes of diarrhoea, lower gastrointestinal cancer,
rectal prolapse and third degree haemorrhoids
If Faecal Incontinence persists following Assessment and Treatment of potentially reversible causes commence
Protocol for the Expected Care Standards for Faecal Incontinence and Continence Promotion
in HSE Older Persons Designated Centres
Table 1
Medications associated with Faecal Incontinence as per NICE 2007
Drug (and mechanism)
Examples (not an exhaustive list)
Drugs altering sphincter tone.
• Nitrates
• Calcium channel antagonists
• Beta-adrenoceptor
antagonists (beta-blockers)
• Sildenafil
• Selective serotonin
reuptake inhibitors
Broad-spectrum antibiotics (multiple
mechanisms).
• Cephalosporins
• Penicillins
• Erythromycin
Topical drugs applied to anus (reducing
pressure).
•
•
•
•
Drugs causing profuse loose stools.
•
•
•
•
Laxatives
Metformin
Orlistat
Selective serotonin
reuptake inhibitors
• Magnesium-containing antacids
• Digoxin
Constipating drugs.
•
•
•
•
•
Tranquillisers or hypnotics (reducing
alertness).
• Benzodiazepines
• Tricyclic antidepressants
• Selective serotonin
euptake inhibitors
• Anti-psychotics
Glyceryl trinitrate ointment
Diltiazem gel
Bethanechol cream
Botulinum toxin A injection
Loperamide
Opioids
Tricyclic antidepressants
Aluminium-containing antacids
Codeine
87
Table 2
Food /Drink which may exacerbate faecal incontinence in residents who present with
loose stools or rectal loading of soft stool (NICE 2007)
Food Type
Examples/ Rationale
Fibre.
Fibre supplements e.g. bulking agents; methylcellulose, ispaghula
husk, sterculia or unprocessed bran.
Wholegrain cereals/bread (reduce quantities).
Porridge/oats may cause fewer problems than whole wheat
based cereals.
Fruit &
Vegetables.
Rhubarb, figs, prunes/plums best avoided as they contain natural
laxative compounds.
Beans, pulses, cabbage & sprouts.
Spices.
e.g. chilli.
Artificial
sweeteners.
May be found in special diabetic products such as chocolate,
biscuits, conserves and in some sugar free items including many
nicotine replacement gums.
Alcohol.
Especially stout, beers and ales.
Lactose.
A few residents may have some degree of lactase deficiency.
Whilst small amounts of milk e.g. in tea or yogurt are often
tolerated, an increase in consumption of milk may cause
diarrhoea. For more information on lactose intolerance see
www.eatwell.gov.uk.
Caffeine.
Excessive intake of caffeine may loosen stool and thus increase
faecal incontinence in some predisposed residents.
Vitamin &
Excessive doses of vitamin C, magnesium, phosphorous and/or
Mineral
calcium supplements may increase faecal incontinence. For more
Supplements. information see www.eatwell.gov.uk
Olestra fat
substitute.
88
Can cause loose stool.
Figure 1
Types 1 and 2 indicate constipation with 3 and 4 being the "ideal stools" especially the
latter, as they are the easiest to pass, and 5–7 being further tending towards diarrhoea
or urgency
89
SAMPLE CARE PLAN
Topic Heading: Faecal Incontinence
and Continence Promotion
PROBLEM / NEED IDENTIFICATION
Number:
Date
Signature
01/01/10 Mary expresses fears of never regaining her normal bowel pattern of
daily bowel motions after dinner. Mary has faecal Incontinence associated with decreased mobility and faecal loading.
Jane
Murphy
GOAL SPECIFICATION
Mary will have a predictable bowel emptying pattern with an ideal consistency stool (Type 3-4 on
the Bristol Stool Scale) within one week. Faecal incontinence will be managed & Mary’s skin will remain intact and free from incontinence associated dermatitis & moisture lesions.
SPECIFIC INTERVENTIONS
Date
Signature
01/01/10 • Provide psychological support by use of positive coping strategies. These
include: giving information/explanation on the specific plan of personalised
care; continence products & choice and information on use; skin care and
odour control; counselling services if needed through the social work
department and advice on how to talk openly to family/significant others
about faecal incontinence and its management (if Mary wishes this).
• Mary prescribed Sodium Citrate Micro-enema 5 ml (e.g. Micralax®) 1 daily
following dinner for 3 days and 50mls of prune juice twice daily, to clear lower
bowel & re-establish bowel pattern. Administer enema as prescribed & ensure
Mary is assisted to the toilet and has the call bell. Closely and discreetly
supervise Mary while using the toilet post enema, for any signs of weakness,
dizziness or nausea and ensure privacy & dignity is maintained.
• Commenced on a modified diet (high fibre) to address faecal incontinence
associated with faecal loading and overflow. Refer to Mary’s Nutritional Care
Plan.
• Encourage Mary to do her exercises four times per day as ordered by the
physiotherapist. See attached list. To be taken for short walks twice daily.
• Continence Products: Mary requires: (state product type & absorbency).
• Skin Protection: Following incontinent episodes/defecation, cleanse skin
with (state product e.g., Clinisan or Water & Silcocks Base). Apply barrier
creams (state product e.g. Petroleum jelly).
• Monitor & record: Mary’s tolerance to rectally administered laxatives.
• Commenced on an intake/output chart, record consistency of bowel
motions/leaks/staining. Monitor amount and consistency of stools evacuated
post enema and ask Mary if feels she had a satisfactory bowel clearance.
• Check skin at each shift for excoriation / moisture lesions.
• Monitor hydration status daily by observing & recording Mary’s urine colour
(use the colour code on the daily Record of Care) and encourage at least 8
cups of fluid daily. Record on intake/output chart.
• Communication: Promptly report monitoring concerns to the Doctor/MDT.
• Information: Provide information sessions to Mary/Significant others on
specific type of incontinence, treatment & progress.
Jane
Murphy
EVALUATION OF CARE (based on goals specified)
Date
Signature
03/01/10 Mary tolerating enemas and had no episodes of faecal incontinence or
staining today. Mary is delighted with her progress. Plan continued.
Jane
Murphy
Discontinued Date: ............../ ............../ 20......... Signature: ................................................
90
Suggested further reading:
NICE (2007) Faecal Incontinence The management of faecal incontinence in adults.
Methods, Evidence & Guidance www.nice.org
References
1
NICE (2007) Quick reference guide. Faecal incontinence. NICE clinical guideline 49
www.nice.org
2
Bardsley, A. (2009) Assessment and management of faecal incontinence, Journal of
Community Nursing, 23(4), 4-10
3
Coffey, A., McCarthy, G., McCormack, B., Wright, J., Slater, P., (2007) Incontinence:
assessment, diagnosis, and management in two rehabilitation units for older people,
Worldviews on Evidence-Based Nursing. 4(4):179-86.
4
NICE (2007) Faecal Incontinence The management of faecal incontinence in adults.
Methods, Evidence & Guidance www.nice.org
5
Wilson L. (2003) Continence and older people: the importance of functional
assessment, Nursing Older People, 15(4), 22-2
6
HIQA (2009) National Quality Standards for Residential Care Settings for Older People in
Ireland
91
Rap 9: Constipation
Definitions:
Constipation is defined as infrequent bowel movements (typically <3 times per week),
difficulty during defecation (straining during more than 25% of bowel movements or a
subjective sensation of hard stools), or the sensation of incomplete bowel evacuation.1
RAI Identifiers of Potential Risks:
■ Signs and Symptoms of Dehydration F21, ■ Constipation F23, G11 ■ Difficulty
with Bowel Management C18, ■ Bowel disease or overflow G1, ■ Requires assistance
to mobilise H1, ■ Palliative care symptoms O6, ■ End of life symptoms P9
Other Risk Factors include:
Primary risks/causes:
• Dehydration – If there is not enough daily fluid the faeces will become small, hard,
dry and difficult to pass. Regular drinks should be offered; approximately eight to ten
glasses of fluid a day is required. Unsweetened fruit juices would also help with giving
increased fibre. Daily fluid intake is recommended for older persons at 1 ½ litres in
24 hours unless contraindicated by fluid restrictions.2, 3 Fruit juices such as orange
and prune juice can help stimulate bowel movements.4
• Lifestyle changes - Issues like reduced privacy, inaccessible toileting facilities and
reliance on other people for assistance.5
• Aging may also affect bowel regularity because a slower metabolism results in less
intestinal activity and muscle tone. This leads to slack muscles and difficulty in
opening the bowels. Encourage residents to have as much regular exercise as
possible.
Secondary causes:
Diseases that cause constipation include neurological and systemic disorders. These disorders
can slow the movement of stool through the colon, rectum, or anus as outlined below.
• Neurological disorders that may cause constipation include multiple sclerosis,
Parkinson’s disease, chronic idiopathic intestinal pseudo-obstruction, stroke, and
spinal cord injuries. Systemic disorders include amyloidosis, lupus, and scleroderma.
Metabolic and endocrine conditions include diabetes, underactive or overactive
thyroid gland, and uremia.
• Problems with the colon and rectum. Intestinal obstruction, scar tissue
(adhesions), diverticulosis, tumours, colorectal stricture, Hirschsprung's disease or
cancer can compress, squeeze, or narrow the intestine and rectum and cause
constipation. Many people with irritable bowel syndrome have irregular bowel
movements.
• Pelvic floor disorders including rectocoeles, pelvic descent, and nonrelaxing
puborectalis syndrome may all cause constipation.
Iatrogenic causes: This results from various medications and treatments as
outlined below:
• Pain medications (especially narcotics), antacids that contain aluminum,
antispasmodics, antidepressants, iron supplements, diuretics, and
anticonvulsants for epilepsy can slow the passage of bowel movements.
92
•
•
Over time, stimulant laxatives can damage nerve cells in the colon and interfere
with the colon's natural ability to contract.
Polypharmacy especially with the older person can be associated with
constipation. (See Appendix 1).
Further Assessments:
Document following assessments on admission, if the resident complains of
constipation, when the resident’s condition improves or deteriorates and at
least three monthly reassess:
1. Assess the resident’s overall risk context (See RAI identifiers and risk factors).
2. Keep bowel records using the flow chart of care to provide a baseline of current
bowel function. This should include information on stool consistency. Use the Bristol
stool chart to detail consistency.
3. Assess dietary history including fluid intake using a validated tool e.g. MUST or MNA
tools. (Refer to RAP 5: Nutritional Status).
4. Refer to the medical practitioner for a general examination.
5. Refer to the pharmacist and the medical practitioner regarding a review of
medications, which may be contributing to constipation (See Appendix 1for a table
of drugs which may contribute to constipation).
6. If symptoms of constipation persist after initial management, the resident may
require further specialized medical / surgical assessment e.g. a digital rectal
examination may be required to assess the contents of the rectum and to identify
conditions which may cause discomfort such as haemorrhoids or anal fissure.6, 7
7. Develop a multidisciplinary plan of care. Refer to multidisciplinary team as
appropriate to assessment findings.
Referrals required:
Refer to multidisciplinary team as appropriate to assessment findings.
• Doctor referral: will be required for all residents with constipation for baseline
assessment and management.
• Pharmacist and medical review: of medications, refer to Appendix 1.
• Dietician referral: is required if constipation is associated with dietary intake or
medical conditions e.g. diet related, malnutrition / Enteral feeding or co-morbidities
such as irritable bowel, inflammatory bowel disease, etc.
• Physiotherapy referral: may be required for constipation exacerbated by mobility
problems.
• Medical/ surgical specialist consult: may be required for specialised further
assessments
Record all referrals made on the MDT Referral record and document the reason/outcome
of the referral in the narrative notes. Update care plans accordingly.
Personalised Care Planning
The aim of care planning is to develop a single multidisciplinary (MDT) plan of personalised
care to address the cause or risks of constipation, where possible. The MDT includes the
resident/significant other(s), carers, nurses, doctors and allied health professionals.
93
Problem/Need Identification
Record the actual or potential constipation problem and its associated or related risk factors.
For example; ‘Mary is constipated associated with immobility’.
Goal Specification
Record: realistic, measurable and obtainable Multi disciplinary team goals. For example; ‘To
re- establish Mary’s normal bowel pattern of having bowel movements every second day within
1 week’.
Specific Interventions
These are the specific steps taken based on expected standards of care in addressing actual
or potential constipation problems. Document:
• What we need to do (specific interventions based on residents/significant other(s) care
choices where possible)
• What we need to monitor (on-going reassessments)
• What we need to communicate (back to the MDT)
• What/who we need to educate (to improve the problem)
1. Specific MDT interventions:
The following should be recorded:
a) Specific interventions to address the resident’s/significant(s) concerns, preferences,
care choices and religious/cultural requirements e.g. the resident may be anxious about
the regularity of their bowel movements, or they may have experienced distressful
symptoms related to constipation in the past. This can be addressed by providing
education and involvement in their plan of care.
b) MDT specific care instructions This includes nursing care instructions for addressing
constipation and other care instructions from members of the MDT. For example: a
dietician’s specific instructions for treatment of constipation associated with nutritional
intake. These should be listed here or a photocopy attached to the care plan. It is
important to refer the reader to the attached instructions.
• Nursing interventions. These may include ensuring that the resident has adequate
fluid intake as recommended by the doctor. Ensuring regular exercise as much as is
possible depending on the resident’s condition and ability. Ensuring adequate fibre
intake.
2. Monitoring and ongoing reassessment
• Monitor bowel movements on the Daily Flow Chart of Care
• Monitor daily intake of diet using the Daily Flow Chart of Care. The amount taken at each
meal is recorded as a %.
• Monitor fluid intake using a fluid balance chart.
• Monitor specific risk factors as identified for the resident.
3. Communication
• Promptly communicate monitoring concerns to the resident’s doctor / dietician or
appropriate MDT member. Update care plans accordingly.
• Communicate the resident’s personalised care plan to all those involved in the
resident’s direct care. Ensure the resident’s significant others/visitors are aware of
any problems associated with constipation, if the resident so wishes. Ensure the
resident/significant other is kept up to date and involved in care planning.
94
•
Educate residents and relatives on the importance of adequate fluid intake, a high
fibre diet and regular exercise. The recommended fluid intake is 1 ½ litres in 24
hours unless medically contraindicated.
4. Information/Education/Health Promotion for Resident, Significant
Other(s) and Carers
• Educate the resident/significant other(s) on the resident’s specific problem associated
with constipation and their personalised plan of care.
• Provide written information where possible and/or provide information in a format that
suits the resident’s communication requirements (Refer to RAP 1: Communication, Vision
and Hearing).
Evaluation of Care (based on the goals specified in the care plan)
• Constipation care plans must be evaluated when the resident’s condition improves or
deteriorates with prevention care plans reviewed at least three monthly.
• Evaluate the effectiveness of the care provided by checking to see if the goals of care are
being met.
Refer to the ‘Protocol for the Expected Standards of Care’ flow chart and
sample ‘Personalised Care Plan’ in documenting personalised care planning
and in providing care.
95
96
Overall Risk Context
Past Medical History
Co-morbidities
Risk factors
Mobility
Diet and fluid intake
Medication that may be attributing to
constipation
• Resident’s main concerns
• Resident’s goals
• Resident’s preferences
• Risk Assessments
Further Assessments
• Keep bowel records using the Flow
Chart of Care
• Assess dietary history including fluid
intake
• Refer to medical practitioner for a
general examination
• Refer to pharmacist and medical
practitioner regarding review/assessment
of current medications
• Further specialized medical/ surgical
assessment
• Assess needs to maintain Dignity,
Respect & Privacy
•
•
•
•
•
•
•
Nursing Assessment-Document
(On admission, if resident’s condition improves
or deteriorates and at least 3 monthly)
Nursing Assessment
No evidence of
constipation
• Reassess when there
is a change in the
resident’s condition,
if the resident
complains of
constipation and at a
minimum every 3
months
Constipated
• Identify risk level.
• Identify risk factors.
• Devise care plan
Nursing Diagnosis
and their family if the resident so wishes.
11.Level of information given to the resident
10.Privacy and dignity requirements
9. Level of assistance required
requirements
8. Recommended daily fluid intake and diet
MDT i.e. physio, OT, Dietician etc.
7. Instructions outlined by members of the
by the Medical team
6. The medication prescribed for the resident
5. The MDT referrals required & made
identified.
4. The Management plan for any risks
3. The Specific Interventions required
2. The identified Goals of care
1. The identified problem(s) / need(s)
Implement a “Personal Care” Care plan
Document:
Nursing Goal & Care planning
Goals unmet or
Condition Changes
• Reassess if condition
changes, if the resident
complaints of
constipation and at least
3 monthly.
.
Measure outcome
against specified goals
Goals met
• Resident/carer aware of
appropriate preventative
measures & involved in
care decisions.
• Resident/carers have
Care Plan on
Constipation
Evaluation, assessment
and monitoring
Protocol for the Expected Standards in Care for Constipation in HSE Older Persons Designated Centres
SAMPLE CARE PLAN
Topic Heading: Constipation
PROBLEM / NEED IDENTIFICATION
Number:
Date
15/02/10 Mary is constipated associated with immobility
Signature
Joe Bloogs
GOAL SPECIFICATION
To re- establish Mary’s normal bowel pattern of daily bowel movements within one week.
SPECIFIC INTERVENTIONS
Date
Signature
Joe Bloogs
15/02/10 • Encourage Mary to increase her oral fluid intake to 1 ½ litres over 24
hours and to have 50mls of prune juice twice daily. Record on a fluid
balance chart.
• May is prescribed 10mls of Lactulose twice daily and Movicol once a day.
Monitor the effectiveness of this and review by doctor as required.
• Record amount and type of bowel motion on the Daily Flow Chart of
Care and enquire with Mary is she feels that her current prescribed
treatment is effective.
• Liaise with members of the MDT in ensuring that Mary’s medical needs
are met
• Mary attends physiotherapy every Tuesday and Thursday. Encourage
Mary to attend these sessions and establish a regular pattern of
mobilisation on the unit with Mary as she can tolerate. Document walks
taken in the narrative notes
• Mary becomes anxious when she is constipated. Ensure that Mary can
call a nurse when required to request assistance
• Ensure that Mary’s privacy and dignity are maintained at all times when
assisting her with her needs.
• Discreetly supervise Mary whilst using the toilet for any signs of
weakness.
• Monitor the effects of interventions outlined in Mary’s plan of care.
• Whilst awaiting dietician review Mary has been commenced on a high
fibre diet. Mary enjoys Weetabix and porridge in the mornings. Add
linseed to this. Mary practically likes fruit especially apples.
• If Mary’s problems persist after initial management refer to medical team.
• Monitor hydration status and urine colour. Record urine colour on
elimination section on the Daily flow chart of care.
EVALUATION OF CARE (based on goals specified)
Date
Signature
Discontinued Date: ............../ ............../ 20......... Signature: ................................................
97
Appendix 1
Table 1 - Medications associated with constipation
Source: World Gastroenterology
Guidelines (2007)
98
•
Opiates
•
Anticholinergics
•
Antidepressants
•
Antipsychotics
•
Anticonvulsants
•
Antacids (aluminum, calcium)
•
Antihypertensives
•
Calcium-channel blockers
•
Diuretics
•
Ganglionic blockers
•
Iron supplements
•
Nonsteroidal antiinflammatory drugs
•
Cholestyramine
Organisation
Practice
References
1
Basson, M.D (2008) Available at: http:emedicine.medscope.com/article/184704overview
2
Taylor, C. (1997) Constipation and diarrhoea. In: Gastroenterology (eds L. Byrne &
T.M.D. Finlay) Churchill Livingstone, Oxford.
3
Day, A. (2001) The nurse’s role in managing constipation. Nursing Standard 16 (8) page
41 – 44.
4
Winney, J (1998) Constipation. Nursing Standard 13 (11) page 49 – 56.
5
Joanna Briggs Institute. Management of constipation in older adults. Best practice:
evidence based practice information sheets for health professionals (1999) 3 (1) Page 1
– 6.
6
Hinnriches, M.D & Huseboe, J. (2001) Research based protocol: Management of
constipation. Journal of Gerontological Nursing 27 (2) page 17 – 28.
7
World Gastroenterology Organisation Practice Guideline (2007) Page 1 – 10
99
RAP 10: Falls Prevention and Risk Reduction
Definitions:
A fall is defined as an event whereby an individual comes to rest on the ground or another
lower level with or without loss of consciousness.1
RAI Identifiers of Potential Risks:
■ Mobility Impairment C11, H1, ■ Falls History C15, ■ Inappropriate Footwear
H3, ■ Impaired Safety Awareness H4, ■ Psychotropic drug use C24, H3, ■ Visual
Impairment D8, ■ Cognitive Impairment D11, ■ Low BMI C1 ■ Urinary
Incontinence C17, G2 ■ Faecal Incontinence C18, G10 ■ Dizziness H3 ■
Identified Falls Risk H6, ■ Disturbed sleep pattern N9.
Other Risk Factors include:
■ Balance deficit, ■ Gait deficit, ■ Fear of falling, ■ Environmental hazards, ■ Number of
Medications, ■ Cardiovascular Medications, ■ Muscle weakness, ■ Depression, ■
Orthostatic and postprandial hypotension.
The presence of more than one of the above risk factors increases the
risk of falling.2
Further Assessments:
Document the following assessments on admission, when the resident’s
condition improves or deteriorates and at least three monthly:
1. Assess the resident’s past and present medical history for any suggestive or actual risk
factors/co-morbidities for falls e.g. history of a falling the last year (resident is
classified as high risk if history of recent fall),2 limitations in mobility and functional
activities, medications- consider the resident’s medications for possible risks of over
sedation or side effects which may cause or exacerbate their fall risk (Refer to RAP 18:
Psychotropic Drug Use)
2. Establish if there is a falls history and assess fall risk using a validated tool e.g.
STRATIFY, FRASE, FRAT
3. Incontinence assessment (Refer to RAP 7: Urinary Incontinence and Continence
Promotion).
4. Assess malnutrition risk using a validated tool e.g. MUST or MNA tools. (Refer to
RAP 5P: Nutritional Status)
5. Assess and Observe for signs of confusion or memory decline using a validated tool
such as the Mini Mental State Exam, (MMSE)
6. Identify and record manual handling guidelines
7. Assess to ensure the safe use of Bed rails, Lap/safety Belts if their use is indicated
(Refer to local policies on Restraint and Bedrail usage)
Several sources of information should be used in information/history gathering e.g.
discussion with the resident, significant others, transfer letters, contact with/and
discussion with the multidisciplinary team. This is especially important for residents with
limited mobility or those requiring the use of a mobility aid e.g. Zimmer frame. If the
resident has already been seen by a Physiotherapist and/or an Occupational therapist
prior to admission, record the date of last review and list/attach their recommendations
in the nursing care plan.
100
Referrals required:
Residents identified as being at increased risk of falling or present with recurrent falls should
be considered for an individualized, multifactoral assessment.2
Refer to the multidisciplinary team as appropriate for further assessment:
• Medical referral - cardiovascular examination and medication review, assessment
of osteoporosis risk, assessment of visual acuity
• Occupational therapy - referral required for seating assessments, environmental
hazards assessment and further cognitive assessment
• Physiotherapy - assessment of gait, balance and mobility, and muscle weakness,
review of current mobility aids
• Speech and language - for communication needs
• Chiropody/Podiatry /Orthotics referral if specialist foot care and/or specialist
footwear is required
• Clinical Nurse Specialist in Falls, Behaviour and /or Older person Care
• Optician referral may be required if eye sight is impacting on safe mobility
• Audiology referral may be required if hearing impairment is impacting on safe
mobility
• Continence Nurse Specialist referral may be required for assessment of
incontinence
• Falls Clinic consider a referral to a falls clinic for further assessment and
management (Falls Clinics are available in St. James’s Hospital and in the Adelaide
Meath incorporating The National Children’s Hospital)
Record referrals made on the MDT Referral Record and document the reason/outcome
of the referral in the narrative notes. Update care plans accordingly.
Personalised Care Planning
The aim of care planning is to develop a single multidisciplinary (MDT) plan of personalised
care to reduce the risks of falls and fall related injury where possible. The MDT includes the
resident/significant other(s), carers, nurses, doctors and allied health professionals.
Problem/Need Identification
Record the actual or potential problem and its associated or related risk factors. For example;
‘Linda’s risk of falling is related to her poor safety awareness, cognitive impairment and dementia ’.
Goal Specification
Record: realistic, measurable and obtainable MDT goals. For example: ‘To reduce Linda’s risk
of falls and risk of fall related injuries over a 3 month period’
Specific Interventions
These are the specific steps taken based on expected standards of care in addressing actual
or potential problems. Document:
• What we need to do (specific interventions based on residents/significant other(s)
care choices where possible)
• What we need to monitor (on-going reassessments)
• What we need to communicate (back to the MDT)
• What/who we need to educate (to improve the problem)
101
1. Specific MDT interventions: Record:
a) The specific interventions to address the resident’s /significant others
concerns, preferences and care choices. For example many older people may
have a fear of falling and be reluctant to mobilise therefore limiting their level of
independence, individual considerations should be addressed in the care plan such
as by Providing psychological care/support to address the resident’s fears
e.g. fear of falling
b) MDT specific care instructions. This includes the nursing care instructions for
addressing fall risk reduction for all residents regardless of fall risk:
1) Interventions to reduce fall and injury risk for all residents:
• Beds should be maintained at their lowest level
• Call bells should be placed within reach of all residents with instructions on their
use and constant reminders
• Always apply brakes to beds, bed tables, wheelchairs and commodes, etc.
• Ensure appropriate footwear
• No trailing clothes e.g. dressing gown belts
• Encourage residents to mobilise and to participate in functional activities to
maintain their abilities and ongoing lifestyle
2) Residents identified as at high falls risk, also consider:
• Use of injury prevention devices - ultra low beds
• Listening monitor systems
• Sensor alarms – chair and bed
• Hip Protectors
• Record a Falls Diary
3) Physiotherapy instructions for correct use of a specific mobility aid (Individual
mobility aids should be labelled and used as recommended)
4) Occupational therapy instructions on appropriate seating for both comfort and
mobility
5) Dietitian instructions and ongoing monitoring of nutrition. Refer to RAP 5:
Nutritional Status
6) Medical management of:
• Osteoporosis risk
• Osteoporosis
• Regular and ongoing monitoring of medications at least 3 monthly.3
c). Environmental interventions must also be considered:
• Prompt management of spillages
• Appropriate use of Signage
• Avoidance of trailing flexes while cleaning and during maintenance work
• Ensure good lighting
• Promote a clutter free environment
• Appropriate assessment prior to use of bedrails
d) MDT specific care instructions in the event of a fall occurring:
• Ensure that the resident receives appropriate first aid at the fall site.
Assess for shock.
• Observe the resident’s neurological status where there is a possible head injury
• Refer to the medical team for review
102
• Report and record details of a fall to nursing administration and appropriate
other managers
• Complete an Incident Report Form and return to the Health and Safety Officer
• Record the residents falls in a Falls Diary, this should be maintained in their
Resident Care Record
• Inform the resident’s significant other of the fall. (With the resident’s consent)
• Reassess fall risk
• Refer to relevant members of the multidisciplinary team for review
• Continue to provide appropriate preventative care
2. Monitoring and ongoing assessment:
• Fall risk assessment will be monitored if the
improves/deteriorates and at least 3 monthly
• Fall risk will be reassessed in the event of a fall occurring
• Record a Fall’s Diary
resident’s
condition
3. Communication:
• Communicate the resident’s personalised care plan to all those involved in the
resident’s direct care
• Promptly communicate monitoring concerns to appropriate members of the MDT
and refer the resident to other healthcare professionals as needed
• Ensure the resident/significant other is kept up to date and notified promptly (with
the resident’s permission) if a fall occurs
4. Information/Education/Health Promotion for Resident, Significant
Other(s) and Carers
• Provide residents/significant others/carers with information (leaflets) on Falls prevention
Evaluation of Care (based on goals specified)
MDT Fall Prevention and Management Care plans must be evaluated if a fall occurs,
when the resident’s condition improves or deteriorates and at least 3 monthly. Evaluate
the effectiveness of the care provided by checking to see are the goals of care are being
met.
Refer to the ‘Protocols of Care Flow Chart’ and Sample Personalised Care
Plan in documenting care planning and in providing care.
103
104
At low risk of falls
Reassess when there is a
change in the residents’
condition and at least 3
monthly.
1. Risk Assessment- Use a fall risk
assessment tool FRASE / STRATIFY
2. Consider:
• Past Medical History/ Co-morbidities
• Falls History
• Mobility impairment
• Fear of falling
• Visual impairment
• Cognitive impairment
• Urinary Incontinence
• Number of Medications-Including
psychotropic and cardiac drugs
3. Re-assess 48-72 hours after admission
4. Record level of fall risk on manual
handling plan.
5. Assess 24hr equipment needs mobility aids, bed and chair needs
(On or within 2hrs of Admission)
Nursing Assessment-Document
17.
16.
15.
14.
11.
12.
13.
10.
9.
6.
7.
8.
4.
5.
3.
2.
1.
Beds should be maintained at lowest
level
Call bells should be placed within
reach of residents with instructions
on their use and constant reminders.
Always apply brakes to beds, tables,
wheelchairs & commodes, etc.
Appropriate footwear
No trailing clothes e.g. dressing
gown belts
Prompt management of spillages
Appropriate use of Signage
Avoid trailing flexes while cleaning
and during maintenance work
Encourage residents to mobilise /
participate in functional activities
and maintain an ongoing lifestyle
Individual mobility aids should be
labelled and used as recommended
Ensure good lighting
Promote a clutter free environment
Appropriate seating for both
comfort and mobility
Appropriate assessment prior to use
of bedrails
Regular and ongoing monitoring of
nutrition
Regular and ongoing monitoring of
medications
Advice leaflet on Falls Prevention
should be given to all
residents/carers on admission
Fall / injury prevention for all
residents
1. Ensure adherence to
fall / injury
prevention for all
residents
2. Referral to all relevant
members of the
multidisciplinary
team for
multifactorial
assessment and care
planning
3. Encourage
compliance with
injury prevention
devices (low beds,
listening monitor
systems, sensor
alarm – chair and
bed)
4. Use of Hip Protectors
for residents as
indicated and
prescribed.
5. Record a falls Diary
At high risk of falls
Procedure in the event of
a fall occurring
1. Ensure that the resident
receives appropriate first aid
2. Observe the resident’s
neurological status where
there is a possible head injury
3. Refer to medical team for
review
4. Report and record details of
fall to nursing administration
and appropriate other
managers.
5. Complete Incident Report
Form and return to Health
and Safety Officer.
6. Update Falls Diary
7. Inform the resident’s
significant other of the fall.
(With the resident’s consent)
8. Refer to relevant members of
the multidisciplinary team for
review
9. Continue to provide
appropriate preventative
care.
No falls
• Resident/carer aware of appropriate preventative
measures & involved in care decisions.
• Resident/carers have leaflets on fall prevention/
management.
NB: Reassess if condition deteriorate or if a fall occurs
Protocol for Fall Prevention and Risk Reduction in HSE Older Persons Designated Centres
SAMPLE CARE PLAN
Topic Heading: Fall Prevention and Risk Reduction
PROBLEM / NEED IDENTIFICATION
Number:
Date
01/01/10 Linda is at high risk of falling, related to reduced mobility, cognitive
impairment & impaired safety awareness
Signature
Jane
Murphy
GOAL SPECIFICATION
To reduce the risk of falls and fall related injury as demonstrated by an absence of falls on three
monthly reassessment
SPECIFIC INTERVENTIONS
Date
11/01/10 • Linda is independently mobile with her Zimmer frame but requires
supervision due to impaired safety awareness
• Linda needs prompting/ reminding to use her Zimmer frame when
mobilising (Individual mobility aids should be labelled and used as
recommended) as per physio guidelines -see attached)
• Ensure that the call bell is placed within Linda’s reach with instructions on
its use and give Linda constant reminders
• Encourage Linda to mobilise and participate in functional activities and
maintain an ongoing lifestyle
• Maintain Linda’s bed at its lowest level at all times
• Assessed for safe use of Bedrails - Unsafe to use bedrails on Linda’s bed as
due to impaired safety awareness she may attempt to climb over same
• Encourage /prompt Linda to wear her hip protector at all times
• Encourage /prompt Linda to wear her appropriate footwear when
mobilising
• Encourage /prompt Linda to use her height adjustable chair when sitting
out of bed (as per OT Guidelines- see attached)
Monitor & record:
■ Commence recording Falls Diary in the event of a fall occurring
■ Reassess Linda’s fall risk if a fall occurs, if Linda’s mobility level alters
and/or 3 monthly
Communication: Promptly report monitoring concerns to theDoctor/MDT.
Ensure the resident/significant other is kept up to date and notified promp
promptly (with the residents permission ) if a fall occurs
Information sessions to be provided to Linda & her family. Leaflets on fall
prevention given.
Signature
Jane
Murphy
EVALUATION OF CARE (based on goals specified)
Date
02/01/10 Linda has not had any falls. Plan continued
Signature
Jane
Murphy
Discontinued Date: ............../ ............../ 20......... Signature: ................................................
105
References
106
1
Department of Health and Children (2008) National Strategy for the prevention of
falls and fractures in Ireland’s Ageing Population, Summary Conclusions and
Recommendations.
2
National Institute for Clinical Excellence 2004 (N.I.C.E) Falls: the Assessment and
prevention of falls in Older People Clinical Guideline 21.
3
Health Information and Quality Authority National Quality, HIQA (2009) National
Quality Standards for Residential Care Settings for Older people in Ireland.
RAP 11: Impaired Ability for Personal Care
Definitions:
Personal care refers to any care which involves washing, touching or carrying out an invasive
procedure that people carry out for themselves.
Impaired ability for personal care is defined as being unable to carry out the above for one’s
self due to a physical disability, cognitive impairment or emotional status.
The elements of Personal Care for this RAP include:
• Maintaining the Resident’s functional independence with the activities of living
• Maintaining the Resident’s dignity and respect
• Personal Cleaning and Dressing
• Oral care
• Eye Care
• Ear Care
• Nail care
• Hair Care
• Foot Care
• Self Image
• Controlling Body Temperature
RAI Identifiers of Potential Risks:
Assistance required in Personal Care I1, Cognitive Impairment I2, Hemiparesis I2, Amputation I2, Involuntary Movement I2, Assistance
required in choosing appropriate clothing to current temperature I9, Assistance
required with Eye Care I10, Assistance required with Ear Care I11, Assistance
required with Nail Care I12, Assistance required with Hair Care I13, Assistance
required with Foot Care I14, Assistance required with Oral Care F26, Assistance
required with Meaningful Activities M1
Other Risk Factors include:
Any psychosocial or physical condition that may limit the individual’s ability for personal care
such as:
1. Functional / Physical Abilities such as fractures, Arthritis, paresis, tremors,
decreased vision, decreased hearing, impaired mobility, etc.
2. Cognitive Abilities such as, Dementia, Acquired Brain Injury, etc.
3. Emotional Abilities such as depression, withdrawal and paranoia.
4. Social/Care practice activities e.g. Any practices which arise from inadequate
ongoing assessment and evaluation of the resident’s social, physical and/or clinical
need which causes the resident to be deskilled, resulting in a preventable loss of the
resident’s functional ability
Further Assessments:
The focus of further assessments is to identify the resident’s current abilities so that they can
be maintained and optimised to prevent loss of independence. The Nurse has a responsibility
and a duty of care to adequately assess residents’ ongoing needs and to put appropriate
plans in place, which promote the individual resident’s functional abilities and independence.
107
The individual’s ability should be considered and determined in their meaningful
activities assessment and weighed against the risks to safety and self identity when
planning for their personal care.
Document the following assessments on admission, when the resident’s condition
improves or deteriorates and at a minimum three monthly:
Assess the resident’s:
1. Overall risk context: Bio/psycho/social risks e.g. co-morbidities, medications e.g.
sedation level, antidepressants; abilities and limitations in functional activities;
psychosocial issues.
2. Functional / Physical Ability assessment using the “Meaningful Activities
Assessment”. Residents’ functional level should be identified as: 1. Planned, 2.
Exploratory, 3. Sensory, or 4.Reflex. A recognised validated assessment tool such as
the Barthel Index can also be used in conjunction with the “Meaningful Activity
Assessment”. Assess for the presence of Pain, this may significantly impact on
residents’ physical ability. Refer to RAP 16-Pain if present. Assess the resident’s
equipment needs; consider what assistive devices may be needed to maximise
their functional potential and independence i.e. walking stick, wheelchair, hearing
aid, spectacles, modified utensils, non slip mats, long handled shoe horn, shirt
buttoner, etc.
3. Cognitive Ability: establish a baseline using a recognised validated assessment
tool such as the MMSE. Consider the resident’s abilities to self care and what special
requirements may be needed. Assess the resident’s ability for Communication.
Consider: Is their ability to communicate impaired? If communication is impaired
refer to RAP 1: Communication.
4. Emotional Ability /Status use a recognised validated tool such as the Cohen
Mansfield Agitation Inventory. Consider the resident’s Preferences and dislikes
for personal care and how best to meet these. Establish from the resident/significant
other how they wish their dignity, respect and privacy to be maintained.
Consider any Quality of life concerns that the resident may have that may impact
on their ability or motivation to participate in self care e.g. pain, social isolation
resulting from a depression, malodorous wound causing social embarrassment,
continence problems, etc. Refer to the relevant RAPs in these areas to help address
the particular issues of concern for the resident. Consider the resident’s self image,
is it important to them? How do they like to dress? Which clothes do they favour?
Does the resident like to wear make up, perfume/aftershave?
5. Foot care requirements. Consider the resident’s abilities to self care and what
special requirements may be needed; Does the resident require the expertise of a
chiropodist/ podiatrist? Is the resident a diabetic? Does the resident have a prosthetic
device? Can the resident manage their own foot care independently or is minimal
assistance/ prompting or total assistance required?
6. Nail care requirements. Consider the resident’s abilities to self care and what
special requirements may be needed. Consider: What type of manicure does the
resident like? Would the resident like access to a beautician? Would they like their
nails painted? What colour would they like? Can the resident manage their own nail
care independently or with prompts/minimal assistance?
7. Eye care requirements Consider the resident’s abilities to self care and what
special requirements may be needed; e.g. Does the Resident have impaired
108
vision? Does the resident need glasses/contact lenses and are they effective? Can the
resident manage their contact lenses, eye drops independently?
8. Ear care requirements: Consider the resident’s abilities to self care and what
special requirements may be needed; e.g. Does the resident have impaired hearing?
Does the resident need ear syringing to dewax? Do they use a hearing aid that
needs maintenance? Do the batteries need to be changed? How much can the
resident do for them self?
9. Oral care requirements Consider the resident’s abilities to self care and what
special requirements may be needed; e.g. Has the resident been seen by a dentist
within the last year? Does the resident wear dentures? Do they fit properly? Do
poor fitting dentures impact on their speech or ability to eat/drink? Can they clean
their dentures independently? How much assistance is required?
10. Hair Care requirements Consider the resident’s abilities to self care and what
special requirements may be needed. Assess how they like their hair styled? Do they
have certain accessories they like? How often do they like to see the
hairdresser/barber? Consider how much can the resident do for them self?
Referrals required:
Refer to the multidisciplinary team as appropriate to the resident’s assessment findings.
•
•
•
•
•
•
•
•
OT/Physiotherapist referral required for specialised equipment needs assessments
to maximise functioning ability and independence
GP/Medical referral for any medical concerns /review of any identified comorbidities that impact on physical, mental and emotional capacity or for a review
of medications that may be impacting on functional capacity
Speech & Language Therapist referral will be required to maximise impaired
communication abilities
Chiropody/Podiatry referral required for foot care for residents with diabetes,
renal/arterial co-morbidities
Ophthalmology referral for any impaired vision
Audiologist referral or any impaired hearing
Dental referral for any dental issues
Doctor, Psychiatry of later life/CNS if available for any mental health issues such as
depression, behaviour that challenges, etc.
Record all referrals made on the MDT Referral Record and document the
reason/outcome of the referral in the narrative notes. Update care plans accordingly.
Personalised Care Planning
The aim of care planning is to develop a single multidisciplinary (MDT) plan of
personalised care to address the cause or risks to the resident’s impaired ability for
personal care and to promote the resident’s functional ability and independence, where
possible. The MDT includes the resident/significant other(‘s), carers, nurses, doctors
and allied health professionals.
Problem/Need Identification
Record the actual or potential personal care problem and its associated or related risk
factors. For example; ‘Joe is at risk of impaired personal hygiene associated with
his decreased mobility, diminished manual dexterity and incontinence.’
109
Goal Specification
Record: specific, measurable, realistic, and achievable MDT goals based on assessment
of needs. For example; ‘Personal care needs will be demonstrated by Joe having a
well groomed appearance daily.”
Specific Interventions
These are the specific steps taken based on expected standards of care in addressing
actual or potential problems associated with impaired ability for personal care.
Document:
• What we need to do (specific interventions based on residents/significant other(s)
care choices where possible)
• What we need to monitor (on-going reassessments)
• What we need to communicate (back to the MDT)
• What/who we need to educate (to improve the problem)
1. Specific MDT interventions: Record:
a) Specific interventions to address the resident’s/significant(s) concerns,
preferences and care choices e.g. Bath, shower, etc and the ways in which the
resident’s functional abilities can be maintained and promoted in care
b. MDT specific care instructions. This includes the care instructions for addressing
any risks associated with the delivery and maintenance of personal care e.g. in the
cognitively impaired resident ways to promote their abilities and independence should
be explored e.g. if they are handed a bath-mitt instead of a facecloth and their hand
is placed on their face, they may be able to wash their own face independently.
c. Document any specialised equipment that is required in maintaining/promoting
the resident’s independence in personal care e.g., grippers, shirt buttoner, etc.
d. Personal Hygiene regime: State the frequency and type of preferred personal
hygiene regime. Be specific e.g. shower, bath every day, alternating days etc. Refer to
the resident’s functional level and using the appropriate ‘Meaningful Activities’ care
plan template, incorporate personal care into the resident’s ‘Meaningful Activities care
plan.
e. Incontinence present - Refer the reader to the resident’s continence promotion
care plan.
f. Pain present - Refer the reader to the resident’s pain management care plan.
g. Eye care: Outline what residents can do for themselves and any specific instructions
given by the optician /Ophthalmologist.
h. Ear Care: Outline what residents can do for themselves; include any specific
instructions given by the Audiologist.
i. Foot Care and Nail Care: Outline what residents can do for themselves and include
any specific instructions given by the Chiropodist/Podiatrist based on an ongoing
assessment of the needs identified.
j. Dental Care Outline any specific instructions given by the Dentist based on an
ongoing assessment of the needs identified.
k. Hair Care Outline what residents can do for themselves and preferences individual
residents may have for their hair style or attending a Hairdresser.
l. Self Image Outline any specific instructions given by the Resident or their significant
other.
m. Controlling Body Temperature Outline any specific action(s) that may be required
to monitor and control body temperature.
110
2. Monitoring and ongoing assessment:
• Monitor the resident’s ongoing functional ability based on their disease progression
and ability to perform tasks
• Monitor the resident’s participation and motivation in their care
• Monitor the resident’s satisfaction with their care
• Monitor the resident’s overall appearance and how well groomed they appear
• Monitor any ongoing risk factors associated with co morbidities
• Update care plan as appropriate, based on monitoring findings, resident’s
satisfaction and their identified needs
• Reassess the resident’s needs if there is any change in their overall condition or at a
minimum every three months
3. Communication
• Discuss and devise the resident’s care plan in conjunction with the resident
/significant other. Communicate the resident’s personalised care plan to all those
involved in the resident’s direct care.
• Ensure any monitoring concerns identified are promptly communicated to all
appropriate members of the MDT and refer the resident to other healthcare
professionals as needed.
4. Information/Education/Health Promotion for Resident, Significant
Other(s) and Carers
• Provide health promotion advice to residents/significant others/carers in order to
maximise the resident’s functional independence in their personal care.
Evaluation of Care
The evaluation of the resident’s care should be based on the goals specified in their
individual care plan.
All MDT Personal Care Plans must be evaluated when the resident’s condition improves
or deteriorates and at a minimum 3 monthly. The effectiveness of the care being
provided should be evaluated by checking to see if the goals of care are being met.
Refer to the ‘Protocol for the Expected Standards of Care’ flow chart and
sample ‘Personalised Care Plan’ in documenting personalised care planning
and in providing care.
111
112
• Overall Risk Context
• Past Medical History
• Co-morbidities
• Risk factors
• Mobility
• Skin Assessment
• Pain Assessment
• Incontinence Assessment
• Resident’s main concerns
• Resident’s goals
• Resident’s preferences
• Risk Assessments
• Functional /Physical Ability
• Emotional Ability/Status
• Cognitive ability
• Communication abilities/deficits
• Incontinence Assessment
Further Assessments
• Engagement in Meaningful
Activities
• Equipment Needs
• Preferences /Likes/Dislikes
• Foot Care Requirements
• Eye Care Requirements
• Ear Care Requirements
• Oral care Requirements
• Quality of Life Concerns
• Dignity, Respect & Privacy
Requirements
Nursing Assessment-Document
(On admission, if resident’s condition
changes & at a minimum every 3 months)
Nursing Assessment
Reassess when there is
a change in the
resident’s condition
and at a minimum
every 3 months.
No Impaired ability
for Personal Care
1. Identify risk level.
2. Identify risk factors.
3. Devise a care plan
with the resident /
significant other
which empowers
resident’s
independence,
participation,
dignity, choice and
self determination.
Impaired Ability for
personal care
Nursing Diagnosis
The identified problem(s) / need(s)
The identified resident orientated goals of care
The Specific Interventions required
The Management plan for any risks identified
The MDT referrals required & made
The MDT Interventions required
Refer reader to relevant RAP’s & Care Plans
The identified appropriate
seating/lifting/specialised equipment
identified/required.
9. The Resident’s preferred washing method, and
abilities to participate in care. Record preferred
frequency for shower, bath, etc
10. The Resident’s preferences in personal care
11. The Resident’s dislikes
12. The Resident’s eye care requirements & their
ability to participate in care
13. The Resident’s ear care requirements & their
ability to participate in care
14. The Resident’s foot care & nail care requirements
& their ability to participate in care
15. The Resident’s dental/oral care requirements&
their ability to participate in care
16. The Residents hair care requirements & their
ability to participate in care
17. Provide health promotion to residents/significant
others & carers in order to maximise functional
independence for personal care.
1.
2.
3.
4.
5.
6.
7.
8.
Implement a “Personal Care” Care plan
Document:
Nursing Goal & Care planning
Goals unmet or
Condition Changes
Reassess if condition
changes.
Measure outcome
against specified goals
Goals met
• Resident/carer aware of
appropriate preventative
measures & involved in
care decisions & care
• Resident/carers have
Care Plan on Personal
Care.
Nursing Evaluation
Assessment &
Monitoring
Protocol of the Expected Standards in the Delivery of Personal Care in HSE Older Persons Designated Centres
SAMPLE CARE PLAN
Topic Heading: Personal Care
PROBLEM / NEED IDENTIFICATION
Number: Page 1
Date
Signature
01/01/10 Joe is at high risk of impaired hygiene and personal care related to his
immobility, diminished manual dexterity and incontinence
Jane
Murphy
GOAL SPECIFICATION
Joe will have a well groomed appearance on daily assessment
SPECIFIC INTERVENTIONS
Date
Signature
01/01/10 • Joe’s main concern(s) for personal care is that he doesn’t like female
carers attending to his personal needs so whenever possible a male carer
should be assigned to this function. He also experiences a significant
amount of back pain on movement Please refer to his Manual Handling
& Pain Care Plans.
• Joe’s functional abilities Based on Joe’s Meaningful activities
assessment, he functions at a planned level. Refer to Joe’s Meaningful
Activity Care Plan
• Joe’s cognitive ability Joe can be somewhat forgetful and needs to be
reminded what he is doing as he becomes easily distracted.
• Joe’s preferred method to wash is to have a bath every second day and
in between to have an assisted wash. Refer to Joe’s ‘Bathing’ Section in his
Meaningful Activity Care Plan and allow Joe to do as much as possible for
himself.
• Specialised equipment. Joe is unable to mobilise independently and
requires two people to walk. Refer to Joe’s Manual Handling Care Plan.
• Impaired Manual Dexterity Joe requires assistance with shirt buttons,
putting on his shoes and shaving. Please see OT’s instructions attached.
• Foot Care - Joe has a number of corns which need attention 3 monthly
from the Chiropodist.
• Hair Care - Joe likes to have a number 2 hair-cut every six weeks.
• Dressing - Joe likes to wear a tie every day with his shirt and trousers.
Refer to the ‘Dressing’ Section in Joe’s Meaningful Activity Care Plan.
• Pain Assessment/Management: Please refer to Pain Care Plan.
• Incontinence: Please see Joes, Continence Promotion Care Plan.
• Monitor Joe’s participation and his functional ability in providing self care
• Information sessions are to be provided to Joe & his family. Ongoing
educational updates are to be provided to Joe’s Carers and significant
others. Any alteration in his care needs must be communicated to all
carers and significant others. Health promotion will be provided in order
to maximise Joe’s independence for his personal care.
Jane
Murphy
EVALUATION OF CARE (based on goals specified)
Date
Time
02/01/10
13.20
Signature
Joe has no problems with the current plan of care and feels
all his concerns are being managed well and that he has a
good standard of hygiene and is smartly turned out. He has
agreed that the current plan of care should remain
unchanged.
Jane
Murphy
Discontinued Date: ............../ ............../ 20......... Signature: ................................................
113
Bibliography
The Royal Australian College of General Practitioners (2005) Medical Care of older
persons in Residential Care Facilities 4th edition
Carnaby, S., Cambridge, P. (2006) Intimate & Personal Care with people with learning
disabilities. Chapter 12 Developing Best Practice in Intimate and Personal Care for
People with Learning Disabilities.
NHS (2009) Common Core Principles to Support Self Care, A Guide to Support
Implementation, Skills for Care, Leeds, U.K. www.skillsforcare.org.uk
HSE (2008) HSE Transformation Programme- Chronic Illness Framework, HSE
Population Health
114
RAP 12: Pressure Ulcer Prevention and Management
Definitions:
Pressure ulcers (also known as a bed sores, pressure sores and decubitus ulcers) are areas
of localised damage to the skin and underlying tissue usually over a bony prominence,
as a result of pressure or pressure in combination with shear .1
European Pressure Ulcer Advisory Panel (EPUAP) Categories:
(For full definitions of EPUAP/NPUAP categories refer to the EPUAP/NPUAP (2009)
Pressure Ulcer Treatment Quick Reference Guide1)
Category I
Category II
Non-Blanchable redness of intact skin.
Darkly pigmented skin-colour may differ
from surrounding skin.
Partial thickness loss of dermis presenting
as a shallow ulcer without slough or as
a serum filled or sero-sanginous blister.
Category III
Category IV
Full thickness skin loss-Subcutaneous fat
may be exposed but bone, tendon or
muscles is not. May include slough,
undermining or tunnelling
Full thickness tissue loss with exposed
bone, tendon or muscle, making
osteomyelitis or osteitis likely. Slough or
eschar may be also present.
RAI Identifiers of Potential Risks:
Wound Present C10, J1 Impaired mobility H1, Requires prompts, minimal
assistance & total assistance in repositioning J4, Pressure ulcer risk identified J2, Pressure Ulcer Present J7, O6, P5 History of a Previous Pressure Ulcer J7, Urinary
Incontinence J5, C17, G2, Faecal incontinence C18, G10 Lower extremity oedema
E9 Lower extremity circulatory problems E9, Malnutrition C9, F1, Dehydration
F21
Other Risk Factors include:
Advanced age and age related skin changes, Co-morbidities such as: end stage renal
disease, thyroid disease, diabetes mellitus, PVD, hypotension, pyrexia, smoking, stress,
using oxygen, having a current fracture2,3,4. Inadequate care practices such as: failure
to evaluate the resident’s clinical condition and pressure ulcer risk factors; failure to define
and implement interventions that are consistent with the resident’s needs/goals and
recognised standards of practice; failure to monitor and evaluate the impact of
interventions and failure to revise interventions as appropriate5.
115
Further Assessments:
Document the following assessments on admission, when the resident’s
condition improves or deteriorates and at least three monthly:
1. Assess the resident’s overall risk context: Bio/psycho/social risks e.g. co-morbidities,
medications [e.g., sedation level/steroid use], limitations in functional activities,
previous wound history, and psychosocial issues6.
2. Assess Pressure Ulcer risk using a validated tool e.g. Waterlow, Braden tools.
3. Skin inspection. Refer to RAP 13: Skin and Wound Care.
4. Incontinence assessment (Refer to RAP 7- Urinary Incontinence and Continence
Promotion).
5. Assess malnutrition risk using a validated tool e.g. MUST or MNA tools. Refer to RAP
5: Nutritional Status.
6. Equipment Assessment (for 24hr period). Consider what is needed for the bed, chair
and to protect/offload resident’s heels. Refer to the Regional Guidelines with regard
to the Protocol on equipment selection.
7. Repositioning assessment. Assess the level of assistance needed e.g. prompts/staff
assistance. Assess the specific frequency of repositioning needed.
Pressure Ulcer Present, conduct above assessments and further include:
8. A wound assessment using a formal tool (Refer to RAP 13-Skin and Wound Care).
Ensure pressure ulcers are categorised using EPUAP/NPUAP classification system.
Assess finger stick blood sugar (to out-rule diabetes), blood pressure, pulse and
temperature (check for systemic signs of infection). Assess pertinent blood lab values
e.g. FBC.
9. Pain Assessment – using a formal tool. Refer to RAP 16-Pain. Assess quality of life
concerns of the resident e.g., insomnia associate with pain, malodour, exudate level,
social isolation due to malodour, depression associated with chronic wounds.
Referrals required:
Refer to the multidisciplinary team as appropriate to assessment findings e.g., Seating
pressure ulcers - OT/Physiotherapist referral required for seating assessments.
Dietitian referral required for those at risk of/ or with malnutrition and for any resident
with a wound. Orthotics referral required for pressure ulcers associated with
inappropriate footwear e.g. hammer toes, etc. Vascular referral required for categories
III-IV foot ulcers. Plastics referral required for non-healing ulcers. Tissue Viability
nurse (if available) for advice on extensive category II pressure ulcers and categories IIIIV pressure ulcers. Record referrals made on the MDT Referral Record and document
the reason/outcome of the referral in the narrative notes. Update care plans
accordingly.
Note: Category II and above pressure ulcers which develop while in
residential care must be reported as clinical incidents.
Personalised Care Planning:
The aim of care planning is to develop a single multidisciplinary (MDT) plan of
personalised care to address the cause or risks of pressure ulceration, where possible. The
MDT includes the resident/significant other(s), carers, nurses, doctors and allied health
professionals.
116
Problem/Need Identification:
Record the actual or potential pressure ulcer problem and its associated or related risk
factors. For example; ‘At risk of pressure ulcers associated with immobility’ or ‘High risk of
further pressure ulcers related to the presence of an existing category II pressure ulcer’.
Goal Specification:
Record: realistic, measurable and obtainable MDT goals. For example: ‘To Prevent (further)
Pressure Ulcer Development as evidenced by daily skin inspection’.
Specific Interventions:
These are the specific steps taken based on expected standards of care in addressing
actual or potential, pressure ulcer problems. Document:
• What we need to do (specific interventions based on residents/significant other(s)
care choices where possible)
• What we need to monitor (on-going reassessments)
• What we need to communicate (back to the MDT)
• What/who we need to educate (to improve the problem)
1. Specific MDT interventions: Record the:
a) Specific intervention to address the resident’s pressure relief needs, their
concerns, and preferences. This includes the nursing care instructions for
addressing pressure relief/risk reduction and other care instructions from members of
the MDT e.g. a dietitian’s instructions for increased protein intake (pressure ulcer
present). Refer the reader to the resident’s Nutritional Care Plan
• Record the type of Pressure redistributing equipment required for the
resident’s bed, chair and to offload their heels (24 hr period). Record the appropriate
settings for manual dial equipment.
• Shear/friction reduction/prevention; record the use of profiling beds, the use
of ‘knee break’ bed positions when sitting upright (if available) and the use of pressure
reducing heel boots. Note: synthetic sheepskin boots or rugs are NOT recommended
(they can cause pressure ulcers). Careful manual handling is required. Massaging
pressures areas should be avoided (this can cause a pressure ulcer). Refer the reader
to the resident’s Manual Handling Care Plan.
• Reposition using the 30° tilt method. Record the specific frequency e.g. 2 hourly.
Evidence repositioning by the use of a repositioning chart.
• Incontinence present - Refer the reader to the resident’s Urinary Incontinence and
Continence Promotion Care Plan.
2. Monitoring and ongoing re-assessments:
• Pressure Ulcer Present. Record the pressure ulcer category. Monitor the wound and
reassess at each dressing change. Refer the reader to the resident’s Wound Assessment
and Management Chart.
• Pain present. Refer the reader to the resident’s Pain Assessment/Management Care
Plan.
• Daily skin inspection, assess bony prominences for signs of redness and document
findings on the daily Flow Chart of Care.
• Pressure ulcer risk reassessment will be reassessed if the resident’s condition
improves/deteriorates and at least 3 monthly.
117
•
•
Malnutrition/dehydration present - Refer the reader to the resident’s Nutritional/Fluid
Maintenance Care Plans.
Monitor pertinent Lab results.
3. Communication
• Communicate the resident’s personalised care plan to all those involved in the
resident’s direct care. Ensure the resident/significant other is involved in care planning
and is kept up to date.
• Promptly communicate monitoring concerns to appropriate members of the MDT
and refer the resident to other healthcare professionals as needed.
4. Information/Education/Health Promotion for Resident, Significant
Other(s) and Carers
• Provide the resident/significant/carers with information (and leaflets) on pressure
ulcer prevention and management7.
Evaluation of Care (based on the goals specified in the care plan)
MDT Pressure Ulcer Prevention and Management Care plans must be evaluated when the
resident’s condition improves or deteriorates and at least 3 monthly. Evaluate the
effectiveness of the care provided by checking to see if the goals of care are being met
Refer to the ‘Protocol of the Expected Standards of Care’ flow chart and
sample ‘Personalised Care Plan’ in documenting personalised care planning
and in providing care.
118
119
Nursing Assessment-Document
1. Past medical history/Co-morbidities
(e.g. arterial disease increases risk of
heel pressure ulcers) and risk factors
(pressure [including history of previous
pressure ulceration], shear, friction,
tissue tolerance, mobility, nutrition &
dressing allergies).
2. Pain Assessment & assess resident’s
main concerns, goals & preferences.
3. Risk Assessment e.g. Braden, Waterlow
Score, Norton Score.
4. Skin Assessment-Inspect pressure areas
(bony prominences).
5. Nutritional Risk Assessment e.g.
MUST/MNA Score.
6. Incontinence Assessment.
7. Repositioning Assessment.
8. 24 hr Equipment needs assessmentfor bed & chair.
Pressure Ulcer Present
9. Remove dressings examine ulcer; size,
site, dept, signs of infection &
category. Complete a Wound
Assessment/ Management Chart.
Clinical investigations
10. Investigations to exclude other
disorders including; blood pressure,
pulse assessment, finger stick blood
sugar & blood tests (FBC, U & E, etc)
as appropriate.
(On admission, if resident’s condition improves
or deteriorates and at least 3 monthly)
Nursing Assessment
•
•
•
4.
3.
2.
1.
Pressure Ulcer
Present
Requires Pressure
Ulcer Prevention &
Management Care
Plan.
Identify factors for
delayed healing.
Out rule other causes
e.g. moisture/
vascular /herpetic
lesions etc.
Signs of infection
present:
Swab for C + S
Refer to doctor for
antibiotics
Antimicrobial
dressings as
appropriate
At No Risk
Reassess when there is a
change in the resident’s
condition and at least 3
monthly.
At low-high risk
1. Identify risk level.
2. Identify risk factors.
3. Pressure Ulcer
Prevention Care Plan
required.
Nursing Diagnosis
Goal: Pressure Ulcer Prevention
No Pressure Ulcer Present but resident at risk
of Pressure Ulcers. Document:
1. Management plan for risks identified.
2. Skin Inspections (document daily), hygiene &
continence care.
3. Nutritional risk reassessment; Low- high risk of
malnutrition- follow local policy, guidelines.
4. Select appropriate pressure redistributing
equipment for 24hr period. Consider: bed, chair
& heels (Use Equipment protocol to guide
selection). Consider Seating (immobile residents)refer to OT/Physiotherapist as appropriate
5. Repositioning Regime, record frequency on a
repositioning chart.
6. Provide information/education to residents /
significant others & carers.
Goal: Pressure Ulcer Prevention &
Management
Pressure Ulcer Present-Resident at High Risk
of further Pressure Ulcers.
(Include all prevention points mentioned above)
7. Categorise Pressure Ulcers 1-IV-EPUAP Tool &
complete Wound Assessment/Management Chart.
8. Monitor pain and provide pain relief
9. Appropriate dressing choice & management of
complications e.g. Infection, Necrotic Tissue.
10. Refer all residents with wounds to the doctor and
dietitian. Further multidisciplinary referral as
appropriate e.g. OT, physiotherapist, orthotics,
surgical/ vascular /plastics consult.
11. Refer extensive category II & category III, IV ulcers
to the tissue viability nurse if available.
12. Category II and above pressure ulcers which
develop while in residential care should be reported
as clinical incidents.
Nursing Care Goals & Planning
Goal unmet ulcer fails to
heal or make progress
despite MDT input- Referral
for surgical/vascular/plastics
consult.
Goal met ulcer heals• Reassess equipment needs
and downgrade if appropriate.
• Continue to provide appropriate preventative care.
Goal met develops no
pressure ulcers
• Resident/carer aware of appropriate preventative
measures & involved in
care decisions.
• Resident/carers have leaflets
on pressure ulcer prevention/ management.
NB Reassess if condition
deteriorates.
Nursing Evaluation
Protocols for Care in the Prevention and Management of Pressure Ulcers in HSE Older Persons Designated Centres
SAMPLE (Personalised) CARE PLAN
Topic Heading: Pressure Ulcer Prevention &
Management Care Plan
PROBLEM / NEED IDENTIFICATION
Number: Page 1
Date
Signature
01/01/10 Cissy is at high risk of pressure ulcer development (or further pressure
ulcers), related to immobility & malnutrition (or presence of an existing
pressure ulcer)
Jane Murphy
GOAL SPECIFICATION
To prevent (further) pressure ulcer development as evidenced by daily skin inspection. To treat
malnutrition. To provide appropriate pressure ulcer prevention and management care strategies.
SPECIFIC INTERVENTIONS
Date
Signature
01/01/10 •
•
•
•
•
•
•
•
•
Cissy’s main concern(s) for pressure ulcer prevention is that she doesn’t like
sleeping on her sides. Information given re: repositioning using the 30° tilt
method. Cissy states she will “give it a try”. Assess Cissy’s comfort level at
each change of position.
Cissy is unable to reposition herself independently. Reposition Cissy
carefully to prevent shear and friction (state frequency, e.g. 2 hourly) using a
30° tilt while in bed and ½ hourly while sitting out. Refer to Manual Handling
Care Plan.
Pressure relieving equipment. Cissy to be nursed on: Bed surface - e.g.
An alternating overlay (record make/model & settings for manual dial
products). Chair - A pressure relieving cushion record make/model). Heels Offload Cissy’s heels (in the bed using e.g. pillows, Heelift Boots®).
Cissy is at risk of malnutrition - Refer to Cissy’s Nutritional Care Plan for
specific care instructions.
Pressure ulcer risk assessments (Waterlow, Braden) must be reassessed
(Specify frequency, e.g. 3 monthly) or sooner if Cissy’s Condition
improves/deteriorates.
Cissy will have a skin inspection for signs of pressure ulcer development
recorded & monitored at each nursing shift.
Pressure Ulcer Present (record category) - Cissy’s wound will be reassessed
at each dressing change and any deterioration will be promptly reported to
her doctor/tissue viability nurse. Refer to Cissy’s Wound Chart.
Pain Assessment/Management - Refer to Pain Care Plan.
Information sessions are to be provided to Cissy & her family. Leaflets on
pressure ulcer prevention have been given to them. Ongoing educational
updates are to be provided to Cissy’s carers.
Jane Murphy
EVALUATION OF CARE (based on goals specified)
Date
Signature
02/01/10 Cissy has no problems with the 30° tilt repositioning regieme. Plan
Jane Murphy
continued
Discontinued Date: …..... / ……… / 20…… Signature: …………………………………………..
120
Suggested further reading:
•
•
•
•
HSE (2009) National best practice and evidence based guidelines for wound
management
European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel
(2009) Treatment of Pressure Ulcers: Quick Reference Guide. Washington DC:
National Pressure Ulcer Advisory Panel. www.epuap.org
European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel
(2009) Prevention of Pressure Ulcers: Quick Reference Guide. Washington DC:
National Pressure Ulcer Advisory Panel www.epuap.org
HSE (2008) Pressure Ulcer Prevention and Management in HSE Older Persons
Residential Care Facilities
http://hsenet.hse.ie/Hospital_Staff_Hub/mullingar/Policies,_Procedures_Guidelines_
Midland_Area/Care_of_the_Older_Persons/Regional_PPG's/ROP067_Guideline__Pressure_Ulcer_Prevention_and_Management.pdf
References:
1
European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel
(2009) Treatment of Pressure Ulcers: Quick Reference Guide. Washington DC:
National Pressure Ulcer Advisory Panel. www.epuap.org
2
Bryant, A., Nix, D. (2007) Acute & Chronic Wounds, 3rd Eds, Mosby, USA
3
Grey, J., Harding, K. (2006) In ABC of Wound Healing, Oxford, Blackwell publishing
4
Heast, D., Parslow, N., Houghton, P., & Norton, L. (2007) Best Practice
Recommendations for the Prevention and Treatment of Pressure Ulcers, Advances in
Skin and Wound Care; 20:447-60
5
Rijswijk, L., Lyder, C. (2005) Pressure ulcer prevention and care: implementing the
revised guidance to surveyors for long-term care facilities. Ostomy Wound
Management, (4): 51-57, (suppl).
6
National Institute for Health and Clinical Excellence (2005) CG29 Pressure ulcer
management: RCN guideline,
http://www.nice.org.uk/page.aspx?o=cg029fullguideline
7
HSE (2009) National best practice and evidence based guidelines for wound
management
121
RAP 13: Skin and Wound Care
Definitions:
Wounds are defined as an injury resulting in tissue damage, which may or may not result
in a loss of intact skin e.g. Category 1 pressure ulcer1.
Chronic wounds are wounds of over 4 weeks duration, that have failed to heal2.
Wound infection is a bacterial imbalance within or extending from the wound bed3.
Diagnosis of wound infection is made on the presenting clinical signs and
symptoms of infection, in the local wound bed, deeper structures and in the
surrounding skin and not on swab reports4,5. Swab reports guide treatment decision
making. Infection can be systemic, regional or local.
Signs and symptoms of wound infection may include;
• Local signs and symptoms e.g. increased pain/change in the nature of pain,
spreading peri-wound erythema, increased exudate, malodour, friable/dark /dusky
red granulation tissue (bleeds easily), increased wound dimensions, wound healing
becomes static, pocketing of the wound base, bridging of the epithelium and
oedema. Treatment with systemic antibiotics is dependent on clinically diagnosed
infection and swab results. Local wound infection restricted to the wound bed
without infiltration of the surrounding tissues may be treated successfully with
antimicrobial dressings alone. Topical antibiotics are generally not recommended in
wound care, due to the development of antimicrobial resistance and an increased
incidence of sensitivity reactions.
• Regional signs and symptoms e.g. cellulitis, myositis, fasicitis, lymphangitis,
abscess formation and osteomyelitis. Treat urgently with systemic antibiotics and
antimicrobial dressings.
• Systemic signs and symptoms of bacteraemia i.e. fever, tachycardia, tachyponea,
altered mental state, hypotension and leukocytosis. Treat urgently with systemic
antibiotics and antimicrobial wound dressings.
RAI Identifiers of Potential Risks:
Wound present J1, J7, J6, C10, I14, O6, P5
Other Risk Factors include:
Intrinsic risks
• Advanced age and age related skin changes.
• Co-morbidities e.g. PVD (Venous insufficiency/Arterial Disease), diabetes, end stage
renal disease, rheumatoid arthritis, malignancy, anaemia, immobility, cardiac and
respiratory conditions increase the risk of chronic wounds such as leg ulcers and
pressure ulcers. These medical conditions may further affect systemic and peripheral
oxygenation and tissue nutrition, prolonging the healing process5,6.
• Acute episodes of illness/medical conditions such as UTIs, respiratory and viral
infections, malnutrition, and dehydration further create significant risks for wounds
such as pressure ulcers.
• Therapies received as part of a prior health condition e.g. radiation therapy,
immunosuppression may further impede wound healing2.
• Negative psychosocial factors can further impair wound healing e.g. stress/
anxiety/depression associated with altered body image/malodor/healing status.
122
Extrinsic risks8,9
• Medications such as non steroidal anti inflammatories (NSAIDs) and steroids reduce
the inflammatory response and delay wound healing.
• Smoking impedes wound healing.
• Inadequate care practices. For example:
– Moisture lesions caused by inadequate hygiene care practices (i.e. inadequate
cleansing, drying and skin protection practices)
– Avoidable pressure ulcers (inadequate pressure ulcer prevention practices).
– Avoidable leg ulcers (non compliance of staff/residents with the use of prescribed
compression hosiery for healed venous leg ulcers).
– Negative attitudes of staff to treatment and healing.
– Failure of staff to identify and correct the underlying cause of the wound where
possible.
– Use of inappropriate treatment modalities.
Further Assessments:
Holistic wound assessment is needed to:
• Identify the cause of the wound
• Provide a clear picture of what the wound looks like (baseline information)
• Provide a comprehensive picture of the resident
• Identify contributory factors
• Communicate findings to other health care professionals
• Allow for continuity of care
• Have a centralised location for wound care information
• Identify what specific personalised care planning is required
• Identify complications as they arise
Assess
1. The resident’s overall risk context: Consider the resident’s bio/psycho/social
risks which may be treatable e.g. co-morbidities, medications, blood profiles,
limitations in functional activities (immobility), malnutrition risk, pressure ulcer risk,
previous wound history, known dressing allergies and psychosocial issues6.
2. Skin Assessment: A thorough, head to toe nursing assessment/examination is
required
• Assess all skin areas and pressure points for signs of tissue damage/wounds.
• Note the presence of existing wounds and old scars.
• Note the appearance of the skin, nail and hair on the extremities (in arterial disease,
lower limbs may be hairless, with shiny skin and thickened toenails).
• Note the presence of bruises (e.g. senile purpura [aged related], steroid or anticoagulant induced) which indicates the resident’s skin is very fragile and at high risk
of skin tears.
• Assess feet and note the presence of wounds and/or callus formation (thickened,
hard skin which can result in pressure related, ulcer formation underneath the callus).
To prevent foot ulcers especially in diabetics, it is essential that calluses/corns are
promptly removed or reduced by a podiatrist/chiropodist.
• Evaluate skin colour, temperature, capillary refill, pulses and oedema.
123
3. Wound Assessment (use a Wound Assessment/Management Chart).
Record the:
• Type and identified cause of the wound e.g. Venous Leg ulcer, Arterial Leg ulcer,
pressure ulcer. Categorise all pressure ulcers using the EPUAP / NPUAP classification
system. Refer to RAP 12: Pressure Ulcer Prevention and Management.
• Location.
• Duration of the wound (days/weeks/months/years).
• Size- measure width, length and depth or trace wound. In cavity wounds assess for
sinus/fistula formation and/or undermining of the wound edges.
• Type of tissue in the wound bed. Record in percentages – epithialisation %,
granulation %, slough %, necrotic %. Refer to the Wound Bed Descriptions chart.
• Condition of wound edges and surrounding skin.
• Amount and type of exudate.
– Low exudate levels: is understood as requiring dressings once per week.
– Moderate exudate levels: is understood as requiring dressings twice weekly.
– A high exudate level: is to be understood as requiring three or more
dressings per week.
• Record the type of exudate: serous, serous sanguineous, purulent, haemopurulent.
• Odour: Note type e.g. foul (may indicate the presence of anaerobic bacteria- select
antimicrobial dressings), sweet smelling (may indicate the presence of
pseudomonas especially if it is associated with a bright blue-green exudate).
• Pain, soreness or discomfort associated with the resident’s wound; assess using a
formal pain assessment tool. Refer to RAP 16: Pain.
• Signs of Infection refer to the definitions section for expected standards in care.
Referrals required:
Assess the resident’s specific referral needs in relation to their specific wound
type. Consider: the cause of the wound and the MDT members that are likely to be
needed to improve or maintain the resident’s quality of life.
• A doctor and dietetics referral is required for all residents with a wound. Repeat
referrals are required if the wound deteriorates or stops healing (becomes static).
• A vascular referral and assessment by a competent practitioner (e.g. Nurse-led
Leg Ulcer Services or a Vascular Consultant) is required for residents with below
knee leg wounds that are at high risk of developing leg ulcers e.g. residents with
diabetes, renal disease, arterial disease, evidence of venous disease such as varicose
veins, brown staining on legs, or for all residents whose below knee wound fails
to heal within 4 weeks.
• A plastics consult, vascular or tissue viability nurse consult (if available) is
required for residents with non- healing, static wounds (no decrease in wound
dimensions for 6 weeks) or wounds that are deteriorating.
• A dermatology consult is required for wounds originating from primary skin
conditions e.g. carcinomas, eczema.
• Physiotherapy/OT referrals may be required for seating assessments e.g.
pressure ulcers related to inappropriate chair/seating equipment.
• Orthotics referral may be required for special footwear e.g. wounds originating
from footwear (e.g. foot deformity/hammer toes and footwear causing pressure).
124
•
Other referrals may be required to improve/stabilise the resident’s underlying
co-morbidities or to treat risks. For example an Endocrinology referral is required
for diabetic foot ulcers. A Podiatry referral is required for callus removal and advice
on the treatment of diabetic foot ulcers (such as offloading using total contact
casts/boots). A Rheumatology referral is required for vasculitic or rheumatoid leg
ulcers, etc.
Personalised Care Planning:
In providing care to residents with wounds it is firstly essential to identify the type of
wound being managed. Different wound types require different therapeutic
management e.g. compression therapy for venous leg ulcers, offloading heels with
pressure ulcers. The aim of care planning is to develop a single multidisciplinary (MDT)
plan of personalised care to treat the underlying cause of the wound and address actual
or potential risks, where possible. The MDT includes the resident/significant other(s),
carers, nurses, doctors and allied health professionals.
Problem/Need Identification:
Record the actual or potential wound problem and its associated or related risk factors.
For example; (‘Joe is at high risk of skin tears associated with age-related skin changes’ or
‘Mary has a venous leg ulcer related to long standing venous hypertension’ or ‘Tim has an
inoperable malodorous cancerous wound on his left lower arm’).
Goal Specification:
Record: realistic, measurable and obtainable MDT goals. For example: ‘Joe will not
develop skin tears’ or ‘Mary’s will have reduced wound dimensions by 6 weeks’ or ‘To
manage Tim’s wound exudate and wound odour and to maintain Tim’s comfort. This will
be demonstrated by an odour free wound within two weeks and by Tim expressing his
pain/comfort levels as acceptable to him’.
Specific Interventions:
These are the specific steps taken based on expected standards of care in addressing
actual or potential wound problems. Document:
• What we need to do (specific interventions based on residents/significant other(s)
care choices where possible)
• What we need to monitor (on-going reassessments)
• What we need to communicate (back to the MDT)
• What/who we need to educate (to improve the problem)
1. Specific MDT interventions: Record:
a) Specific interventions to address residents/significant(s) concerns,
preferences and care choices; For example: Pain (must be assessed and
addressed refer to RAP 16: Pain), Malodour (identify the cause and treat
appropriately e.g. necrotic tissue, refer to Section: Wound Bed Descriptions,
Treatment Aims & Dressing Selection), Fears/worries (provide psychological support
using positive coping strategies. This includes the provision of:
• Information/explanation to the resident on their specific plan of personalised care.
• Information and choice on the use of wound care products.
• Advice on skin care and odour control.
• Accessing counselling services if required by the resident.
125
b) MDT specific care instructions. This includes the nursing care instructions for
addressing the specific wound risks/problems and other MDT care instructions e.g.
A dietitian’s specific instructions, refer the reader to the resident’s nutritional
personalised care plan.
• Skin Care for Older People
i. Avoid soap in older persons’ care5,6. Soaps can dehydrate the skin causing dryness,
affect pH balance and may impair bacterial resistance6. Use an emollient for washing
residents such as Aqueous Cream or Silcock’s Base. Ensure each resident has their
own individual tube of emollient. Apply emollients in the direction of hair growth;
rinse skin and pat dry (never rub the skin vigorously). Re-apply emollient as a
moisturiser to the skin twice daily.
ii. Apply barrier products sparingly to groin/anal region for those who are
incontinent or in skin areas likely to have high moisture (skin folds, under breasts).
Example of barrier products include: Vaseline®, Petroleum jelly, Sprilon Spray®, Triple
Care®. Refer to Moisture lesions in Wound Bed, Dressing Selection and Treatment
section for further information.
iii. Avoid dusting powders and talc. Dusting powders should not be applied to
moist areas because they can cake and abrade the skin6. Talc is a lubricant and does
not absorb moisture; it is not a barrier product and should be avoided.
• Equipment required specific to the wound type. Consider:
• Pressure relieving/redistributing equipment required. Refer to RAP 12- Pressure Ulcer
Prevention and Management.
• Dressings required, refer to section: Wound Bed Descriptions, Treatment Aims and
Dressing Selection.
• Prevention of skin tears: consider:
i. Equipment risks and remove where possible e.g. lockers, etc.
ii. Need for padded bed rails, shin protectors, long sleeve clothing.
iii. Careful use of hoists/slings and careful manual handling practices.
iv. Consider staff manual handling practices. The wearing of engagement rings, watches
jewelry, false nails or having long nails must be avoided.
2. Monitoring and ongoing reassessment
• Reassess the resident’s wound at each dressing change. Refer the reader to the
resident’s wound assessment and management chart. Measure wounds at least
weekly.
• Record a finger stick blood sugar for all residents who have a wound.
• Pressure ulcer risk present; refer the reader to the pressure ulcer prevention care plan.
• Malnutrition/dehydration present; refer the reader to Nutritional, Fluid Maintenance
Care Plans.
• Incontinence present; refer the reader to the resident’s Incontinence and Continence
Promotion Care Plan.
• Pertinent Lab results e.g. FBC, U&E.
3. Communication
• Promptly communicate monitoring concerns to the resident’s doctor and appropriate
members of the MDT. Update care plans accordingly.
• Communicate the resident’s personalised care plan to all those involved in the
resident’s direct care. Ensure the resident/significant other is involved in care planning
and is kept up to date.
126
4. Information/Education/Health Promotion for Resident, Significant
Other(s) and Carers.
• Provide information to the resident/significant other(s) if they so wish on:
– Their wound type, monitoring and progress.
– Strategies to promote healing, prevent reoccurrence and maintain comfort e.g.
offloading/repositioning for pressure ulcers.
– Care of Older Persons’ skin.
– The importance of nutrition and hydration in wound healing.
• Information should be given in a suitable format that meets the resident’s
communication requirements and in written format where possible7. Refer to RAP 1:
Communication, Vision and Hearing.
Evaluation of care: (based on goals specified)
•
•
Wound Prevention Care plans must be evaluated when the resident’s condition improves
or deteriorates and at least 3 monthly.
Evaluate the wound at each dressing change. Compare the current wound assessment
to the previous assessment and to the initial baseline assessment, to evaluate the
effectiveness of care
Refer to the ‘Protocol of Expected Standards in Wound Care, Wound Bed
Descriptions, Treatment Aims and Dressing Selection’ and sample ‘Personalised
Care Plan’ in documenting personalised care planning and in providing care.
Please note:
• In the following section “Wound Bed Descriptions, Treatment Aims and Dressing
Selection” deals with the main wound types encountered in Older Persons Care. Refer
to RAP 13 for Pressure Ulcer Prevention and Management.
• Products listed are in alphabetical order and are given as examples of generic product
types. The HSE does not endorse any specific wound products.
• Dressings are classified as medical devices and do not require a doctor’s prescription. In
ordering products from HSE Central Pharmacy please ensure that similar generic
dressings on contract are ordered.
• Never apply a dressing in ignorance. Always read the manufactures instructions
and contra-indications, this is especially pertinent for antimicrobial dressings such as
Iodine based dressings.
127
128
Nursing Assessment-Document
1. Past medical history/Co-morbidities.
• Assess risks for wounds: e.g. PVD
(increase risk of arterial/venous leg
ulcers), diabetes (increase risk of leg/foot
ulcers), history of recurrent wounds,
assess pressure ulcer risk & incontinence.
• Assess risks for delayed healing: e.g.
psychosocial factors (e.g. stress) comorbidities (e.g. anaemia), medications
(e.g. steroids), smoking, dressing allergies
& mobility. Assess hydration status and
nutritional risk.
2. Skin Assessment: Check all skin areas,
pressure points & feet. Note: presence of
wounds, scars, bruises (Senile, steroid or
anticoagulant induced purpura),
calluses/corns, appearance of the skin,
nails & hair on extremities (shiny/hairless/
thickened toenails suggestive of arterial
disease). Assess skin colour, dryness,
fragility, temperature, capillary refill,
pulses and oedema.
3. Wound Assessment: Assess: duration,
site, size, wound bed tissue type,
exudate, odour & signs of infection.
Complete a Wound Assessment/
Management Chart.
4. Investigations to exclude other
disorders e.g. ABPI, B/P, pulse, finger stick
blood sugar & blood tests e.g. FBC, U & E,
as appropriate.
(On admission, remove dressings, assess
Wounds at each dressing change)
Nursing Assessment
Wound Present
1. Identify the type of
wound
2. Identify risk factors for
delayed healing.
3. Requires a Wound
Assessment &
Management Care
Plan.
4. Clinical Signs of
infection present:
• Swab for C + S
• Refer to doctor for
antibiotics
• Antimicrobial dressings
as appropriate
At No Risk of Further
Wounds
Reassess when there is a
change in the resident’s
condition and at least 3
monthly
At Risk of Further
Wounds
1. Identify risk factors.
2. Develop a MDT Wound
Prevention Plan of
personalised Care
Nursing Diagnosis
Goal-Wound Prevention
No wound present but resident at risk of wound e.g.
skin tears/leg ulcer. Document:
1. MDT management plan for identified risks, Consider MDT
referrals required & specific care instructions.
2. Skin/feet inspections (document daily).
3. Skin Care: Avoid soap & talc. Wash with an emollient e.g.
Silcocks Base, Aqueous Cream, rinse & pat dry skin. Moisturise
skin twice daily.
4. Incontinence care/continence promotion, refer to RAPs: 6 & 7.
5. Pressure Ulcer Risk -Refer to RAP 12.
6. Nutritional Risk - Refer to RAP 5.
7. Select appropriate preventative equipment, devices &
products for the 24hr period. Consider: specific resident needs
in relation to their wound type e.g. compression hosiery for
venous leg ulcer prevention.
8. Consider environmental hazards & remove if possible.
9. Provide information/education to residents/significant others
& carers.
Goal- Wound Prevention & Management
(Wound present-Include all prevention points above)
10. Complete a Wound Assessment/Management Chart. Measure
wound at least weekly.
11. Monitor & address resident’s pain, if in doubt assume all
wounds are painful.
12. Monitor & address resident’s/significant other(‘s) specific
wound related concerns.
13. Use appropriate dressings & manage complications e.g.
Infection, Necrotic Tissue. Refer to Wound Bed Descriptions,
Treatment Aims & Dressing Selection.
14. Refer all residents with wounds to the doctor and dietitian.
Further MDT referral as appropriate to specific wound type
e.g. TVN, OT, Physiotherapist, Orthotics, Surgical/
Vascular/Plastics consult.
Nursing Care Goals & Planning
Goal unmet-Wound Fails to
Heal or make progress despite multidisciplinary
input- Referral for Surgical/
Vascular/ Plastics consult.
Goal met-Wound heals
• Reassess equipment needs
and downgrade if appropriate.
• Update Care Plan.
• Continue to provide appropriate preventative care.
Goal met-Develops no
Wound
• Resident/carer aware of appropriate preventative measures & involved in care
decisions.
• Continue with Wound Prevention Care Plan.
• NB Reassess if condition
deteriorates.
Nursing Evaluation
Protocol for Expected Standards in Wound Care in HSE Older Persons Designated Centres
Wound Bed Descriptions, Treatment Aims & Dressing Selection
Epithealialising Wound Bed
Healthy Granulating Wound Beds
Wound Bed Treatment Aims
To protect from infection and injury,
promote complete epithialisation and
comfort.
Pain must be assessed/addressed.
Wound Bed Treatment Aims
To protect from infection and injury, promote further
granulation tissue/epithelialisation, manage exudate
and provide comfort.
Pain must be assessed & addressed.
Dressing Selection
Low/non-adherent dressing e.g.
Adaptic, Atramun, Tricotex (requires
secondary dressing) or a foam
adhesive e.g. Allevyn, Biatain, Mepilex
Tegaderm, or Thin Hydrocolloid e.g.
Duoderm. For Fragile skin consider
Silicone dressing e.g. Allevyn
Gentle®, Mepilex®.
Dressing Selection
Low to moderate exudate: Foam adhesive e.g.
Allevyn, Biatain Tegaderm or for Fragile skin
consider a Silcone dressing e.g. Allevyn Gentle®,
Mepilex®
High exudate: Use a primary dressing first such as a
hydrofibre e.g. Aquacel or an alginate e.g. Algisite M/
Kaltostat, Sorbsan. Secondary dressings: Use a
foam adhesive e.g. Allevyn, Biatain, Tegaderm. For
fragile skin consider Silicone-based dressings e.g.
Allevyn Gentle®, Mepilex®.
Sloughy Wound Bed
Necrotic Wounds
Wound Bed Treatment Aims
To remove slough through autolysis
and promote granulation and wound
closure.
Pain must be assessed/addressed.
Wound Bed Treatment Aims
Identify cause of necrosis & determine vascular status of
wound (i.e. an adequate blood supply). Vascular
assessment/referral required for all below knee
necrotic wounds. Pain must be assessed & addressed.
For healable wounds, debridement is the aim.
Dressing Selection
Low Exudate: hydrogel e.g.
Granugel, Intrasite Gel, Nu-Gel &
secondary dressing.
Moderate-High Exudate: alginates
e.g. Algisite M/Kaltostat or a
hydrofibre dressing such as Aquacel.
Secondary dressings: Use a foam
adhesive e.g. Allevyn, Biatain,
Tegaderm. For fragile skin consider
Silicone-based dressings e.g. Allevyn
Gentle®, Mepilex®
Dressing Selection
Awaiting vascular consult Keep all necrotic leg
wounds clean and dry. Apply a dry dressing e.g.
Inadine, Betadine spray, low non adherent dressing &
bandage loosely with absorbent padding roll e.g.
Soffban, Surepress. This can be held in place with a
loose retention sock e.g. Netelast or loose cling
bandage. Hydrogels are contraindicated due to
the risk of ‘wet’ gangrene & sepsis.
For wounds with a good blood supply & Low
exudate: consider a hydrogel e.g. Granugel, Intrasite
gel & secondary dressing. Moderate-High exudate:
consider an alginate e.g. Algisite M, Sorbsan or a
hydrofibre dressing e.g. Aquacel [GMS].Sharp
debridement should be considered and executed by
an experienced person.
129
Wound Bed Descriptions, Treatment Aims & Dressing Selection
Cavity Wound
130
Wound Infection
Wound Bed Treatment Aims
Management of exudates.
Protection of surrounding skin.
Removal of devitalized tissue.
Promotion of granulation from the base of
the wound.
Assess wound edges for presence of
undermining, fistula or sinus formation
(measure depth in all angles).
Pain must be assessed/addressed.
Wound Bed Treatment Aims
To address local & systemic treatment of
infection. (Assess resident for signs of
systemic infection e.g. pyrexia, nausea,
confusion etc., ensure a prompt
Medical review and antibiotic cover
[may need IV antibiotics & surgical
debridement], send swab for culture).
Manage wound exudate/odour.
Pain must be assessed & addressed.
Dressing Selection
Dry granulating cavity: Fill cavity loosely
with a hydrofibre ribbon e.g. Aquacel ribbon
moistened with a hydrogel or fill cavity
with hydrogel first.
Low to moderate exudate: Fill cavity
loosely with a dry hydrofibre e.g. Aquacel
ribbon, if exudate very low consider the
addition of a hydrogel.
Heavy exudate: Use an alginate rope e.g.
Algisite M rope/Kaltostat/ Sorbsan cavity or
hydrofibre ribbon e.g. Aquacel.
Infected cavity: silver dressing e.g. Aquacel
Ag Ribbon or a silver alginate e.g. Acticoat
absorbent rope.
Secondary dressings: Use a foam adhesive
e.g. Allevyn, Biatain, Tegaderm.
For fragile skin consider Silicone-based
dressings e.g. Allevyn Gentle®, Mepilex®.
Dressing Selection
Low to moderate exudate: use an
antimicrobial dressings e.g. Iodine-based
(Inadine, Iodoflex) or silver-based e.g.
Acticoat, Aquacel Ag Contreet Ag, or
hospital grade mannuka honey & a
secondary dressing as for sloughy wounds.
Moderate to heavy exudate: use
antimicrobial dressings e.g. Iodine- based
(Iodoflex) or silver based (Acticoat
absorbent, Aquacel Ag) or hospital grade
Mannuka honey & cover with dressing as for
primary dressings in sloughy wounds.
Secondary dressings: Use a foam adhesive
e.g. Allevyn, Biatain, Tegaderm.
For fragile skin consider Silicone-based
dressings e.g. Allevyn Gentle®, Mepilex®.
Wound Bed Descriptions, Treatment Aims & Dressing Selection
Skin Tear
Moisture Lesions
Treatment Aims
Stop bleeding. Prevent infection. Minimise
pain & discomfort. Recover skin integrity.
Prevent reoccurrence. Assess environment.
Pain must be assessed/addressed.
Treatment Aims
To treat underlying cause e.g. diarrhoea, etc.
To promote resident comfort & treat pain.
To promote good skin care protocols.
To prevent further skin damage.
Treatment & dressings
Identify category of skin tear using Payne
Martin Classification System (1993):
Category I: Skin tear fully approximates the
wound.
Category II: Skin tear with partial thickness
skin loss.
Category III: Skin tear with complete tissue
loss.
Local Wound Treatment:
Cover wound with a sterile pad and apply
light pressure until bleeding stops.
If flap rolled up & dried out remove
aseptically.
If flap viable or partially viable, cleanse with
saline/potable water & roll flap back into
place to achieve optimum cover. If edges
approximate secure flap over wound using:
adhesive wound closure strips, skin glue,
silicone-on-adhesive dressings & apply an
appropriate secondary dressing for
fragile skin e.g. Mepilex® range or
Allevyn® Gentle range or a non adherent
dressing, padding and a loose bandage. If
flap partially covers wound, treat open
wound as per wound bed presentation and
only apply a fragile skin dressing as
above. All other dressings, adhesive tapes
should be avoided. Provide ongoing
assessment & evaluation of healing.
Other Consideration:
Determine cause & remove if possible e.g.,
use padded bed rails, move lockers, etc.
Skin Care Regime- avoid soap, wash and
moisturise with emollient e.g. Silcocks Base,
Use long sleeves, careful & gentle manual
handling, use of padded shin protectors.
Document Prevention & Management Plan.
Treatment & dressings
• Document incontinence assessment &
skin condition. Consider secondary fungal
infection (presence of satellite spots) swab
if present & send for fungal cultures. Refer
resident to the doctor for anti fungal
treatment. If skin is ‘burned’ in
appearance (as above) consider addition
of a corticosteroid such as Daktacort.
• Develop & implement individualised
program of skin/incontinence care &
continence promotion. Consider
temporary urinary catheterisation for
extensive moisture lesions
• After each incontinent episode cleanse
skin with a pH balanced cleanser e.g.
Clinisan®, Silcocks Base, do not rub skin
vigorously. Avoid soap & talc.
• Gently apply a barrier ointment/ cream
such as Emulsifying Ointment, Triple
Care®, Zinc Ointment or Cream. For wet,
weeping areas a light coat of skin barrier
powder e.g. Orahesive powder® applied
first may increase adherence of the
moisture barrier ointment/cream.
• For moisture lesions in skin folds; twice
daily skin care is recommended. Cleanse
as above, pat dry and thinly apply a
barrier cream. Separate skin folds with
cotton wound pads to prevent friction &
moisture.
• Moisture lesions in the groin area require
skin care post defecation & after voiding
urine.
• Encourage fluids & diet.
• Assess and address pain.
131
Wound Bed Descriptions, Treatment Aims & Dressing Selection
132
Venous Leg Ulcer
Arterial Leg Ulcers
Wound Bed Treatment Aims
Vascular Assessment to establish if the leg has an
adequate blood supply to support compression
therapy i.e. Ankle brachial Pressure Index (ABPI) >0.8.
Following a holistic vascular assessment by a
competent health professional, compression
therapy will be advised. Wound treatment is
aimed at managing venous insufficiency through
compression therapy by improving venous return
and managing oedema. Local wound treatment
aims are the same as those listed in ‘Wound Bed
Descriptions’.
Pain must be assessed/addressed.
Wound Bed Treatment Aims
Revascularisation of the limb (Vascular Consult).
While awaiting vascular consult dress wound according
to necrotic wound bed presentation. For those where
revascularisation or amputation is not a viable option,
the Vascular team may decide on Palliative Care. The
aim here is to maintain resident’s comfort, disturb
dressing as little as possible, provide good pain relief,
manage odour & exudate & provide
resident/significant other with psychological support.
Pain must be assessed & addressed, if pain is
uncontrolled despite best efforts residents must
be referred to the local Palliative Care Team/Pain
Consultants for analgesia advice.
Skin Care & Dressing Selection
• Good skin care is essential. Wash leg(s) with
an emollient e.g. emulsifying ointment (steep
legs in warm [drinking] water or shower with
potable water if available). Gently remove any
loose, flaky, skin scales. Rinse skin and pat dry.
Moisturise from below knee to toes using an
emollient e.g. Paraffin gel, emulsifying
ointment.
• Assess bony prominences for signs of pressure
damage from bandages e.g. tibial crest, heel,
malleoli etc. These areas may require extra
padding.
• Assess for signs of allergy to bandages; itchy,
red rash from below knee to toes. If noticed
apply a cotton sock (e.g. Tubiton 78)
underneath compression bandages (below
knee to base of toes).
• Assess wound bed & apply dressing according
to wound bed description.
• Measure ankle circumference.
• Apply compression therapy as advised &
provide frequent circulation checks.
Please note: compression therapy requires
training; inappropriately applied compression
therapy can lead to tissue necrosis and may result
in amputation. Contact company reps for onsite
training.
Post Healing: Compression hosiery as advised
to prevent reoccurrence.
Dressing Selection in Palliative Care
• The aim of care is to keep the wound dry.
• Ensure pain relief is provided at least 1 hr before
dressing. These wounds are extremely painful.
• If eschar (necrotic area) is intact and dry, keep area
dry & apply a non-adherent dressing such as
Tricotex & a secondary dressing (see below).
• If eschar is separating from the sides, use a dry
antimicrobial dressing such as Inadine, Betadine
spray, Acticoat. Iodoflex (paste dressing) is not
recommended. Please note in some individuals
Iodine causes pain.Do not use for these residents.
• If necrotic area is wet, malodorous and exudating,
apply a non-adherent antimicrobial dressing such
as Acticoat, Inadine Or an activated charcoal
(absorbs odour) e.g., Actisorb® Silver 200.
Consider use of Metronidazole (Metrotop®
(prescription only)-only use in wet, malodorous,
necrotic wounds. Do not use in dry necrotic
wounds). Consider use of plug in ‘Air Fresheners’ in
resident’s room.
• If wound continues to be painful despite analgesic
interventions or while awaiting review by Palliative
Care Team/Pain Consultant, consider applying
Instillagel® (prescription only & only suitable for
wet, wounds. Do not use on dry, necrotic wounds)
or use Biatain-Ibu dressings (releases ibuprofen).
• Secondary dressings: bandage loosely with
absorbent padding roll e.g. Soffban, Surepress.
Cover with a loose retention sock e.g. Netelast or a
loose cling bandage. Dress weekly or sooner if
exudate breakthrough.
SAMPLE: Wound Assessment and Management Chart
Initial Assessment Details
Type of Wound: Venous Leg Ulcer
Name: Margaret (Cissy) McDermott
Duration of Wound:
Ward: The Aspens
2 months
Location of Wound: Right Medial Gaiter
Date: 11/01/2010
Nutrition: MUST Score: 4
Please state:
1) Is a dietician available to refer this
resident to? Yes
2) Referred to Dietician: Yes
3) No dietician Available. Hospital/
Community guidelines dietary plan for
resident: Yes/No
D.O.B.: 08/08/1932
M.R.N. No: 00124x
G.P./C.O.H.:
Dr. McEvoy
Community Hospital: The Burren
Factors Which May Delay Healing (Tick If Present)
This is Not a Definitive List
Rheumatoid Arthritis
Diabetes Mellitus
Cardiac Disease
Anaemia
Reduced Tissue Perfusion
Chronic Breathing Difficulties
Malabsorption Syndrome
Wound Infection Present
Foreign Body
Radiotherapy
Immobility
Allergies:
Drugs
Steroids
N.S.A.I.D.S
Cytotoxic
Immunosuppresents
Anticoagulants
Smoker
Other
Dressing Allergies:
None Known
Finger Stick Blood Sugar:
B.P.: 130/90mmhg
Braden Scale:
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
Adhesive Tapes
4.5mmols/L
16
Ankle Brachial Pressue Index: Date: 24/11/09
Signature of Assessing Nurse:
Right: 1.1
Left: 1.2
Jane Murphy
133
Sample Wound Assessment Chart
Resident Name: Margaret (Cissy) McDermott
Wound:
Right Medial Gaiter Venous Leg Ulcer
DATE
11/01/2010
SIZE (cms)
Length
Width
Depth
Trace: Yes/No
4cms
2cms
Superficial
Yes
Wound Bed % (Chart Letter)
A. Granulation (Red)
B. Epithelialisation (Pink)
C. Slough (yellow)
D. Necrotic (Black)
80%
10%
10%
0%
Exudate
A. What Colour
B. Amount Mild/Moderate/Severe
C. Odour (1) None (2) Some
(3) Offensive
D. Maceration Yes/No
Infection (Chart Letter)
A. Nil
B. Suspected-Swab sent
C. Confirmed
D. Doctor notified Yes/No
Surrounding Skin
A. Cellulitis Yes/No
B. Eczema Wet/Dry
C. Erythema (measure distance from
wound
Oedema
A. Mild
B. Moderate
C. Severe
D. None
Pain Severity (0-None 10=Extreme)
A. Continuous
B. Intermittent
C. Increased at dressings
D. Unable to verbalise, demonstrates
pain by facial expression (Use Pain
Faces Score) or by moaning, crying
etc.
Signature of Nurse
134
MRN No: 00124x
Serous
Mild
1
None
A
A=No
B=None
C=0.5cms
B
B=1 to 2
Jane Murphy
Page No: ___
Sample Wound Assessment Chart
Resident Name: Margaret (Cissy) McDermott
Wound:
MRN No: 00124x
Page No: ___
Right Medial Gaiter Venous Leg Ulcer
Date:11/01/2010
Treatment Objective
Date:
Date:
To address venous
insufficiency.
To debride slough
and promote
granulation tissue.
Type of Cleansing Solution
Wash legs (shower)
with potable water.
Treatment of Surrounding Skin
Wash with
emulsifying
ointment, remove
loose skin scales
atraumatically, pat
dry & reapply
emulsifying
ointment in
direction of hair
growth.
Type of Primary Dressing
Aquacel.
Type of Secondary Dressing
Profore size 1825cms.
Method of Securing Dressing to Skin
Not applicable.
Type of Compression
Profore Multilayer
Compression.
Frequency of Dressing Changes
Weekly.
Removal of Sutures/Staples/Steristrips
Not applicable
Patient Education
(Briefly outline topics covered)
Benefits of
Compression, Leg
Exercises.
Complications of
compression.
Information Leaflets Given (State Type)
Leaflet on Leg
Ulcers given.
Pain Addressed: State how
Refuses to take
analgesia despite
education. Dr XX
& family aware
Signature
Jane Murphy
135
Suggested further reading:
HSE (2009) National best practice and evidence based guidelines for wound
management
References:
136
1
Collier, M. (2006) Understanding the principles of wound management, Journal of
Wound Care, Supp; 15(1): S7-S10
2
Baranoski, S., Ayello, E. (2008) Wound Care essentials: practice principles. Second Edition.
Lippincott, Williams and Wilkins, USA
3
European Wound Management Association, (2005), Position Document. Identifying
Criteria for Wound Infection. London: MEP Ltd.
4
European Wound Management Association, (2006), Position Document. Management
of Wound Infection. London: MEP Ltd.
5
Bryant, A., Nix, D. (2007) Acute & Chronic Wounds, 3rd Eds, Mosby, USA
6
British National Formulary (2008) BNF 2008 Pharmaceutical Press, UK
7
HIQA (2009) National Quality Standards for Residential Care Settings for Older People in
Ireland
RAP 14: Psychosocial Well-being
Definitions:
Psychosocial is defined as “of or relating to the interrelation of social factors and
individual thought and behaviour.1
Well-being is the state of being comfortable, healthy or happy.
Psychosocial Well-being refers to feelings about self and social relationships.
RAI Identifiers of Potential Risks:
Admission Concerns A65, Communication Impairment C6, D3, D4, Difficulties
with eating C7, F22, Modified Diet F5, Difficulties with drinking C8, Thickened Fluids
F8, Dehydration F21, Wounds C10, J1, J8, Impaired Mobility C11, H1 Impaired
ability for Personal Care C12, C13 Disturbed Sleep Patterns C14, N9 Urinary
Incontinence C17, G2 Faecal Incontinence C18, G10, Constipation G11, Stoma
G12, G13, Breathing Problems C19, E4, Behaviours that Challenge C20, D16, Pain C22, Emotional state: Anxious, Low Mood, Tearful, Nervous D11, H5, Hemiparesis I2, Cognitive Impairment I2, Amputation I2, Involuntary Movements
I2, Altered Body Image I15, Communication, Mood & Behaviour Concerns D23,
Breathing & Circulation Concerns E10, Nutrition & Hydration Concerns F24, Continence & Elimination Concerns G16, Mobility & Safety Concerns H10, Personal
care, Controlling Body Temperature and Self Image Concerns I16, Skin Condition,
Wounds & Pressure ulcer prevention Concerns J8, Sleep, Rest & Spiritual Needs
Concerns N18 Palliative Care Concerns O9, End of Life Concerns P12, Unresolved
grief, unresolved inter-personal relationships, feelings of loss as identified in “A Key To
Me” K1-38, Section L- Events which are likely to impact on psychosocial well-being,
Events likely to impact on psychosocial well-being as identified in “My Day, My Way”.
Other Risk Factors include:
Individual:
• Feelings of loss, for example: in lifestyle, place of residence, independence,
autonomy/control, disease progression, functional decline
• Change in individual’s expectations and daily routines or the affects of moving
residence/institutionalisation
• Interpersonal relationships e.g. conflict with family, friends or staff, unresolved grief
issues, unresolved bereavement, lack of integration in the community prior to
entering residential care, lack of family support and a lack of appropriate support in
the preparation and transition to long term care
• Uncompleted personal affairs- e.g. End of Life planning
Environmental:
• Lack of privacy and dignity
• Unhappy with shared facilities
• Unhappy with surroundings
• Unhappy with other residents
• Unhappy with residential daily routines
137
Co- morbidity risks:
• Loss of Independence
• Functional decline
• Organic disease (e.g. Dementia, Underlying infection, Cancer, Chronic Pain).
• Mental health disorders (e.g. delirium, psychosis, depression).
• Emotional trauma (e.g. loneliness, boredom).
(The above list is not exhaustive.)
Further Assessments:
Where possible document the resident’s/significant other(s) concerns in each of the
assessment areas on the Resident Assessment Instruments (RAIs). Further assessment in
specific areas may be required to fully explore the resident’s/significant others concerns.
A key worker should be identified i.e., one who has developed a good relationship with
the resident. Identify where possible, the origins of the resident’s negative
psychosocial well-being. Negative psychosocial well-being may be related to:
1. Psychosocial Causes:
Assess and explore all areas that have been identified during RAI assessment as impacting
negatively on the resident’s psychosocial well-being e.g. the resident may have several
issues of concern identified in the RAIs. These should be collated together to give an
overall picture of the resident’s psychosocial well-being.
2. Environmental Causes:
Ask the resident what specific environmental issues are impacting on their psychosocial
well-being e.g. privacy, dignity, routines and expectations, dining facilities, bathroom
facilities, availability of quiet area, social facilities and interaction with residents, staff. For
residents who have difficulty with, or are unable to communicate refer to RAP 1:
Communication, Vision and Hearing.
3. Physiological causes:
Physiological causes that may impact on a resident’s psychosocial well-being may include
delirium, malnutrition, pain, infection. If relevant assess:
• Mood and Behaviour changes e.g. complete ABC analyses of behaviour. Refer to RAP
2: Mood and Behaviour
• Cognitive impairment, dementia and the impact of disease progression on
psychosocial well-being e.g. complete M.M.S.E. or Cohen Mansfield Agitation
Inventory. Refer to the Doctor for further assessment if required and/or specialist in
the area e.g. C.N.S., Psychologist, Psychiatrist as appropriate
• Functional decline- Complete a validated functional assessment tool e.g. Barthel
score.
• Level of depression- Complete a H.A.D.S. (Hospital Anxiety & Depression Scale).
• Assess pain status- Complete a validated pain assessment tool e.g. Abbey Pain Scale,
numeric pain scale, refer to RAP 16: Pain Assessment and Management
• Communication difficulties. Refer to RAP 1: Communication, Vision and Hearing
• Nutritional status, refer to RAP 5: Nutritional Status. Assess hydration status, refer to
RAP 6: Dehydration and Fluid Maintenance. Assess constipation status, refer to RAP
9: Constipation.
(The above lists are not exhaustive.)
138
Referrals Required:
Refer to the multidisciplinary team with the resident’s/significant other(s’)
consent and as appropriate to the individual’s assessment findings and specific needs:
•
•
•
•
•
•
•
•
•
•
•
•
GP/Medical referral for any medical concerns and to aid identification of underlying
causes which may be treatable
Where there is a social work service available, referral should be prioritised to this
service so that appropriate expertise is accessed for psychosocial issues
O.T./Physiotherapy referral to record baseline of physical ability/activity level &
address an appropriate plan of personalised care/specialised equipment needed
Speech & Language assessment to maximise communication abilities, etc.
C.N.S. Dementia/Behaviour/Older Persons Care if available
Consultant Specialist services as required e.g. neurologist, psychiatry of later life
Counselling service
Spiritual Advisor
Complementary therapy
Advocacy services
Addiction services
Psychology/ Psychiatric services
(The above list is not exhaustive)
Personalised Care Planning:
The aim of care planning is to develop a single multidisciplinary (MDT) plan of
personalised care to address the cause or risks of negative psychosocial well-being, where
possible. The MDT includes the resident/significant other(s), carers, nurses, doctors and
allied health professionals.
Problem/Need Identification:
Record the actual or potential psychosocial well-being problem and its associated or
related risk factors. For example: ‘Mary displays anger towards her family members
related to her recent admission to extended care’.
Goal Specification:
Record: realistic, specific (to the cause of negative psychosocial well-being), measurable
and obtainable MDT goals. For example: ‘To help Mary cope with issues that are
triggering her feelings of anger as evidenced by a reduction in angry outbursts
directed towards Mary’s family within six weeks’.
Specific Interventions:
These are the specific steps taken based on expected standards of care in addressing
actual or potential psychosocial well-being problems. Document:
• What we need to do (specific interventions based on residents/significant other(s)
care choices where possible)
• What we need to monitor (on-going reassessments)
• What we need to communicate (back to the MDT)
• What/who we need to educate (to improve the problem)
139
1. Specific MDT interventions: Record
• The specific MDT care instructions for addressing any risks /needs /underlying causes
associated with the resident’s problem of negative psychosocial well-being. Specific
care instructions are aimed at reducing/addressing negative psychosocial well-being
feelings where possible, by treating/managing the underlying causes and by
promoting positive ways for the resident to regain/restore their usual pattern of
psychosocial wellbeing. Specific care instructions will be based on the individual’s
assessment findings and interests e.g. ‘Mary would like to attend the Day Care
Centre she has always attended. This has been organised for Monday,
Wednesday and Friday from 10:00-14:00hrs. Day Care Centre transport is
arranged, pick up at 09:30hrs’.
• A named key worker(s) should be identified i.e., one who has developed a good
relationship with the resident. This key worker should encourage the resident to
express their fears/concerns and provide emotional/psychological support and
information on positive coping strategies. Positive coping strategies include: giving
information/explanation/choice on all aspects of care and encouraging the resident
to discuss their feelings/choices and goals in relation to their lifestyle and active
participation in care. Encouraging residents to talk about their previous life in the
community and their present worries and fears may help some residents in coming
to terms with feelings of loss. Offer and access social work services/counselling /
advocacy services to empower/enable residents to seek further help in discussing and
resolving their feelings if they so wish. In undertaking the above tasks it is important
that the key worker is aware of their reporting accountability i.e. to their unit nurse
manager and that they are further aware of the designated centre’s policy on
confidentiality and on Elder Abuse. It is further essential that key workers are aware
of their own limitations and know when they need to refer the resident on for
specialist advice.
• Record the MDT specific interventions to treat any underlying cause(s) identified e.g.
low mood associated with infection / pain. Monitor closely the treatment outcome
and its impact on the resident’s psychosocial well-being. Consider each area in the
RAIs where the resident has reported a concern in conjunction with the risk factors
outlined. An MDT meeting may be required where these services are available to
draw up MDT interventions in Care Planning, that are time specific, measurable and
that outline areas of specific responsibility, if the resident’s needs are sufficiently
complex.
• While it is essential that a key worker provides psychosocial support for specific
residents, all staff should familiarise themselves with the resident needs including their
past and current interests, previous life and present wishes using the information
obtained from the resident/significant other in the assessments ‘A Key to Me’
(Resident profile), the resident’s ‘Diary of Important Events’ and ‘My Day, My
Way’ document. This will assist staff in better knowing the resident and in providing
care to those with negative psychosocial feelings.
• Devise an activity schedule or refer the reader to the resident’s ‘Meaningful Activity
Care Plan’. This must be based on the resident’s identified meaningful activities.
Encourage the resident’s participation on an ongoing daily basis with all staff
members. Further encourage participation with planned onsite activities e.g. weekly
visit to library (based on the specific interests of the individual). Take account of the
resident’s previous lifestyle, their priorities and the issues that matter to them.
140
2. Monitoring and ongoing assessment:
Monitor psychosocial well-being, mood and behaviour by assessment of:
a. Participation and interest in his/her care.
b. Interpersonal relationships e.g. record the frequency/intensity of episodes of angry
outburst towards significant other(s).
c. Resident’s participation in activities of choice.
d. If underlying physiological conditions are impacting on the resident’s psychosocial
wellbeing, these need to be monitored and treated where possible e.g. pain.
e. Monitor effectiveness of specific interventions recorded and evaluate at weekly
intervals unless otherwise indicated e.g. the degree of negative psychosocial
wellbeing gets worse rather than improves.
f. Report monitoring concerns to appropriate members of the MDT.
3. Communication:
• Discuss and agree the resident’s care plan and their wishes in conjunction with the
resident where possible and /or their significant other/advocate. Inform them of any
proposed change to the plan of personalised care and encourage/enable/empower
them to be involved.
• Plan regular MDT meetings with the resident’s consent e.g. Doctor, Psychiatrist,
Nurse, CNS, O.T., Physiotherapist, Social Worker, Activity team, Dietician, Art
Therapist, Music Therapist, Speech and Language Therapist, resident/significant
other(s) to discuss monitoring findings and the effectiveness of the Multidisciplinary
plan of personalised care.
• Communicate the resident’s preferences and wishes with their consent to all those
involved in the resident’s direct care. Residents must be referred back to the MD team
if there is deterioration in psychosocial wellbeing, despite implementing the MDT
plan of agreed care. Ensure staff are informed of any changes in the resident’s
care/wishes at the start of each shift.
• Ensure any changes are recorded as agreed by the resident to their individualised
plan of care and that these are communicated to the appropriate M.D.T members.
4. Information/Education/Health Promotion for Resident, Significant
Other(s) and carers:
Provide information and education to the resident, significant other(s) and all staff
involved in individualised care giving regarding:
• Understanding the resident’s identified individual and diverse psychosocial needs.
• Empowering and enabling residents by listening to their concerns and offering
choices and autonomy in decision making regarding their care.
• Ensuring residents are involved in communication and are not isolated.
• Understanding the impact of change and its affect on lifestyle and personal routine.
• Understanding that the ‘timescales’ of adjustment required for adapting to change
is different for each individual resident.
141
Evaluation of care:
Evaluate care, based on the goals specified for improving the resident’s psychosocial wellbeing. Psychosocial well-being care plans must be evaluated when the resident’s condition
improves or deteriorates and at least three monthly. Evaluate the effectiveness of the care
provided by checking if the goals of care are being met e.g. improved mood, resident
demonstrates increased interest in Activities of Living / participation in onsite activities,
improved social interest in other resident’s, significant other and staff. Encourage self
reporting of improved feelings of well-being.
Refer to the ‘Protocol of Expected Standards in Care for Psychosocial Wellbeing’ and ‘Personalised Care Plan’ in documenting personalised care planning
and in providing care.
142
143
A. Psychosocial Causes
1. Any section of RAIs identified by the resident or
significant other(s) as being an issue of concern
2. Past social relationship & lifestyle assessment.
Complete ‘A Key to Me’, ‘Diary of Important
Events’, ‘My Day, My Way’ & ‘Meaningful
activities’.
3. Assess usual behaviour pattern. Ask resident/
significant other- complete ABC Functional
Analyses or H.A.D.’s (Hospital Anxiety &
Depression Scale) if appropriate.
4. Identify a Key Worker to further explore the areas
of concern with the resident
B. Physiological Causes
5. Assess physiological conditions which may impact
negatively on the resident’s psychosocial wellbeing e.g. delirium, malnutrition, pain, infection
which may be treatable once diagnosed
6. Baseline cognitive status, complete M.M.S.E. (Mini
Mental Score Examination) within 48 hours of
admission.
7. Assess pain status.
8. Complete Functional Assessment e.g. Barthel
Score.
9. Complete Nutritional risk assessment M.U.S.T.
D. Environmental Causes
10. Ask the resident about what specific
environmental issues that are impacting on their
psychosocial well-being e.g. issues with regard to
privacy/dignity/routines & expectations. Refer to
RAP 1 for those with communication problems.
(on or within 5 days of admission, if the
Residents condition improves or deteriorates and
at least 3 monthly
Nursing Assessment
Identify
specific need
for individual
risk and
develop a
personalised
plan of care
with the
resident/
significant
other.
At Risk
Reassess when
there is a
change in the
resident’s
condition & at
least 3
monthly.
At No Risk
Nursing
Diagnosis
1. Empower and enable the resident and/or
their significant other/advocate to be
involved in all aspects of multi -disciplinary
personalised care planning, having first
sought the resident’s consent where possible.
2. With the resident’s consent, decide on
specific goals of care.
3. Ensure an identified Key Worker is appointed
to work with the resident
4. Interact positively with resident to their
identified needs.
5. Refer to multi-disciplinary team with the
resident’s consent and as appropriate e.g.
Social Worker, O.T., Physiotherapist,
Psychiatrist / Psychologist.
6. Include M.D.T specifics care instructions
7. Offer resident personal choices in everyday
activities.
8. Implement personalised plan & closely
monitor.
Implement an Enteral Feeding Care plan
Document:
Nursing Care Goals & Planning
4. Update care plans as appropriate.
3. Liaise with M.D.T. and discuss changes, monitoring
findings, improvement or
deterioration in psychosocial well-being.
2. Communicate with the resident to assess a verbal improvement in their
psychosocial well-being, if
possible.
1. Continuous observation is
required to assess the resident’s progress/ condition.
Refer to the resident’s goals
to assess if they are being
met.
Nursing Evaluation
Protocol of Care for Psychosocial Well-being in H.S.E. Older Persons Designated Centres
SAMPLE CARE PLAN
Topic Heading: Psychosocial well-being
PROBLEM / NEED IDENTIFICATION
Number:
Date
Signature
11/01/10 Mary displays anger towards her family members related to her recent
admission to extended care.
C. Byrne
GOAL SPECIFICATION
To help Mary cope with the issues that are triggering her feelings of anger as evidenced by a
reduction in angry outbursts towards Mary’s family within six weeks.
SPECIFIC INTERVENTIONS
Date
Signature
11/01/10 1.
Mary particularly likes to talk to Ann (night carer). Ann has been assigned as
Mary’s Key worker and will encourage Mary to discuss her feelings/anger
towards her family and explore her feelings with her.
2. Establish permission from Mary to discuss Mary’s angry outbursts with her
significant other(s) and explore their feelings if appropriate.
3. Provide education/information to both Mary and her family on adjustment to
change/loss and on the importance of maintaining Mary’s normal routines
and personal choices in all aspects of care and lifestyle
4. Mary wishes to talk to her family about her feelings and would like to talk to
an advocate first and for them to be present when she is talking to her family.
Advocacy referral sent. Awaiting a date for a meeting.
5. Mary and her family do not want an onward referral to counselling services at
present. Monitor situation and approach topic of counselling at a later date if
needed.
6. Refer to Mary’s-A Key to Me, Diary of Important Events & My Day, My
Way to familiarise with Mary’s interests and previous life
7. Encourage Mary’s participation in her Meaningful Activity Care Plan and to
participate in daily organised activities of her choice.
8. Mary likes to sit beside Ann during mealtimes / evenings
9. Mary’s daughter will take her mother out every Saturday afternoon- returning
at approx. 20.00 hrs & her friend Peg will visit on Tuesday mornings and
accompany her to mass. Mary is happy with this arrangement.
10. Monitor Mary’s angry outburst, mood & behaviour. Record on a mood and
behaviour diary.
11. Monitor Mary’s participation and interest in ADL’s and interpersonal
relationships. Record a daily narrative note
12. Report monitoring concerns to the MDT as appropriate
C. Byrne
EVALUATION OF CARE (based on goals specified)
Date
Signature
Discontinued Date: …..... / ……… / 20…… Signature: …………………………………………..
144
Bibliography:
Cantwell, L. (2008) An Exploration of the Psychosocial needs of The Older Person in
Extended Care Services
Health Information and Quality Authority, (2009), National quality standards for residential
care settings for older people in Ireland
Corey.G (2005) Theory and Practice of Counselling and Psychotherapy, Brooks/Cole: U.
S. A.
Perroto, R. & Culkin, J. (1993). Exploring Abnormal Psychology, Harper: New York
References:
1
Oxford dictionary 10th edition (edited by Judy Pearsall)
145
RAP 15: Activities
In our lives our leisure activities are just as much a part of our identity and
quality of life as any other pursuits.
Individually planned activities programme not only facilitate the leisure interests and
enjoyment of residents, but are also beneficial to their potential physical, emotional, social
and psychological outcomes. Through enjoyable, purposeful activities, individual
programmes must aim to achieve maximum independence, choice and selfdetermination, while enabling and motivating residents to reach their highest potential.
Meaningful activities provide the potential for improved function, mobility, dexterity, pain
reduction, diminished helplessness and isolation, release of tension, promotion of self
esteem and social interaction.
Definitions:
•
Activity: is the execution of a task or action by an individual. An activity can be
anything we do from the moment we get up in the morning, to when we go to bed
at night.
•
Meaningful Activities: The term ‘Meaningful Activities’ is to be understood as any
endeavour, including activities of daily living in which a resident participates, where
the intention is to enhance the resident’s sense of well-being and to promote or
enhance physical, cognitive and emotional health. Meaningful activities also include
leisure activities that promote quality of life, self-esteem, pleasure, comfort, education,
creativity, success and independence.
•
Activity therapy: is a holistic person centred practice. It is concerned with the
promotion of recreation and leisure opportunities, in addition to functional an
psychological wellbeing of people of all ages who experience barriers to participation
in the ‘fullness of life’ due to health problems, disability, ageing or frailty.
Many staff may think that activities are not a part of their role and consider ‘activities’ as
an event such as running a group or organising an outing. However, if we accept that
everything a resident does in a day is an ‘activity’ which can be participated in a
meaningful way by the resident, then all staff have a part to play in the provision of
Meaningful Activities. Helping a person to remain active and socially engaged is the job
and responsibility of every member of the team.
The types of activities which provide meaning in our lives include all of the
following:
•
146
Physical Activities – Are activities that can help to improve a person’s mobility, coordination, respiration and circulation. Examples include exercise and movement,
ball games, engaging in different household tasks and daily life in their place of
residency.
•
•
•
•
•
•
Mental Activities – Include activities that stimulate thinking and memory which
further encourages and enhances orientation. Examples include reading newspapers
or having newspapers read to them, social discussions between staff and residents on
current news events, providing opportunities for residents to participate in
meaningful mental activities appropriate to their level of cognition, so that residents
can achieve a feeling of self worth e.g. ‘the sequences involved in setting the table
for meals’, gardening, bingo, quizzes, word games and crafts.
Personal Care Activities such as enabling and promoting independence in
washing, dressing, brushing one’s teeth or brushing one’s hair, mealtimes, etc
Social Activities – encourage communication, interaction and involvement and
can enhance self-esteem, reduce boredom and stress and provide fun and relaxation.
Examples include; meals and mealtimes, chatting with residents or staff, shopping,
card games, participation in on-site and off-site Older Persons groups, sing along,
dancing, outings, parties, bingo, story telling and poetry.
Creative Activities – can help develop self-expression. Examples include; enabling
and promoting choice in daily life such as choice in clothing/jewellery/perfume/
aftershave, Menu planning and developing pictorial menus, enabling residents to
personalise their rooms/living area, arts and craft, music, drama.
Spiritual Activities enabling residents to carry out their usual pre-admission
spiritual routines such as night time prayers or attending religious services, singing
hymns participating in or listening to prayer groups
Vocational Activities, residents may have a vocational role that they want to
continue at some level
Activity is essential to human wellbeing and will help maintain a person’s
sense of self worth and give purpose and enjoyment to the day. Activities
may be structured or unstructured see Appendix 1.
RAIs identifiers of Potential Risk that may impact on the resident’s
activities include:
Mobility Problems C11, H1 Impaired ability for Personal Care C12, C13 Behaviours that Challenge C20, D16 Impaired Communication D3, D4, Impaired
Hearing D6, Impaired vision D8, Pain D22, Cognitive & Emotional State D11,
D13, D14, Impaired Safety Awareness H4, Resident’s Likes and Dislikes K27-38,
‘My Day, My Way’ Assessment Findings ‘Meaningful Activities’ Assessment findings
M1-10.
Other Risk Factors include:
Other risk factors which may impact on residents’ activities include:
1. Cognitive impairment
2. Sensory impairment
3. Cardiac problems
4. Medications – i.e. Psychotropic drugs, Antidepressants, Cardiac Medications
5. Limitations in functional capabilities
6. Communication difficulties
7. Low Mood
8. Behaviour that challenge
147
Further Assessments:
Assess the resident’s overall ability; this assessment must include assessment of their
lifestyle and leisure preferences, their needs, strengths, weaknesses, ability to perform a
range of tasks and their ability to interact positively with others.
The challenges of ageing affect each person in different ways and in varying degrees of
intensity. In order to propose suitable activities to older people it is important to be aware
of the unique physical and sensory challenges they may have. Learning the specific
physical and sensory needs of the resident can help to better determine which activities
are most suited for them e.g. the needs of cognitively intact residents will differ from
those with cognitive impairment. Similarly immobile, bed bound or chair bound residents
will have different activity needs.
Residents who have capacity to decide what their level of involvement in the activities
programme must have their choices respected. When a person says no to being involved
in an activity, we have to think of different ways of engaging their interests. Ask them what
activities they enjoy and would like to do with you, rather than trying to decide for them.
Allow residents to tell you about activities they enjoy and they will likely suggest ideas that
you can do together.
Identifying Interests:
In finding out how best to assist a person to become involved in recreational and leisure
activities, it is important to begin by getting to know the person. This involves spending
time with the person and possible with others who know him/her well, in order to learn
about the resident’s family, their background, experiences, their cultural and ethnic
identifications, cultures, traditions, strengths, likes or dislikes etc.
Plan a personalised activity programme with the resident/significant where possible with
consideration to the following:
1. Is resident suitably challenged/over stimulated
a. Available activities should correspond to resident lifetime values, attitude,
expectations and wishes.
b. Establish if the resident considers “leisure activities” a waste of time- he/she never
learned to play, or to do things just for enjoyment.
c. Consider the resident’s wishes and prior activity interests.
d. What was the resident’s preadmission routine for activities?
e. Consider how activities requiring lower energy levels may be of interest to the
resident – i.e. reading a book, talking with families, friends, other residents and
staff.
f. Does the resident have cognitive/functional deficits that either reduce options or
preclude involvement in all/most activities that would otherwise have been of
interest to the person?
2. Health Related factors may affect participation in activities.
a. Assess if the resident is suffering from an acute health problems.
b. Assess if the resident is hindered because of embarrassment / unease due to the
presence of health-related equipment e.g. catheter bags, etc.
c. Assess if the resident has just recovered from an illness and is well enough to
actively participate in any activities.
d. Assess if the resident has some degree of disability.
148
3. Recent decline in resident health status – cognition, communication,
function, mood or behaviour.
a. Staff should be aware of the current health status of the resident.
b. Assess the resident retained skills and capacity to learn new skills to ascertain the
level of participation.
c. Consider life history of the resident (what was the resident like prior to the most
recent decline).
d. Assess if the resident has the interest to learn new activity.
4. Environmental factors
a. Physical space limitation for the activity.
b. Residential care setting policy (Safety)
5. Availability of staff and family support
Activities for Residents with Cognitive Impairment:
The most important thing we have to give people with cognitive impairment is our time
and our attention – if we remember this we can then bring activity into all parts of the
day.
A vital consideration when selecting and presenting activities are ‘knowing the person’
and analyzing the activity. It is vital to ‘match’ the resident’s level of ability and interest
with a meaningful activity of the correct degree of challenge; too easy may be boring and
too difficult may be frustrating. The Meaning Activities Assessment (based on the Pool
Activity level (PAL) instrument), ‘My Day, My Way’ and ‘A Key to Me’ are tools which
have been developed for residential care staff to develop a profile of a person’s likes and
dislikes. The PAL tool provides a simple checklist that reveals the level of ability of an
individual. This information can then be used to plan how to present activities to the
person at just the right level.
Knowing the person:
There are two aspects to this. Firstly gather information about the person’s life (A Key to
Me) their background, family and social networks, past interests and hobbies. It is not
sufficient to list the persons interests, what was it about the interest that the resident
valued?
Secondly, it is important to understand how dementia affects the individual’s ability to
‘do’. The PAL checklist is an assessment of the activity level the resident is functioning at.
The outcome of the Meaningful Activities Assessment will indicate to staff the ability of a
resident with cognitive impairment to engage in different activities. The tool broadly
indicates four levels of functioning: Planned, Exploratory, Sensory and Reflex levels. It is
not possible to be prescriptive about suitable activities as activity preference is very
individual. However, the stages in the PAL can give a good indication of the level of ability
of the resident with dementia.
It is important that activities are risk assessed and that staff are aware of the risks for each
resident. The resident’s activity plan should be reviewed with the resident/significant
other at least every 3 months or sooner if necessary.
149
Referrals required:
Onward referrals to the multidisciplinary team should be made as appropriate to the
resident’s RAIs findings, to ensure each resident can achieve their full potential in all activities.
For example:
• Physiotherapists are the experts on mobility problems and can advise on activities which
maximise functional ability, gait, circulatory and breathing problems.
• A speech and language therapist can advise on activities, techniques, assistive
technologies and aids to help improve overall communication.
• Occupational therapists can provide an assessment of the residents’ ability to carry out
activities of living such as eating, drinking, bathing and dressing and will advise on
appropriate adaptations and assistive aids to facilitate independence in activities of living.
Occupational therapists can also provide advice on leisure activities that will promote
physical and mental wellbeing.
• Activities co-ordinators can advise on activities appropriate to the residents holistic needs.
• Other referrals may include hairdresser, massage therapist, resident’s spiritual advisor,
etc.
Personalised Care Planning:
The aim of the care plan is to develop a single multidisciplinary team (MDT) plan of
personalised care that will facilitate the resident to participate in activity or activities that will
empower the resident to have a meaningful day. The MDT meeting is an opportunity for all
the members of the team to match their assessment information to the interview information
and for the team to plan activities which accurately reflect the resident’s needs/interests and
current ability to participate.
Need/Problem Identification:
Care planning for activities should be interest or need led and not necessarily problem based.
For example: Following Mrs Smith’s Meaningful Activities Assessment her Activity level Profile
is identified at a Planned Activity Level.
Goal Specification:
Goal: Record desired outcome/s that is specific, measurable, attainable, realistic and time
bound.
For example: To enable Mrs Smith to take control of the activity being performed and to master
the steps involved within 3 months.
Specific Interventions:
These are the specific steps taken based on expected standards of care in addressing actual
or potential needs/problems. Document:
• What we need to do (specific interventions based on residents/significant other(s) care
choices where possible)
• What we need to monitor (on-going reassessments)
• What we need to communicate (back to the MDT)
• What/who we need to educate (to improve the problem/need)
150
1. Specific MDT interventions:
This includes MDT and nursing care instructions and interventions to promote participation
of the resident in meaningful activity/activities. The following should be recorded in the
interventions:
• Appropriate activities which are based on the findings of the resident’s comprehensive
assessments
• The interventions must specify the individual’s interests and needs and these should
reflect past and present interests
• The interventions should specify meaningful activities that enable the resident to meet
their highest level of functioning
• Structured and unstructured activity interventions should be recorded
For example
Mrs Smith is able to plan what to wear and select her own clothes from the wardrobe,
encourage her to dress herself, be available to assist if required.
2. Monitoring and ongoing reassessment:
Continuous monitoring and assessment of the planned interventions is needed to evaluate
the effectiveness of the meaningful activity approach in enhancing the resident’s sense of well
being and in promoting or enhancing the resident’s physical, cognitive and emotional
health.
For example
• Observe and document the resident’s participation and response to the activity.
• Determine the resident’s perception of the causes of problems which may arise
• Monitor participation of unstructured/structured activities where possible in the daily
flow sheet or in the narrative notes.
3. Communication
Discuss and plan the resident’s meaningful activity care plan in collaboration with the resident
and their significant others. Inform or discuss with the members of the MDT the residents
personalised meangiful activity care plan. Discuss what activities the resident really enjoyed
or engages in and identify if they match the care plan. Meaningful activities must be
discussed among the ward/unit team at least daily, it is important that all members of the
care team are involved in this process.
4. Information/Education/Health Promotion for Resident, Significant Other(s)
and Carers
Educate and provide advice to the resident and their significant others regarding the
resident’s personalised meaningful activity care plan. Provide written information or a copy
of the Meaningful Activities care plan to the resident/significant other if they so wish.
Evaluation of Care
Meaningful Activity care plans should be evaluated to determine the effectiveness of the
MDT interventions. Care plans should be evaluated at least every three months or sooner if
there is a change in condition. In evaluating care the ward/unit team members should reflect
on the resident’s responses and progress to determine the effectiveness of the interventions
in meeting the resident’s goals of care.
Refer to the Protocols of Care Flow Chart and Sample Personalised Care Plan
in documenting care planning and in providing care.
151
152
2. Develop activity promotion care plan
incorporating the following:
a) Identify problem/need
b) Goal specification (SMART)
c) Specific intervention
• Specific MDT interventions
• Monitoring and ongoing assessment.
• Communication
• Information/education/health promotion for
resident, significant other and carers.
3. A Key to Me
5. Identify the resident’s holistic needs
4. My Day, My Way
3. Evaluation of care
1. Nursing goals focus is to reduce the effect of
inactivity, promote optimal physical activity, and
assist the person to maintain a satisfactory life style.
1. Personal likes and dislikes
2. PAL
Establish resident goals and devise care plan
Document:
Nursing Care Goals & Planning
(Goals of care are based on the resident’s goals and wishes)
Nursing Assessment
(Within one week of admission, if the resident’s
condition improves or deteriorates & at least 3
monthly)
2. Unmet Goals
Reassess and review nursing care
plan. Consider are the activities
being offered suitable? What
would the resident like to do?
Reassess
Establish effectiveness of
nursing and MDT interventions
1. Goals met
Evaluate the need for
progression in the activity to
maintain or progress gained
physical and psychological
conditioning.
Establish effectiveness of
nursing and MDT
interventions
Nursing Evaluation
Protocol of Care for Meaningful Activities in DML, HSE Older Persons Designated Centres
Addressograph Label
or complete the following
Name: ...............................….....................…
D.O.B .…..............................……………….…
MRN: ……........................………..……………
Ward/Unit: …........................……..................…
Nurse’s Signature: … ........................................
Date: .................................. Page no: ..............
Meaningful Activities Programme
Residents Activity Level Profile
Pool Activity Level (PAL) Profile©
Sample Personalised Care Plan for: Planned Activity Level
Likely Abilities
Can explore different ways of carrying
out an activity.
Can work towards completing a task with
a tangible result.
Can look in obvious places for any
equipment.
Likely Limitations
May not be able to solve problems that
arise.
May not be able to understand complex
sentences.
May not search beyond the usual places
for equipment.
Method of engagement
Activity objectives
To enable…Mary… to take control of the activity and to
master the steps involved.
Position of tools
Ensure that equipment and materials are in their usual,
familiar places.
Verbal directions
Explain task using short sentences by avoiding using
connecting phrases such as “and”, “but”, “therefore”, or “if”.
Demonstrated directions Show …Mary… how to avoid possible errors.
Working with others
..Mary.. is able to make the first contact & should be
encouraged to initiate social contact.
Activity characteristics
There is a goal or end product, with a set process, or “recipe”,
to achieve it. An element of competition with others is
motivating.
For dressing, bathing and dining please refer to the plan of care on the next page, please
record and reassess Mary’s activity level of function on a daily basis while assisting her with
these meaningful activities of daily living.
Suitable Activities (based on knowledge of the person’s life history ‘A Key To Me’&‘My Day,
My Way’)
• Mary really enjoys baking. Organise with the OT for Mary to attend the weekly baking
group on Wednesdays. Referral to OT sent on xx/xx/2010.
• Mary enjoys reading the daily newspaper preferably the Irish Independent with her
morning tea, ensure that Mary receives the paper each morning and chat with her
throughout the day on what is currently in the news.
• Mary enjoys watching old movies, her favourite actors are Humphrey Bogart and Cary
Grant; her favourite movies of all time are Casablanca, Key Largo and To Catch a Thief.
• Mary likes to wear some make up every day and hates going out without at least her
lipstick on.
• She was very active in her local church and sang in the choir, and wishes to be included
in all Church of Ireland activities, her spiritual representative is Rev Malone contact no.
01 xx…………
• Mary’s family are very involved in her care and enjoy bringing their Mum out regularly,
ensure that they are involved in all activity planning.
153
Addressograph Label
or complete the following
Ward/Unit: …........................……..................…
Name: ...............................….....................…
D.O.B .…..............................……………….…
MRN: ……........................………..……………
Nurse’s Signature: … ........................................
Date: .................................. Page no: ..............
Planned Activity Level
Activity: DRESSING
•
•
•
•
Encourage Mary to plan what to wear and to select own clothes from the wardrobe
Encourage Mary to put on her own clothes, be available to assist if required
Point out labels on clothing to help orientate the back from the front
Encourage Mary to attend to grooming such as brushing hair, putting on make-up,
cleaning shoes
Activity: BATHING
•
•
•
Encourage Mary to plan when she will have the bath, to draw the water and select
toiletries from the usual cupboard or shelf. Ensure a slip resistant bath mat is in the
bath and on the floor
Encourage Mary to wash her own body, be available to assist if required
Encourage Mary to release the water afterwards, and to wipe the bath
Activity: DINING
•
•
•
Encourage Mary to select when and what she wishes to eat
Encourage Mary to prepare the dining table and to select the cutlery, crockery and
condiments from the usual cupboards or drawers
Encourage Mary to clear away afterwards
Note: Consideration of National Infection Control Guidelines and HSE Health
& Safety Guidelines is required in undertaking the above.
154
Addressograph Label
or complete the following
Name: ...............................….....................…
D.O.B .…..............................……………….…
MRN: ……........................………..……………
Ward/Unit: …........................……..................…
Nurse’s Signature: … ........................................
Date: .................................. Page no: ..............
Meaningful Activities Programme
Residents Activity Level Profile
Pool Activity Level (PAL) Profile©
Sample Personalised for: Exploratory Activity Level
Likely Abilities
Can carry out very familiar tasks in
familiar surroundings.
Enjoys the experience of doing a task
more than the end result.
Can carry out more complex tasks if they
are broken down into 2-3 step stages.
Likely Limitations
May not have an end result in mind when
starts a task.
May not recognise when the task is
completed.
Relies on cues such as diaries, newspapers,
lists and labels.
Method of engagement
Activity objectives
To enable…Peter…to experience the sensation of doing
the activity rather than focusing on the end result.
Position of tools
Ensure that equipment and materials are in the line of
vision.
Verbal directions
Explain task using short simple sentences. Avoid using
connecting phrases such as “and”, “but”, or “therefore”.
Demonstrated directions Break the activity into 2-3 steps at a time.
Working with others
Others must approach…Peter and make the first contact.
Activity characteristics There is no pressure to perform to a set of rules, or to
achieve an end result. There is an element of creativity and
spontaneity.
For dressing, bathing and dining please refer to the plan of care on the next page, please
record and reassess Peter’s activity level of function on a daily basis while assisting him
with these meaningful activities of daily living
Suitable Activities (based on knowledge of the person’s life history ‘A Key To
Me’&‘My Day, My Way’)
• Peter loves talking about his family, occasionally he forgets some of their names and
this upsets him, encourage him to talk about his family using his photo album which
has his family’s names under each picture and where it was taken, encourage his
family to continue to build this photo album.
• Peter enjoys exercise refer to the physiotherapist for inclusion in the exercise class
referral sent xx/xx/2010, he also enjoys Tai Chi on Wednesdays
• His favourite type of movies are westerns and he enjoys listening to country and
western music particularly Johnny Cash and Hank Williams
155
Addressograph Label
or complete the following
Name: ...............................….....................…
D.O.B .…..............................……………….…
MRN: ……........................………..……………
Ward/Unit: …........................……..................…
Nurse’s Signature: … ........................................
Date: .................................. Page no: ..............
Exploratory Activity Level
Activity: DRESSING
•
•
•
•
Encourage discussion about the clothing to be worn for the day: is it suitable for the
weather or the occasion, is it a favourite item
Spend time colour matching items of clothing and select accessories
Break down the task into manageable chunks: help lay the clothes out in order so
that underclothing is at the top of the pile. If Peter wishes to be helped, talk Peter
through the task: “put on your underclothes” “now put on your shirt and cardigan”
Encourage Peter to check his appearance in the mirror
Activity: BATHING
•
•
•
•
•
Ensure a slip resistant bath mat is in the bath and on the floor
Break down the task into manageable chunks: suggest that Peter fills the bath, then
when that is accomplished suggest that he gathers together items such as soap
substitute (e.g. Silcock base®), shampoo, flannel, and towels
When Peter is in the bath, suggest that he washes and rinses his upper body, and
when that is accomplished, then suggest that he washes and rinses his lower body
Ensure that bathing items are on view and that containers are clearly labelled
Have attractive objects around the bath such as unusual bath oil bottles or shells
and encourage discussion and exploration of them.
Activity: DINING
•
•
•
Store cutlery and crockery in view and encourage Peter to select own tools for dining
Offer food using simple choices
Create a social atmosphere using table decorations, music, and promote
conversation
Note: Consideration of National Infection Control Guidelines and HSE Health
& Safety Guidelines is required in undertaking the above.
156
Addressograph Label
or complete the following
Name: ...............................….....................…
D.O.B .…..............................……………….…
MRN: ……........................………..……………
Ward/Unit: …........................……..................…
Nurse’s Signature: … ........................................
Date: .................................. Page no: ..............
Meaningful Activities Programme
Residents Activity Level Profile
Pool Activity Level (PAL) Profile©
Sample Personalised Care Plan for: Sensory Activity Level
Likely Abilities
Is likely to be responding to bodily
sensations.
Can be guided to carry out single step
tasks.
Can carry out more complex tasks if they
are broken down into one step at a time.
Likely Limitations
May not have any conscious plan to carry
out a movement achieve a particular end
result.
May be relying on others to make social contact.
Relies on cues such as diaries, newspapers,
lists and labels.
Method of engagement
Activity objectives
To enable Ann to experience the effect of the activity on
the senses.
Position of tools
Ensure that Ann becomes aware of equipment and
materials by making bodily contact.
Verbal directions
Limit requests to carry out actions to the naming of
actions and objects e.g. “lift your arm”, “hold the brush”.
Demonstrated directions Show Ann the action on the object. Break the activity
down into 1 step at a time.
Working with others
Others must approach Ann and make the first contact.
Use touch and Ann’s name to sustain social contact.
Activity characteristics The activity is used as an opportunity for a sensory
experience. This may be multi-sensory and repetitive.
For dressing, bathing and dining please refer to the plan of care on the next page, please
record and reassess Ann’s activity level of function on a daily basis while assisting her with
these meaningful activities of daily living.
Suitable Activities (based on knowledge of the person’s life history ‘A Key To
Me’&‘My Day, My Way’)
• Ann enjoyed music and dancing throughout her life; she won a prize for waltzing
and jiving in her younger years, encourage her to take an active part in the weekly
dance class. Her favourite music for dancing to is jive music from the 1960’s. She
enjoys singing and will actively take part in sing –a-longs.
• Ann worked as a dressmaker and has lots of fabrics, lace and buttons in her rummage
box, she is a very sensory person and also enjoys the feel of soft toys
• Ann responds well to therapeutic massage and has a weekly massage session on
Tuesdays. However, she enjoys a hand massage other days using scented hand
creams.
157
Addressograph Label
or complete the following
Ward/Unit: …........................……..................…
Name: ...............................….....................…
D.O.B .…..............................……………….…
MRN: ……........................………..……………
Nurse’s Signature: … ........................................
Date: .................................. Page no: ..............
Sensory Activity Level
Activity: DRESSING
•
•
•
•
•
•
Offer a simple choice of clothing to be worn
Spend a few moments enjoying the sensations of the clothing: feeling the fabric,
rubbing the Ann’s finger up and down a zip fastener, or smelling the clean laundry
Break down the task into one step at a time: “put on your vest” “now put on your
pants” “now put on your stockings” “now put on your dress”
Activity: BATHING
Prepare the bathroom and run the bath water for Ann
Make the bathroom warm and inviting - play music, use scented oils, have candles
lit on a safely out of reach shelf. Ensure a slip resistant bath mat is in the bath and
on the floor
Break down the task into one step at a time and give Ann simple directions: “rub the
soap (e.g. Silcocks Base®) on the cloth, rub your arm, rinse your arm, rub your chest,
rinse your chest......”
Activity: DINING
•
•
•
Serve food so that it presents a variety of colours, tastes and textures
Offer Ann finger foods, encourage her to feel the food
Offer Ann a spoon, place it in her hand and direct her to “scoop the potato” “lift
your arm” open your mouth”
Note: Consideration of National Infection Control Guidelines and HSE Health
& Safety Guidelines is required in undertaking the above.
158
Addressograph Label
or complete the following
Name: ...............................….....................…
D.O.B .…..............................……………….…
MRN: ……........................………..……………
Ward/Unit: …........................……..................…
Nurse’s Signature: … ........................................
Date: .................................. Page no: ..............
Meaningful Activities Programme
Residents Activity Level Profile
Pool Activity Level (PAL) Profile©
Sample Care Plan for: Reflex Activity Level
Likely Abilities
Can make reflex responses to direct
sensory stimulation.
Can increase awareness of self, and others,
by engagement of senses.
May respond to social engagement
through the use of body language.
Likely Limitations
May be in a subliminal or subconscious
state.
May have difficulty organising the multiple
sensations that are being experienced.
May become agitated in an environment
that is over stimulating.
Method of engagement
Activity objectives
To arouse……Michael…… to a conscious awareness of
self.
Position of tools
Stimulate area of the body being targeted e.g. stroke
……Michael’s arm before placing it in a sleeve.
Verbal directions
Limit spoken directions to movement directions i.e. “Lift”,
“Hold”, “Open”.
Demonstrated directions Guide movements by touching the relevant body part.
Working with others
Maintain eye contact, make maximum use of facial
expressions, gestures and body posture for non-verbal
conversation. Use social actions which can be imitated e.g.
smiling, waving, shaking hands.
Activity characteristics
The activity is in response to direct selective sensory
stimulation.
For dressing, bathing and dining please refer to the plan of care on the next page, please
record and reassess Michael’s activity level of function on a daily basis while assisting her
with these meaningful activities of daily living.
Suitable Activities (based on knowledge of the person’s life history ‘A Key To Me’ &
‘My Day, My Way’)
• Michael always had a dog and he still responds well to animals, ensure that the visitor
from PEATA spends extra time with Michael on the visits on Monday and Thursday.
• Make sure Michael can always see your face when you are speaking to him, he
responds well to smiles.
• Involve Michaels family in his care and ensure they are aware of his level of activity
• Michael enjoys the snoozelum room when he becomes agitated, with just the soft
music playing.
• Ensure that he is not in an environment which may over stimulate him and cause
agitation.
159
Addressograph Label
or complete the following
Ward/Unit: …........................……..................…
Name: ...............................….....................…
D.O.B .…..............................……………….…
MRN: ……........................………..……………
Nurse’s Signature: … ........................................
Date: .................................. Page no: ..............
Reflex Activity Level
Activity: DRESSING
•
•
•
•
•
•
•
Prepare the clothing for Michael, ensure the dressing area is private and that a chair
or bed at the right height is available for sitting
Talk through each stage of the activity as you put the clothing onto Michael. Use a
calm tone, speak slowly and smile to indicate that you are non threatening
Stimulate a response in the limb being dressed by using firm but gentle stroking. Ask
Michael to assist you when necessary by using one word requests: “lift” “stand”
“sit”
At the end of dressing, spend some time brushing Michael’s hair using firm
massaging brush strokes
Activity: BATHING
Prepare the bathroom and run the bath water for Michael, put in scented bath
products (lavender will aid relaxation)
Ensure that the bathroom is warm and inviting, and feels secure by closing the door
and curtains. Provide a slip resistant bath mat in the bath and on the floor. Clear
away any unnecessary items which may be confusing
Use firm, massaging movements when washing and rinsing Michael. Wrap him
securely in a towel when he is out of the bath
Activity: DINING
•
•
•
Use touch on Michael’s forearm to make contact, maintain eye contact, and smile
to indicate the pleasure of the activity
Place a spoon in Michael’s hand. Close your hand over Michael’s and raise the spoon
with food on it to his mouth
As the food reaches Michael’s mouth say “open” and open your own mouth to
demonstrate. Touch Michael’s lips gently with the spoon
Note: Consideration of National Infection Control Guidelines and HSE Health
& Safety Guidelines is required in undertaking the above.
160
References:
Gulanick M. & Myers J. (2007) Nursing Care Plans: Nursing Diagnosis and Intervention
(6th ed). Mosby Elsevier, United States of America.
Kenny J., O’Donnell M., Greehan N. & McDermott-Scales L. (2009) Guidelines on the
Provision of Activities for Older People in Residential Care. Health Executive Service, Dublin,
Ireland
Linton A.D. & Lach H.W. (2007) Matteson & McConnell’s Gerontological Nursing, Concepts
and Practice (3rd ed). W.B. Saunders Company, St. Louis Missouri. United States of
America.
Pool J. (2008) The Pool Activity Level (PAL) Instrument for Occupational Profiling: A Practical
Resource for Carers of People with Cognitive Impairment (3rd ed). Jessica Kingsley Publishers,
United Kingdom.
Redfern S. & Ross F.M. (2006) Nursing Older Person (4th ed). Elsevier Church Hill
Livingstone, United Kingdom.
Ulrich S.P. & Canale S. W. (2005) Nursing Care Planning Guides for Adults in Acute,
Extended, and Home Care Settings (6th ed). Elsevier Saunders, United States of America.
Cohen-Mansfield J, Werner P. Environmental influences on agitation: An integrated
summary of an observational study. American Journal of Alzheimer’s Disease.
1995;10(1),32-39.
161
162
Large Group
8 + People
Small Group
2 – 8 People
Individual
1:1
Type of Activity
Music groups
Concerts in community
Group quizzes
Bingo
Bus trips
‘Parachute’ activity
Exercise group
Bean bag games/skittles
Mass/Church services
Balloon/Ball/Throwing games
Requires staff planning and leading. Residents need to be able
to follow social rules like the ability to remain seated and have a
degree of concentration. Examples:
Card playing/games
Oratory/Rosary/Adoration
English Literature
Laundry sorting
Reminiscence
Watching a film/DVD.
Visiting musicians/entertainers.
Watching RTE/T.V.
Set up a larger space for participation by those who are already
there and those who may wander in. Examples:
Laundry sorting by basket
Place 2 or 3 chairs around a fire.
Place chairs looking out onto the garden.
Rosary or Reminiscence DVD’s.
Relaxation or soft music CD.
Sports programmes/matches on T.V.
Busy tablecloth
Workshop boards
Prayer books
Sorting laundry.
Newspapers/Books
Baking group
Art/Craft Group
Gardening
Afternoon tea
Sonas
Enhanced Dining
Busy aprons/overlays
Informal chats; staff/volunteers
Rosary beads
Lacing cards
Place chairs facing a fire
Set up the environment so that two or more people can join.
Examples:
Hairdressing
Spirituality/Oratory
Looking at Life
Bright Light
SIMS (Individual Sonas)
Requires the environment to be ‘set up’ to encourage
unprompted participation. Leave ‘half done’ activities within
reach, or ‘position’ seating. Examples:
Unstructured
Usually a prepared group, led by a staff member.
These groups have a set ‘goal’. Examples:
Dressing
Showering
Hand Massage
Relaxation
Aromatherapy
These are what we usually call “one to one”
They are directed and monitored by the staff. Examples:
Structured
Appendix 1: Meaningful Activities of Daily Living; for Residents with Cognitive Impairment in
HSE, DML Older Persons Designated Centres
Activities can be structured or unstructured, and can be carried out with individuals, small groups or large groups.
Setting-up the environment creatively will maximise the residents’ abilities to participate in activities (Meredith Gresham OT Australia)
RAP 16: Pain Assessment and Management
Definitions:
Pain is a subjective, personal experience only known to the person who suffers. The
experience of pain is multidimensional and may be described at several levels, sensory
dimension, affective dimension and impact.1
Chronic pain: is defined as ‘pain without apparent biological value that has persisted
beyond normal healing time,’ usually taken to be 3 months.2
Acute pain: pain of recent onset and probable limited duration, usually having an
identified temporal and causal relationship to injury or disease.
RAI Identifiers of Potential Risks
Pain Present C21, D22 Communication Impairment D3, D4, Emotional State:
Tearful, Low Mood D11, Behaviours that Challenge (? unmet pain need) D16, Restlessness/Agitation D13, D14, Difficulty with breathing E4, Wound Present J1, J7,
J6, Disturbed Sleep Pattern N9, Palliative Care pain symptoms O6, End of Life pain
symptoms P5.
Other Risk Factors include:
Cognitive impairment, Presence of chronic disease associated with pain e.g. arthritis,
post stroke pain, peripheral vascular disease, diabetic neuropathy, Social diversity (e.g.
educational levels, cultural, ethnic and linguistic differences), Being over 65 and
resident attitudes (e.g. pain is sometimes incorrectly considered as an expected part of
ageing) Staff practices (inconsistent and inadequate pain identification, assessment
and treatment).
Further Assessments:
Document the following assessments on admission, when the resident’s
condition improves or deteriorates, any time pain is suspected, if the
resident displays any of the signs or symptoms of pain and at least three
monthly. Pain has been referred to as the Fifth Vital Sign™3, this emphasises the importance
of considering, measuring and monitoring the presence of pain systematically.3
Self reporting of pain is the gold standard method for identifying pain.4
1. Assess the resident’s overall risk context: bio/psycho/social risks e.g. comorbidities, medications, limitations in functional activities, psychosocial
issues.
2. Assess for signs and symptoms associated with pain.
Signs and Symptoms:
Observational assessment is essential for assessing the signs and symptoms
of pain in older people with cognitive impairment or for those with impaired
communication.
Observe for:
• Autonomic changes; pallor sweating, tachyponea, altered breathing patterns,
tachycardia, hypertension
163
•
Facial expression; grimacing, frowning, rapid blinking, brow raising or lowering,
cheek raising, eyelid tightening, nose wrinkling, lip corner pulling, chin raising, lip
puckering. Body movements; altered gait, pacing, rocking, hand wringing, repetitive
movements, increased tone, guarding (an abnormal stiff rigid or interrupted
movement while changing position), bracing
• Verbalisation/vocalisation; sighing, grunting, groaning, moaning, screaming, calling
out, aggressive/offensive speech
• Interpersonal interaction; aggressive, withdrawn, resisting
• Changes in activity pattern; wandering, altered sleep, altered rest patterns
• Mental status changes; confusion, crying, distress, irritability
• Self reporting
Note: In some neurological conditions, facial expressions are absent e.g. Parkinson’s and
end stage Alzheimer’s, residents who have a neurological impairment may not
demonstrate the signs and symptoms of pain. If pain is suspected it should be treated.
When it has been established that there is pain present5
3. Assess the multidimensional aspects of pain including;
• A sensory dimension which describes the intensity and nature of pain. The resident
should be asked about pain in a broad and open ended way using at least two
questions phrased in different ways, such as: ■ Does it hurt anywhere? ■ Do you
have any aching or soreness? ■ Do you have any ache, pain or discomfort? ■ Is
your pain a big problem, a medium sized problem or a small problem? ■ Describe
the pain; is it crushing, throbbing, sharp, burning, etc?
• An affective/evaluation dimension which describes the emotional component of
pain and how pain it is perceived e.g. dangerous, exhausting, frustrating, frightening.
• Impact on life including physical, functional and psychosocial effects. Impact of pain
on the activities of daily living, spontaneous movement, evidence of activity,
avoidance of activity, comfort on movement, functional assessment, the resident’s
coping resources, their belief about the cause of pain, the resident’s cognitive state,
their family’s belief and expectations about pain and stress/distress, presence of
anxiety and/or depression, effect on sleep, suicidal thoughts; impact on relationships,
impact on social activities.
4. Factors relevant to a pain assessment include:
Pain history
When pain began
Site
Severity
Quality
Aggravating and relieving factors
Radiation
General Medical History
Relevant diseases (e.g. dementia, arthritis, vascular, neurological,
gastrointestinal, renal)
Associated symptoms (e.g. nausea).
Allergies
Physical examination
Comprehensive examination covering and including:
Sites of reported pain and referred pain
The musculoskeletal and neurological systems
Signs of arthritis
Sensory changes
164
Physical impact of pain
Impact of pain on activities of daily living
Spontaneous movement
Evidence of activity
Comfort on movement
Functional assessment
Psychosocial situation
Resident’s coping resources
Resident’s belief about the cause(s) of pain
Resident’s cognitive state
Family expectations and beliefs about pain and stress
Presence of anxiety and/or depression
Effect on sleep
Suicidal thoughts
Social impact of pain
Impact on relationships
Impact on social activities
Review of medications and other treatments
Treatments that have been tried (list dates and reasons for discontinuation if
known)
Effectiveness of current treatments
5. Baseline assessment for residents able to self report
A multi dimensional pain assessment instrument is the best choice for the initial
assessment of communicative people and subsequent formal reviews at weekly or
longer as appropriate intervals e.g. the “Resident’s Verbal Brief Pain Inventory”
(RVBPI).
Ongoing assessment
Uni-dimensional assessments can be performed daily, or more frequently if the
information gained will help to guide treatment. This can be done using either a
numeric rating scale (NRS) or a verbal descriptor scale (VDS). One or the other may
be chosen on the basis of resident preference and understanding. It has been
suggested that the vertical form of the NRS may be preferable and more easily
understood by older people with impaired abstract reasoning skills.
6. Baseline assessment for residents unable to report pain
The two structured procedures to assess pain in residents who are unable to report
pain, mostly due to dementia, dysphasia or delirium are staff observation and
informant report.
With both procedures it is important to record, if the identified pain occurs at rest
(and over what time) or only in relation to a certain activity (e.g. being turned) or in
conjunction with another activity (moving a certain part during dressing or bathing).
Staff observation
Staff should formally observe and document both the known kinds of pain related
behaviours seen in people who are not cognitively impaired, as well as other
behavioural and clinical changes that could indicate pain in people suffering from
dementia. These are outlined in the signs and symptoms.
165
Informant report
This involves obtaining and documenting a report from people familiar with the
resident including family members, carers and others who know the resident well.
Once pain has been identified as a significant issue the use of an observational
instrument such as the Abbey pain scale and the PAINAD, will help indicate the
presence and intensity of pain in these residents.
Referrals Required:
Refer to the multi disciplinary team as appropriate to the assessment findings e.g. The
doctor should be informed and a full examination carried out, a comprehensive
examination covering and including; the site of the reported pain, the musculoskeletal
and neurological systems, signs of arthritis, sensory changes. A referral should be made
to the physiotherapist if the pain is musculoskeletal in nature, to the dietician and
tissue viability nurse for wounds, to the pharmacist for review of medications and
other treatments; assess what has been tried and how did it work. Consider music
therapy, occupational therapy, diversional therapy, social worker, counselling services
or pastoral care team for residents with psychosocial issues which may be aggravating
pain. Psychotherapy may be beneficial based on the premise that pain is a sensory and
emotional experience with psychological factors contributing to the pain. It may be
necessary to refer outside to a specialist pain clinic.
Record all referrals made on the MDT referral record and document the reason/outcome
in the narrative notes, remember to update care plans accordingly.
Personalised Care Planning:
The aim of care planning is to develop a single multidisciplinary (MDT) plan of
personalised care. The MDT includes the resident/significant other (if appropriate), carers,
nurses, doctors and allied health professionals. The primary aim is to treat the pain where
possible, however, it is also very important to reduce the risks of exacerbating pain during
delivery of care e.g. manual handling may exacerbate pain by stimulation of tissue which
has an increased sensitivity to pain and movement that exceeds the impaired range of
joints and muscles.
Problem/Need Identification:
Record the actual or potential pain problem and its associated or related risk factors. For
example; Mary has pain associated with a pressure ulcer on her sacral area, or Mary is at high
risk of pain associated with the pressure ulcers on her sacrum.
Goal Specification:
Record: realistic, measurable and obtainable MDT goals. For example, ‘Mary reports pain
severity less than when previously assessed. Mary’s pain will be assessed at each interaction
with Mary’. Or, ‘Mary’s level of pain will be at an acceptable level as defined by Mary herself
following the planned interventions. Mary reports a level of pain that allows her to participate
in activities. Pain will be assessed at each interaction with Mary’ (The score can be measured
using a pain scale e.g. NRS or VDS).
166
Specific Interventions:
These are the specific steps taken based on expected standards of care in addressing actual
or potential problems/needs. Document:
• What we need to do (specific interventions based on residents/significant other(s) care
choices where possible)
• What we need to monitor (on-going reassessments)
• What we need to communicate (back to the MDT)
• What/who we need to educate (to improve the problem)
1. Specific MDT interventions: Record
a) Specific interventions to address resident/significant others concerns,
preference and care choices e.g. educate the resident/significant others that pain is
not a normal process of ageing and that pain is a common and treatable condition.
Encourage the resident to talk about their fears. Often residents are afraid to tell anybody
about their pain as they think it may be a symptom of something more sinister or they
fear developing an addiction to medication.
b) MDT specific care instructions This includes the nursing care instructions
/programmes for assessing, reducing and managing pain and other MDT specific care
instructions. Establish a plan for management in collaboration with the multidisciplinary
team that is consistent with the resident’s and family/significant other’s goals for pain
relief, taking into consideration the following factors;
assessment findings baseline characteristics of pain physical, psychological
and socio-cultural factors shaping the experience of pain aetiology most effective
pharmacological and non-pharmacological strategies
Pharmacological approach advocate for use of the simplest analgesic dosage
schedules and least invasive pain management plans.
Non pharmacological approach
For residents with significant cognitive impairment
superficial heat (mild) superficial cold (mild) vibration (mild) Complementary
and alternative medicine therapies (CAM) mobilising exercise passive relaxation
For residents with no significant cognitive impairment, all treatments listed above plus
educational approaches biofeedback/relaxation guided imagery coping skills
problem solving behaviour reactivation transcutaneous electrical nerve
stimulation (TENS) mind body CAM strengthening exercise aerobic exercise
2. Monitoring and ongoing reassessments
Pain is reassessed on a regular basis according to the type and intensity of pain and the
treatment plan.
• Pain is reassessed: at each new report of pain; new procedure; when the intensity
increases; when pain is not relieved by previously effective strategies and when a resident
complains or shows any indicators of pain.
• Pain is reassessed after the intervention has reached its peak effect (15-30 minutes after
parenteral drug therapy, 1 hour after immediate release analgesic, and 4 hours after
sustained release analgesic or transdermal patch, 30 minutes after non-pharmacological
intervention).
• Monitor for medication side effects e.g. constipation if using opoid analgesics.
167
3. Communication
• Communicate the resident’s pain assessment findings to MDT members, by describing
the parameters of pain based on the tool used, the relief or lack of relief obtained from
treatment methods, the person’s goals for pain treatment and the effects of pain on the
person. Update care plans accordingly.
• Communicate the resident’s personalised care plan to all those involved in the resident’s
direct care.
• Ensure the resident/significant other is kept up date.
4. Information/Education/ health promotion for resident significant other(s)
and carers
• Educate the resident/significant other(s) on how best to manage pain and what the
personalised plan of care involves. Provide information on what they can do to assist in
the pain management plan.
• Provide written information where possible and/or provide information in a format that
suits the resident’s communication requirements. Refer to RAP 1: Communication, Vision
and Hearing.
Evaluation of care:
Care plans must be evaluated every time the resident’s condition improves or deteriorates
and at least 3 monthly. Evaluate the effectiveness of the care provided by checking to see if
the goals are being met.
168
169
Reluctant to complain of pain
•
•
•
•
•
Take a detailed pain history
Examine the resident
Treat cause
Treat symptoms if cause is not identifiable
Consider referral
Yes
• Assess pain intensity using a simple scale
such as a verbal rating scale (VRS) or
numeric rating scale (NRS).
• Ask the person to show you where their
pain is (pointing to the area)
Is pain present?
Yes
• Ask whether the person has pain at rest or
on movement. Use alternative descriptors
such as sore, hurting or aching.
• Observe for potential indicators of pain.
• Is pain reported/apparent?
Yes
Can the person communicate successfully?
No
No
No
No immediate
action needed.
Continue to
monitor.
• No immediate
action needed.
• Continue to
monitor and treat
as required.
Yes
Treat morbidity
Do potential pain
indicators persist?
Yes
Is there evidence
of morbidity that
may be causing
pain?
Yes
Observe for potential indicators of pain:
• Facial expression.
• Verbalisation/vocalisation.
• Body movements.
• Altered interpersonal interactions.
• Changes in activity patterns or routines.
• Mental status changes.
• Physiological changes.
Yes
• Consider empirical
analgesic trial or
other pain-relieving
intervention.
• Monitor response
carefully.
Yes
No
• No immediate
action needed.
• Continue to
monitor.
Yes
• Attempt to interpret meaning of
behaviour with help of caregivers
familiar with the person. Provide
individualised care.
• Ensure basic comfort needs are
met.
• Provide reassurance if behaviour
suggests fear.
• Consider providing analgesics prior
to movement.
• No immediate treatment
needed
• Continue to monitor
Protocol for Care for the Assessment and Management of Pain in HSE Older Persons Designated Centres
SAMPLE CARE PLAN
Topic Heading: Pain
PROBLEM / NEED IDENTIFICATION
Number: Page 1
Date
Signature
11/01/10 Mary has pain on movement associated with her osteoarthritis
GOAL SPECIFICATION
Mary will be pain free or that pain will be at an acceptable level so that Mary can keep her
independence as much as possible as evidenced by self report and by Mary maintaining her
personal care with minimal assistance and attending her favourite recreational activities.
SPECIFIC INTERVENTIONS
Date
Signature
11/01/10 •
•
•
•
•
•
•
•
Record Mary’s initial comprehensive assessment using the RVBPI and the
NRS in order to establish a baseline characteristic of the pain.
Record the intensity of Mary’s pain using the NRS before and after every
intervention in order to build up an accurate pain history.
Mary reports her pain to be worse in the mornings with her knees
experiencing the highest level of pain – she enjoys a bath and finds that
this loosens up her joints and thus decreases the pain- Offer Mary a bath
every morning.
Administer analgesia as prescribed approx 30 minutes before Mary’s
favourite activities start to allow it time to take effect.
Mary finds that some cream rubbed into her skin in the evenings helps
the pain to settle enough so she can have a good nights rest – use gentle
touch when carrying out this procedure, Mary’s daughters also like to do
this for her, encourage and facilitate this.
Monitor and assess Mary at each contact throughout the day and offer
analgesia as prescribed – record the intensity of the pain using the NRS
before and approx 30 minutes after drug administration to monitor the
effectiveness.
Reassess pain at each new report of pain.
Provide information sessions to Mary and her family on the importance of
reporting and monitoring pain, so that effective pain management can
be achieved. Allow them the time and the opportunity to discuss her
diagnosis and management options. Educate them further on the other
non- pharmacological strategies used to manage pain such as relaxation,
diversional therapy.
EVALUATION OF CARE (based on goals specified)
Date
Signature
11/01/10 Outcomes were partially met; Mary is now enjoying her activities but feels
her pain is now waking her during the night. For referral to the MDT to
review her care plan.
Discontinued Date: …..... / ……… / 20…… Signature: …………………………………………..
170
Suggested further reading:
Weiner, et al (1999) Pain in nursing home residents; an exploration of prevalence, staff
perspectives and practical aspects of measurement, Clinical Journal of Pain: 15(2): 92-101.
Kane, et al (2004) Pain management in older adults in care, Nursing and Residential Care,
6(5): 226-231.
WHO analgesic step pain management ladder.
References:
1
The British Pain Society, The assessment of pain in older people. National Guidelines
http://www.bgs.org.uk/Publications/Clinical%20Guidelines/pain%20concise%20gui
delines%20WEB.pdf
2
International Association for the Study of Pain (1986)
3
Pain the Fifth Vital Sign ™ http://www.ampainsoc.org/advocacy/fifth.htm
4
The Australian Pain Society (2005) Pain in Residential Aged Care Facilities;
Management Strategy
5
The American Geriatrics Society (AGS) panel guidelines on persistent pain in older
persons, Clinical practice Guidelines P211, Table 3.
171
RAP 17: Disturbed Sleep and Rest
Definitions:
Sleep – a condition of body and mind such as that which typically recurs for several
hours every night, in which the nervous system is relatively inactive, the eyes closed, the
postural muscles relaxed, and consciousness practically suspended
Disturbed Sleep – sleep that is interrupted.
Rest – the repose of sleep that is refreshing to body and mind and is marked by a
reduction in metabolic activity.
– a state or period of refreshing freedom from exertion
RAI Identifiers of Potential Risks:
■ Disturbed Sleep Pattern C14, N9, ■ Individual Reported Symptoms N8, ■ Difficulties
with Urinary Management C17, ■ Difficulties with Bowel Management C18, ■
Breathing Difficulties C19, E4, ■ Behaviours that Challenge C20, D16 ■ Pain C21, D22,
■ Cognitive & Emotional State D13, D14 ■ Wound C10, J1, J7, J6
Other Risk Factors include:
•
•
•
•
•
•
•
•
•
Pain/Discomfort/Impaired skin integrity e.g. sunburn, pruritus, arthritis, etc.
Environmental changes/stimuli (too noisy, too bright, etc)
Anxiety/Fear
Depression
Medications
Caffeine
Excessive or inadequate stimulation
Abnormal physiological status or symptoms (e.g. urinary frequency, dyspnoea,
hypoxia, or neurological dysfunction)
Normal changes associated with aging
Further Assessments:
Document the following assessments on admission, if the resident’s
condition improves or deteriorates and at least three monthly:
1. Assess past patterns of sleep in normal environment: amount, bedtime rituals, depth,
length, positions, aids, and interfering agents.
2. Assess the resident’s perception of cause of sleep difficulty and possible relief measures
to facilitate treatment.
3. Document nursing or caregiver observations of sleeping and wakeful behaviours.
Record number of sleep hours. Note physical (e.g. noise, pain or discomfort, urinary
frequency) and/or psychological (e.g. fear, anxiety) circumstances that interrupt sleep.
4. Identify factors that may facilitate or interfere with normal patterns.
5. Evaluate timing or effects of medications that can disrupt sleep.
172
Personalised Care Planning:
The aim of care planning is to develop a single multidisciplinary (MDT) plan of
personalised care to promote optimal amounts of sleep as evidenced by rested
appearance, verbalization of feeling rested and improvement in sleep pattern. The MDT
includes the resident/significant other(s), carers, nurses, doctors and allied health
professionals.
Problem/Need Identification:
Record the actual or potential nutritional problem and its associated or related risk factors.
For example: “Maureen expresses difficulty of falling asleep following her transfer to the
residential home”.
Goal Specification:
Record: realistic, measurable and obtainable MDT goals. For example: “In two weeks
time, Maureen will report that she finds it easier to get to sleep and expresses feelings of
being rested” or “Maureen achieves optimal amounts of sleep as evidenced by rested
appearance.”
Specific Interventions:
These are the specific steps taken based on expected standards of care in addressing
actual or potential disturbed sleep and rest problems. Document:
• What we need to do (specific interventions based on residents/significant other(s)
care choices where possible)
• What we need to monitor (on-going reassessments)
• What we need to communicate (back to the MDT)
• What/who we need to educate (to improve the problem)
1. Specific MDT interventions: Record:
a) Specific interventions to address the resident’s/significant other(s’)
concerns, preferences, care choices and religious/cultural requirements
e.g. anxiety related to transfer to a residential unit. This can be addressed by providing
reassurance that it is quite a common feature that during the settling-in period, a
new resident often finds it difficult to sleep, this can be associated with the change
in environment, bedding, disruption to normal bedtime routines, worries, fears, etc.
It is important to ask the resident about their specific concerns that may be affecting
their normal sleep patterns and address these where possible or to refer the resident
on to the MDT where concerns fall outside the scope of practice of nurses, e.g., Social
Work services for counselling, etc.
b) MDT specific care instructions. This includes the nursing care interventions to
enhance sleep such as:
• Advise the resident to follow as consistent a daily schedule for retiring and arising if
possible.
• Instruct the resident to avoid large fluid intake before bedtime.
• Increase daytime physical activities as indicated, but instruct the resident to avoid
strenuous activity before bedtime.
• Discourage pattern of daytime naps unless deemed necessary to meet sleep
requirements or if part of one’s usual pattern.
173
•
•
•
•
•
•
•
•
•
•
•
•
Consider the following to promote an environment conducive to sleep or rest (e.g.
quiet, comfortable temperature, ventilation, darkness, closed door). Suggest use of
earplugs or eyeshades as appropriate.
Suggest engaging in a relaxing activity before retiring (e.g. warm bath, calm music,
reading an enjoyable book, relaxation exercises).
Explain the need to avoid concentrating on the next day’s activities or one’s problems
at bedtime.
Encourage the resident to keep a journal or write down their problems or activities
before going to sleep.
Suggest hypnotics or sedatives as ordered; evaluate effectiveness.
If unable to fall sleep after 30 to 45 minutes, suggest getting out of bed and engaging
in a relaxing activity.
Provide nursing aids (e.g. backrub, bedtime care, pain relief, comfortable position,
relaxation techniques)
Eliminate nonessential nursing activities.
Prepare the resident for necessary anticipated interruptions and disruptions.
Attempt to allow for sleep cycles of at least 90 minutes.
Move the resident to a room father from the nursing station if noise is a contributing
factor.
Post a “Do not disturb” sign on the door.
2. Monitoring and ongoing reassessment
• Assess individual’s sleep pattern and changes, naps, amount of activity, awakenings
and frequency, and complaints of lack of rest.
3. Communication
• Discuss further with the individual as they may have an insight into the aetiological
factors of the problem (e.g. depression over the selling of their property, fear of not
being able to get out of the unit for family outings).
• Promptly communicate monitoring concerns to the resident’s doctor and appropriate
members of the MDT team. Update care plans accordingly.
4. Information/Education/Health Promotion for Resident, Significant
Other(s) and Carers
• Provide the individual with information on non-pharmacological sleep enhancement
techniques such as relaxation techniques, guided imagery, muscle relaxation,
meditation, etc.
Evaluation of Care (based on goals specified):
•
Based on the time frame specified, the care plan must be evaluated when the
resident’s condition improves or deteriorates and at least 3 monthly. Evaluate the
effectiveness of the care provided by checking to see if the goals of care are being
met.
Refer to the Sample Personalised Care Plan in documenting care planning
and in providing care.
174
SAMPLE CARE PLAN
Topic Heading: Sleep Enhancement Care Plan
PROBLEM / NEED IDENTIFICATION
Number: Page 1
Date
Signature
01/01/10 Maureen expresses difficulty in falling asleep following her transfer to the
residential home.
Jane Doe
GOAL SPECIFICATION
Maureen will report that she finds it easier to get to sleep and expresses feelings of being rested
within 2 weeks, or Maureen achieves optimal amounts of sleep as evidenced by daily self report and
by her rested appearance.
SPECIFIC INTERVENTIONS
Date
Signature
02/01/10 •
•
•
•
•
•
•
•
•
•
Instruct Maureen to avoid stimulants, such as caffeinated drinks (e.g. tea,
cola, coffee), stressful activity, prior to sleep
Provide nursing aids (e.g. backrub, bedtime care, pain relief, comfortable
position, relaxation techniques). Maureen particularly finds a back rub
helpful in getting to sleep
Provide soft music, and other relaxation techniques
Provide ritualistic procedures of warm drink, night prayers, extra covers,
and/or warm bath prior to bedtime
Promote an environment conducive to sleep or rest (e.g. quiet,
comfortable temperature, ventilation, darkness, closed door). Suggest
use of earplugs or eyeshades as appropriate. Eliminate non-essential
nursing activities
Administer medications as ordered to promote normal sleep patterns and
monitor their effectiveness
If unable to fall sleep after 30 to 45 minutes, suggest getting out of bed
and engaging in a relaxing activity
Record & monitor the effectiveness of the specific interventions in the
Narrative Notes
Communicate monitoring concerns to Maureen’s Doctor
Provide Maureen with opportunities to discuss her concerns and provide
information to help address these where possible or refer to the MDT as
appropriate
Jane Doe
EVALUATION OF CARE (based on goals specified)
Date
11/01/10 Maureen verbalizes she had a good night’s sleep and feels rested when
asked in the morning.
Signature
Jane Doe
Discontinued Date: …..... / ……… / 20…… Signature: …………………………………………..
175
References:
176
1
Encarta World English Dictionary (1999), Bloomsbury Publishing Plc
2
The Oxford Pocket Dictionary of Current English (2009)
3
Gulanick, M., Myers, J., Nursing Diagnosis and Intervention, Nursing Care Plans 6th
Edition
4
Comer, S., Delmar’s Geriatric Nursing Care Plans 3rd Edition
RAP 18: Psychotropic Drug Use
Definitions:
Psychotropic drugs are substances that act directly on the central nervous system,
affecting mood, cognition and behaviour. When used appropriately and judiciously and
in accordance with their licensed indications, these medications can enhance the quality
of life of residents who need them. It should be noted that most anti-psychotic drugs are
not licensed for use of behavioural problem associated with dementia. Risperidone is the
only anti-psychotic agent, which is licensed for use with behavioural problem associated
with dementia.1
RAI Identifiers of Potential Risks
Note: The resident must be prescribed with psychotropic drug under the classification
of antipsychotic, antidepressant, antianxiety/hypnotics and mood stabilisers C23, (See
list of psychotropic drugs Appendix 1)
Potential RAI risks (unwanted effects of psychotropic drugs) that may be
triggered include:
Impaired Verbal Communication D1, D3, D4, Cognitive impairment and confusion
D11, Restless and agitated, D13, D14 Aggressiveness D16, Depression N9, Delusions, Hallucinations, Anxiety D21, Insomnia N9, Dehydration F21, Nausea
and Vomiting F23, Urinary Retention G4, Constipation G11, Dizziness H3, Fatigue H3, Falls Risk H6.
Special Considerations:
Age (65 and above) in relation to prescribed dosage, history of renal, hepatic, respiratory
and cardiac conditions; a non-existent ability to communicate and a hypersensitivity to
the drug.
Unwanted/Side Effects:
1. Presence of movement disorders- Primarily associated with anti-psychotic agents and
mood stabilisers.
2. Signs of over sedation
3. Fainting.
4. Unsteady gait.
5. Fall in the past month.
6. Period of altered perception or awareness.
7. Periods of disorganised speech.
8. Mental function varies over the course of the day.
9. Changes in mood.
10. Increased hostility and aggression (may occur as a paradoxical effect of
benzodiazepines).
11. Change in behaviour
12. Changes in cognitive function.
13. Alterations in weight and glucose tolerance
14. Hypo or Hyperthermia.
15. Signs of neuroleptic malignant syndrome with antipsychotic drugs: a rare but
potentially life threatening acute side effect of some psychotropics: Hyperthermia,
sweating, alterations in blood pressure, tachycardia, muscle rigidity.
177
Other Adverse Reactions:
•
Antipsychotic agents – Residents on long-term anti-psychotic medicines are at
increased risk of stroke. However, this risk must be balanced against the drugs positive
effect on well being.
•
Anxiolytics and hypnotics – Dependence and tolerance develop to these agents,
which may result in increasing anxiety or insomnia requiring increasing doses. Sudden
withdrawal after prolonged use of these medicines is not recommended in older
people. Side effects to sudden withdrawal includes: acute confusion, psychosis and
convulsions.
Note: It is important to consider whether the side effects observed could be related to
centrally acting drugs prescribed for other co-morbidities, for example analgesics, antiemetics, antihistamines, anti-cholinergics, medicines for Parkinson’s disease, dementia or
epilepsy.
Further Assessments:
•
•
•
•
•
•
Assess for adverse/unwanted/side effects, note what RAI identifiers were ticked in
completing these assessments.
Assess for indications of postural hypotension, increasing incidents of falls, dizziness,
ataxia or staggering gaits, unsteady movements and lack of co-ordination.
Observe for the presence of movement disorders such as Parkinsonism (any
combination of tremors, postural unsteadiness and rigidity of muscles in the limbs,
neck or trunk), Akinesia (marked decrease in spontaneous movement, often
accompanied by non-participation in activity or self-care), Dystonia (marked by
holding of the neck or trunk in a rigid, unnatural position. Head is either
hyperextended or turned to the side), Akathisia (inability to sit still, person is driven
to constant movement, including pacing, rocking or fidgeting which can persist for
weeks) and Tardive Dyskinesia (Persistent, sometimes permanent movements
induced by long term anti-psychotic drug therapy. Most typical are thrusting
movement of the tongue, movements of the lips, or chewing or puckering
movements. Other variations include abnormal limb movement, such as peculiar and
recurrent posture of the hands and arms, or rocking or writhing trunk movements).
Observe for signs of over sedation, drowsiness, delirium and paranoia.
Observe for signs of decreased concentration, memory impairment or the person
being easily distracted.
Complaints of dry mouth and blurred vision.
Note: If any suspected adverse reactions or unwanted/side effects are observed, the
resident’s Doctor/prescriber must be contacted urgently, to facilitate prompt action in the
need for any treatment alterations. A narrative note must be recorded. Suspected adverse
reactions are reported to the Irish Medicine Board as per designated centre’s policy.
Referrals Required:
The medical doctor/prescriber and pharmacist to review medication administration
record at least every three months or sooner if side effects are noted.
178
Protocols of Care:
1. Before initiating prescribing, or changing a resident’s medication, due attention
should be given to the possibility of the resident’s behaviour resulting from other
causes, for example, urinary tract infection, tooth ache, ear ache, constipation, need
for change of incontinence pads, leg cramps or other precipitating pain, discomfort,
need or stimulus.
2. Assess complaints reported by the resident and observation reported by the staff.
Each resident on long-term medication is reviewed by his/her medical practitioner on
a three monthly basis, in conjunction with nursing staff and the pharmacist. Special
consideration is given on to the use of:
- Antipsychotic Medication.
- Sleeping tablets and other sedating medication.
- Anticonvulsant medication.
- Medication for management of depression.
- Analgesic medications (pain management).
- Medication for the management of constipation.
- Antiplatelet and anticoagulant medication (prevention of stroke).
- Influenza and pneumococcal vaccines.
- Non-steroidal anti-inflammatory drugs.
3. Review medication administration record. This review should involve input from the
following people: the resident and their significant others, the nurse, a pharmacist and
medical doctor/prescriber. The potential drug related problem should be recorded:
a. Drug – drug interaction.
b. Drug – disease interaction.
c. Contraindication for one or more drugs.
d. Evidence of an adverse drug event/ side effect of a drug.
e. Assess appropriateness of drug selection.
f. Review of dose/ frequency.
g. Assess compliance/ concordance problems.
h. Problems for safe administration of drug.
i. Assess the need for investigations, refer to British National Formulary for
recommended routine blood test specific to the psychotropic drug being taken by the
resident such as Liver Function Test, Full Blood Count, Urea & Electrolytes, therapeutic
drug levels, thyroid function tests and others.
4. Following review of medication and discussions, actions taken should be recorded or
documented, such as:
a. Discontinue medication.
b. Reduce dose.
c. Substitute an alternative drug.
d. Discuss drug regimen with the resident and their family.
e. Discuss side effects with the resident and their family.
f. Continue.
5. Assess the resident’s medical condition and identify factors that may impair drug
metabolism (i.e. metabolic disorders like renal and hepatic conditions, fluid and
electrolytes imbalance-dehydration).
179
6. Assess the resident’s behaviour/mood/overall mental status with recommended
assessment tools and his/her current behavioural management if appropriate (i.e.
MMSE) (Refer to RAP 2: Mood and Behaviour).
7. Document recommended changes in the resident’s narrative notes and update care
plan as appropriate and its rationale.
8. Develop appropriate care plans for other identified needs in collaboration with the
resident and their significant others.
9. Inform relevant members of the staff about the changes in the resident’s medication
management and nursing care plan.
10. All medication errors, suspected adverse reactions and incidents are recorded,
reported and analysed within an open culture of reporting. Learning is fed back to
improve resident safety and to prevent reoccurrence.
Personalised Care Planning:
The aim of the care plan is to develop a single multidisciplinary team (MDT) plan of
personalised care that is specific to the management of problems identified with the use
of psychotropic drugs.
Need/Problem Identification…
Record the specific problem and the related factors you have identified relating to the use
of psychotropic drugs.
For example: John is showing signs of over sedation from his prescribed risperidone
medication as diagnosed by his medical doctor.
Goal Specification:
Record desired outcome/s that is specific, measurable, attainable, realistic and time bound
(SMART).
For example: John will demonstrate improvement in his thought processes as evidenced
by orientation to person, place, time and situation within two days.
Specific Interventions:
These are the specific steps taken based on expected standards of care in addressing
actual or potential problems in psychotropic drug use. Document:
• What we need to do (specific interventions based on residents/significant other(s)
care choices where possible)
• What we need to monitor (on-going reassessments)
• What we need to communicate (back to the MDT)
• What/who we need to educate (to improve the problem)
1. Specific MDT interventions:
The following should be recorded:
a. Specific interventions to address the resident’s/significant(s) concerns,
preferences and care choices. Explain the plan of care, the interventions and the
implementation process to manage the identified cognitive problem associated with
psychotropic drug use. Encourage the resident and their significant others to ask
questions and clarify any information that is not clear.
180
b. MDT specific care instructions. This includes MDT and nursing care instructions
and interventions to improve the person’s cognitive function. It also includes the
assessment of the person’s cognitive function and management of the identified
cognitive problem. Develop a personalised care plan in collaboration with the MDT, the
resident and their significant others.
2. Monitoring and ongoing assessment:
Continuously observe and assess for signs and symptoms of psychotropic drug toxicity
or adverse reaction. For Example: Assess for the resident’s degree of disorientation to
time, place, person and situation.
Monitor pertinent lab results for signs of drug toxicity as appropriate.
3. Communication
Discuss and plan the resident’s care plan with the MDT, the resident and the significant
others. Inform or discuss with the members of the MDT, resident and significant others
about any changes in the care plan or improvement in the resident’s condition.
4. Information/Education/Health Promotion for Resident, Significant Other(s)
and Carers
Educate and provide advice to the resident and their significant others regarding the
personalised care plan for identifying and managing cognitive problems associated with
psychotropic drug use. For example: Disorientation. Provide written information
regarding the use of psychotropic drugs and its adverse reaction.
Evaluation of Care:
Nursing care plans must be evaluated on a regular basis to ascertain if the resident’s condition
is improving, deteriorating or if there is no change. Evaluating the nursing care plan
determines the effectiveness of the formulated nursing interventions. It is recommended
that the nursing care plan must be evaluated every three months or sooner if needed.
Refer to the Protocols of Care Flow Chart and Sample Personalised Care Plan
in documenting care planning and in providing care.
181
182
10. Behaviour and mood.
9. Functional ability.
8. Level of cognitive ability.
7. Communication
difficulties.
6. Current medications.
5. Presence of sign &
symptoms of adverse
reactions.
4. Presence of conditions
stated in the risk category
and further assessments.
3. Medical & Social history
2. Observations of staff
1. Complaints of the
resident.
Document:
Nursing Assessment
3. Identify defining
characteristics (sign &
Symptoms)
2. Identify the common
related factors (Cause)
1. Identify the problem
Nursing Diagnosis
3. Evaluation of care
a. Identify problem/need
b. Goal specification (SMART)
c. Specific intervention
- Specific MDT interventions
- Monitoring and ongoing assessment.
- Communication
- Information/education/health promotion for
resident, significant other and carers.
2. Develop nursing care plan incorporating the
following:
1. Nursing goals should focus on maximising the
resident’s functional potential and well being while
minimising the hazards associated with drug side
effects.
Establish nursing goals and devise care plan
Nursing Care Goals & Planning
2. Unmet Goals
- Reassess and review nursing
care plan
Establish effectivity of
nursing and MDT interventions
1. Goals met
- Sign off the nursing care plan
Establish effectivity of
nursing and MDT interventions
Nursing Evaluation
Protocol of Care in the Delivery of Personal Care in HSE Older Designated Centres
SAMPLE CARE PLAN
Topic Heading: Disorientation
PROBLEM / NEED IDENTIFICATION
Number: Page 1
Date
Signature
01/01/10 John has disturbed thought processes related to unwanted side effects of
psychotropic drug Risperidone as diagnosed by the doctor.
Jane Murphy
GOAL SPECIFICATION
John will demonstrate improvement in his thought processes as evidenced by orientation to person,
place, time and situation within two days.
SPECIFIC INTERVENTIONS
Date
Signature
01/01/10 •
•
•
a)
b)
c)
d)
•
a.
b.
c.
d.
e.
•
•
•
•
•
Assess John’s degree of disorientation to time, place, person and situation
at each shift, record on the flow chart of care.
John’s medication has been reviewed with his significant others, medical
doctor and pharmacist. It has been agreed to gradually reduce
Risperidone therapy under close monitoring to avoid the risk of acute
withdrawal syndrome. Administer reduced dose as prescribed.
Monitor for other signs and symptoms of psychotropic drug toxicity or
adverse reaction. Monitor vital signs 4 hourly x 48hours, observe for:
Postural hypotension- Record Blood Pressure lying and standing, twice
daily.
Tachycardia
Assess finger stick blood sugar
Record all episodes of disturbed thought processes using a Mood and
Behaviour diary (ABC Functional Analysis Chart)
Orient John to surroundings and reality as needed:
Use John’s name when speaking to him.
Speak slowly and clearly.
Refer to time of day, date and recent events when interacting with John.
Encourage John’s wife Jean to bring familiar personal belongings into the
residential care setting.
Provide reality orientation with respect and sensitivity when correcting
John’s misperceptions of reality.
Use the words “You” and “ I” instead of We when talking to John.
Maintain a consistent fairly structured routine. Encourage John to
participate in activities (Refer to John’s Meaningful Activities care plan).
Have John perform only one activity at a time and allow adequate time
for performance of activities. Assist John to problem solve if necessary.
Involve his wife Jean to participate in helping John with his ADL’s.
Communicate monitoring concerns to the doctor or if disturbed thought
processes worsen.
Jane Murphy
EVALUATION OF CARE (based on goals specified)
Date
Signature
John
is
now
able
to
tell
the
time,
place
and
identify
person
but
still
Jane Murphy
02/01/10
requires assistance in problem solving situational events. John is for
review by the doctor tomorrow. Care plan to be updated following review
Discontinued Date: …..... / ……… / 20…… Signature: …………………………………………..
183
References:
Medicines and Healthcare Regulatory Agency (2010) Antipsychotic drugs
http://www.mhra.gov.uk/Safetyinformation/Generalsafetyinformationandadvice/Prod
uct-specificinformationandadvice/Antipsychoticdrugs/index.htm
2 British Medical Association and Royal Pharmaceutical Society of Great Britain, British
National Formulary.
3 Culhane C. (2005) A Guide to Psychotropic Drugs. Mental Health Research Institute,
Melbourne, Australia.
4 Health Information and Quality Authority (2009) National Quality Standards for
Residential Care Settings for Older People in Ireland. Health Information and Quality
Authority Dublin, Ireland.
5 Irish Medicines Board (2009) Drug Safety Newsletter, 30th Ed, Update on safety of
antipsychotic medicines – Risk of stroke and increased risk of mortality in elderly
patients treated for dementia. Pharmacovigilance section, Irish Medicine Board,
Dublin.
6 Linton A.D. & Lach H.W. (2007) Matteson & McConnell’s Gerontological Nursing,
Concepts and Practice (3rd ed). W.B. Saunders Company, St. Louis Missouri.
7 Nursing Home Ireland (2009) Medication management template: standards for practice
in residential care. Nursing Home Ireland, Dublin Midleinster.
8 Redfern S. & Ross F.M. (2006) Nursing Older Person (4th ed). Elsevier Church Hill
Livingstone, United Kingdom.
9 Stone J.T., Wyman J.F. & Salisbury S.A. (1999) Clinical Gerontological Nursing, A guide
to advanced practice (2nd ed.) W.B. Saunders Company, Philadelphia.
10 Voyer P., Cohen D., Lauzon S. & Collin J. (2004) Factors associated with psychotropic
drug use among community dwelling older persons: A review of empirical studies
available on line http://www.biomedcentral.com/1472-6955/3/3.
11 www.medicines.ie (The IPHA website contains the summary of product characteristics
and patient information for most licensed drug in Republic of Ireland.
1
184
Appendix 1: Psychotropic Drugs
What are Psychotropic drugs?
Psychotropic drugs can be described as any drug capable of affecting the mind, emotions
and behaviour. This group of drugs act primarily on the CNS (Central Nervous System)
where it alters brain function resulting in temporary changes in perception, mood,
consciousness and behaviour. Psychotropic drugs are used in medical day to day practice
but are also substances of abuse. Some substances of abuse include Caffeine, Alcohol,
Cocaine and Cannabis.
The most common groups of drugs classified as psychotropic are;
• Hypnotics
• Anxiolytics
• Antipsychotic:
– Typical
– Atypical
• Mood Stabilisers – some of which are anti-epileptic drugs
• Antidepressants:
– Tricyclic
– MAOI’s
– SSRI’s
– Others
• CNS stimulants and drugs used in ADHD
• Drugs used in substance dependence
DRUG GROUP
DRUG NAME
INDICATIONS FOR USE
Hypnotics
(Mainly Benzodiazepines)
Nitrazepam
Flunitrazepam
Flurazepam
Loprazolam
Lormetazepam
Temazepam
Zaleplon
Zolpidem
Zopiclone
Chloral Hydrate
Triclofos Sodium
Clomethiazole
Promethazine
Triazolam
Treatment of insomnia
185
186
DRUG GROUP
DRUG NAME
INDICATIONS FOR USE
Anxiolytics
(Mainly Benzodiazepines)
Diazepam
Alprazolam
Chlordiazepoxide
Lorazepam
Buspirone
Meprobamate
Barbiturates
Prazepam
Clobazam
Bromazepam
Pregabalin (Lyrica)
Hydroxyzine
Alleviating anxiety states
Pregabalin is an antiepileptic
drug indicated for use in
generalised anxiety disorder.
Antipsychotics
(Typical - Older)
Chlorpromazine
Flupentixol
Haloperidol
Levomepromazine
Pericyazine
Perphenazine
Pimozide
Prochlorperazine
Promazine
Sulpride
Trifluoperazine
Zuclopenthixol
Schizophrenia
Relieve symptoms such as
thought disorder,
hallucinations, delusion and
also prevent relapse.
Antipsychotics
(Atypical - Newer)
Amisulpride
Ariprazole
Clozapine
Olanzapine
Paliperidone
Quetiapine
Risperidone
Sertindole
Zotepine
Schizophrenia
Relieve symptoms such as
thought disorder,
hallucinations, delusion and
also prevent relapse.
Mood Stabilisers
Lithium
Carbamazepine
Lamotrigine
Sodium Valporate
Lithium used in mania to
control acute attacks and to
prevent their recurrence. Also
used in the prophylaxis of
bipolar disorder (manicdepressive disorder). All other
drugs are anti-epileptic
agents used in bipolar
disorder.
DRUG NAME
INDICATIONS FOR USE
Amitriptyline
Clomipramine
Dosulepin
Doxepin
Imipramine
Lofepramine
Nortriptyline
Trimipramine
Mianserin
Trazadone
Moderate to severe
depression. Also used in the
management of panic
disorders and neuralgia.
Antidepressant drugs
(Monoamine-oxidase
inhibitors)
MAOI’s
Phenelzine
Isocarboxazid
Tranylcypromine
Moclobemide (reversible
MAOI)
Depressive illness
unresponsive to other
antidepressants. Have high
food and drug interactions.
Antidepressant drugs
(Selective serotonin reuptake inhibitors)
SSRI’s
Citalopram
Escitalopram
Fluoxetine
Fluvoxamine
Paroxetine
Sertraline
Depressive illness, also used
for panic disorder, obsessivecompulsive disorder,
generalised anxiety disorder,
social anxiety disorder and
bulimia nervosa.
Antidepressant drugs
(Others)
Duloxetine
Flupentixol
Mirtazapine
Reboxetine
Tryptophan
Venlafaxine
Depressive illness, also used
for diabetic neuropathy
(duloxetine), stress urinary
incontinence (duloxetine)
and generalised anxiety
(Venlafaxine)
CNS stimulants and drugs
used in ADHD
Atomoxetine
Dexamfetamine
Methylphenidate
Modafanil
Treatment of attention deficit
hyperactivity disorder –
Atomoxetine, dexamfetamine and
methylphenidate. Treatment of
daytime sleepiness associated with
narcolepsy- Modafanil.
Drugs used in substance
dependence
Acamprosate – alcohol
Disulfiram – alcohol
Bupropion – nicotine
Nicotine – nicotine
Varenicline – nicotine
Buprenorphine – opioid
Lofexidine – opioid
Methadone – opioid
Naltrexone – opioid
Drugs used to help in the
withdrawal of alcohol,
nicotine and opioids.
DRUG GROUP
Antidepressant drugs
(Tricyclics and related)
187
RAP 19: MRSA (Methicillin Resistant Staphylococcus
Aureus) Colonization and Decontamination Protocol
This protocol deals only with MRSA colonization which requires a multidisciplinary team
(MDT) approach to assessment and management. If MRSA is present with signs of
infection, then advice on such infections must be sought from the resident’s doctor and
the Infection Control Team.
Definitions:
MRSA stands for methicillan-resistant Staphylococcus aureus. Staphylococcus aureus live
harmlessly on the skin and in the nose of approximately a third of the population. Some
strains of Staphylococcus aureus have developed resistance to Methicillin (a type of
penicillin) and other common antibiotics. These resistant strains of Staphyloccous aureus
bacteria are called MRSA.1
MRSA colonization means that MRSA is present on the body or in the nose of an
individual but is not causing any ill effects or infection.
MRSA infection means that the MRSA is causing clinical signs and symptoms of local
or systemic infection, which require prompt medical intervention. Systemic signs of
infection may include: elevated temperature (fever), general malaise, nausea/vomiting,
tachycardia, acute confusional state/delirium (Refer to RAP 3: Cognition and Acute
Confusion), hypotension and leukocytosis. Local signs of infection may include:
pain/soreness, spreading skin redness (erythema) or tracking as for IV sites; for signs and
symptoms of local wound infection refer to RAP 13: Skin and Wound Care.
RAI Identifiers of Potential Risks:
MRSA positive, A59
Other Risk Factors for MRSA colonization include:
Advanced age, the very ill, open wounds or sites such as skin lesions, leg ulcers, pressure
ulcers, PEG sites, I.V. sites, tracheotomy and urinary catheters. While inadequate care
practices e.g. inadequate hand hygiene, lack of Standard Precautions in Infection Control
or a history of recent hospitalisation (within previous 6 months of admission), a history
of multiple courses of antibiotics, excessive antibiotic duration or under-dosing create
further risks.1
Further Assessments:
A. Screening for MRSA
Residents should be screened on first admission only, to identify the presence of MRSA.
Respite residents need not be screened on subsequent admissions unless they have been
exposed to a possible risk of contracting MRSA (i.e. they have been resident in another
healthcare facility between respite admissions).
MRSA screening sites:
• Nasal (anterior nares), one swab only
• Perineum or groin, one swab only
• All sites where the resident has a break in skin, e.g. wounds, I.V., PEG sites.
188
•
•
PLEASE NOTE: Throat, Axilla, Sputum and CSU/MSU’s are not routinely screened.
Urine samples are only to be sent if there are signs of a Urinary Tract Infection (UTI).
When sending a urine sample, please record the reason for sending the sample on
the lab form, e.g. pyrexia, frequency, dysuria, clinical signs/symptoms of UTI. Note:
The presence of a urinary catheter is not an indication for sending a urine sample.
Each sample must be accompanied by its own individual laboratory form
fully completed.
B. Risk Assessment of MRSA Positive residents
A multidisciplinary team risk assessment (e.g. doctor, infection control nurse/team,
ward nurse) must be undertaken on all residents who screen positive for MRSA to
determine:
(i) Is the resident colonized or infected
(ii) The appropriateness of ward/room allocation for the resident. Residents
who are MRSA positive must not share bedrooms with residents who have any of the
following conditions:
• Eczema/skin lesions/open wounds
• Chronic respiratory problems, tracheotomy
• PEG, urinary catheters or IV lines
• Immunosuppressed
(ii) If a decontamination protocol is required. For example:
• Decontamination is recommended for residents who are planned for elective surgery
• MRSA positive residents maybe cohorted together or isolated (if appropriate), after
discussion with the Infection Control Team
If in doubt of risks posed, seek advice from your local Infection Control Team.
If the MRSA screen is positive or it is identified on admission that the resident has MRSA,
an “MRSA positive resident check sheet” should be completed and inserted into the
resident’s care record (Appendix 1).
Referrals required:
Refer the resident to the multidisciplinary team (Doctor, Infection Control Team) to
determine the risk with regard to the appropriateness of room allocation and whether or
not a decontamination protocol is required. Further referrals should be made as soon as
concerns arise e.g. on daily review, concerns on re-screening results following MRSA
decontamination, etc. Record all referrals made on the MDT Referral Record.
Personalised Care Planning:
The aim of care planning is to develop a single multidisciplinary team (MDT) plan of
personalised care to address the actual or potential risks of MRSA colonization or infection.
The MDT includes the resident/significant other(s), carers, nurses, doctors and allied
health professionals.
189
Problem/Need Identification:
Record the resident’s MRSA status and its associated or related risk factors. For example;
‘MRSA identified on nasal and groin Swab 12/01/10 which creates a potential risk of crossinfection’.
Goal Specification:
Record: realistic, measurable and obtainable MDT goals. For example: ‘To eradicate MRSA
skin and nasal carriage within a five day period and to prevent MRSA cross
contamination/infection’
Specific Interventions:
These are the specific steps taken based on expected standards of care in addressing
MRSA colonization and in preventing cross contamination/infection. Document:
• What we need to do (specific interventions based on the resident’s/significant other(s)
care choices where possible)
• What we need to monitor (on-going reassessments)
• What we need to communicate (back to the MDT)
• What/who we need to educate (to improve the problem)
190
1. Specific MDT interventions
Record the:
a. Specific interventions to address the resident’s/significant others(s)
concerns, preferences and care choices. Encourage the resident/significant
other(s) to voice their concerns. Provide psychological support and information on
MRSA colonization to the resident and their significant others. Discuss and address
where possible the resident’s/significant other(s’) concerns. Where it is not possible to
address the resident’s/significant other’s concerns, seek advice from the local Infection
Control Team and inform the resident/significant other of the Infection Control Team’s
advice.
b. MDT specific care instructions. This includes nursing care instructions for
addressing MRSA colonization and for the control and prevention of infection. Other
specific MDT care instructions should be listed here. For example: a Doctor’s specific
instructions for MRSA decontamination or the Infection Control Team’s specific
instructions for care.
• Contact Precautions in addition to Standard Precautions must be used in
caring for residents with MRSA.
i. Hand hygiene, before and after every contact with the resident or their immediate
environment is essential. Encourage the resident to practice good hand hygiene and
be assisted with this if their physical or cognitive condition makes this difficult (Refer
to SARI Hand Hygiene Guidelines).2
ii. Disposable aprons/ gloves should be worn if contact with body fluids or dressings are
expected and hands should be washed after removing the gloves. Use a fluid-shield
mask with visor if splashing to the face is likely.
iii. The resident’s physical environment should be kept clean and dust free. Chemical
disinfection is not required for equipment with which the MRSA colonized resident has
been in contact e.g. a commode, cleaning with detergent and hot water is
recommended. However, where there is a risk of heavy shedding (e.g., MRSA positive
urine, MRSA throat colonization with the resident spitting, etc,) it is advisable to follow
routine cleaning with disinfection with a suitable disinfectant such as chlorine (e.g.
Presept, Actichlor). Clothes and bedding should be machine-washed, preferably on the
hottest wash that the fabric will allow and where possible to follow this with tumble
drying. Clothes may dry-cleaned if unsuitable for machine washing.
•
•
•
Residents colonized with MRSA may join other residents for therapeutic care and
social activities in the sitting room, dining room and other communal areas. Isolation
of residents is generally not required, other than in exceptional circumstances. These
include where a resident poses a risk of shedding large numbers of bacteria (e.g.
heavily exudating wounds not contained by dressings or tracheostomy with frequent
coughing), or where resident’s have been implicated in the development of infection
in other residents. Due to the negative impact of isolation on residents’ psychosocial
well-being, advice on whether isolation is truly necessary must be sought from the
Infection Control Team (ICT).
Complete an MRSA positive resident check sheet and maintain this in the resident’s
care record.
MRSA Decontamination Process (5 Day Protocol)- if indicated after a risk
assessment; for some residents colonized with MRSA, decontamination may be
indicated. This protocol is to be attempted once only, unless otherwise specified by
the ICT. Please ensure that staff who perform the MRSA protocol, (if indicated
by the risk assessment) adhere strictly to the protocol guidelines, in order to
provide the resident with the best chance of achieving a successful
decontamination and to avoid future resistance. The decontamination
preparations must be used for a full 5 days as follows:
A) MRSA Nasal colonization:
i. Apply Mupirocin Ointment to the nasal cavity three times a day as prescribed.
Method for applying Mupirocin:
• Ask resident to blow his/her nose into a disposable tissue.
• Squeeze a pea size amount of ointment onto a cotton bud and apply to inside of the
nostril.
• Repeat for other nostril.
• Spread the ointment inside each nostril by pressing the nose together for a moment.
Do not use Mupirocin on:
• Residents who do not have MRSA carriage in their nasal cavity or
• Where the MRSA identified is known to be resistant to Mupirocin, seek the advice of
the Infection Control Team
B) MRSA Skin colonization:
i. Wash hair with Triclosan (EPI WASH) or Chlorhexidine on the first and the third day
of treatment.
ii. Each of the 5 days wash body all over with Triclosan (EPI WASH) or Chlorhexidine
using a disposable cloth. NOTE: SOAP/SOAP SUBSTITUTES MUST NOT BE USED
DURING THE 5 DAY PROTOCOL.
iii. Clothes day/night, underwear and bed linen should be changed daily after
shower/wash.
C) MRSA Throat colonization:
i. Chlorhexidine mouth wash (CORSODYL) if prescribed should be gargled three times
a day.
D) MRSA wound colonization:
i. Wounds to be cleaned with normal saline and an appropriate impermeable dressing
applied.
191
Supply and use of following products for residents, must be prescribed by the
doctor and obtained through a pharmacy:
• Triclosan (EPI WASH) or Chlorhexidine 250mls for each individual resident
• Mupirocin
• Corsodyl mouthwash.
All the above products are for single resident use only. The protocol is discontinued after
5 days.
2.
•
•
•
Monitoring and ongoing reassessment:
48 hours following the last protocol day, the resident is re-screened for MRSA.
Monitor the resident’s skin for any signs of allergies to the decontamination products.
Monitor the resident for signs and symptoms of infection.
3. Communication
• Promptly communicate any monitoring concerns to the resident’s doctor, or Infection
Control Team. Update care plans accordingly
• Communicate the resident’s personalised Infection Prevention and Control care plan to
all those involved in the resident’s direct care. Ensure the resident’s significant
others/visitors are aware of the required infection control precautions. Ensure the
resident/significant other(s) is kept up to date on their plan of personalised care.
4. Information/Education/Health Promotion for Resident, Significant Other(s)
and Carers
• Communicate and educate residents and relatives on the importance of hand washing
and contact precautions in preventing the spread of MRSA. Support this with resident
information leaflets on MRSA (available from www.hspc.ie) or provide information in a
format that suits the resident’s communication requirements (Refer to RAP 1:
Communication, Vision and Hearing).3
Evaluation of Care (based on goals specified):
•
MRSA Care Plans must be evaluated when the resident’s condition improves or
deteriorates and at least 3 monthly. Evaluate the effectiveness of the care provided by
checking to see if the goals of care are being met e.g. results of re-screening.
Refer to the ‘Protocol of Expected Standards for Care’ flow chart and sample
‘Personalised Care Plan’ in documenting personalised care planning and in
providing care.
192
193
1. Assess MRSA status on
admission.
2. Screen all residents on
first admission only.
3. Respite residents need not
be re-screened on
subsequent re-admissions
unless they have been
resident in another
healthcare facility in the
interim period between
respite admissions.
4. MRSA screening sites:
• Nasal (anterior nares), one
swab only.
• Perineum or groin, one
swab only.
• All sites where there is a
break in the skin, e.g.
wounds, I.V./PEG sites.
• NOTE: Throat, axilla,
sputum, CSU/MSU are
not routinely screened
unless there are signs &
symptoms of infection.
Nursing AssessmentDocument
(On admission)
Nursing Assessment
MDT Risk Assessment to decide:
1. If the resident is Infected
or Colonized
2. Decide on bed allocation.
MRSA positive residents
should not share a bedroom
with residents who have:
• Eczema/skin lesions/open
wounds.
• Chronic respiratory
problems, tracheotomy.
• PEG, urinary catheters or I.V.
lines.
• Immunosuppressed.
3. Following a risk
assessment to decide on
whether decontamination
is required i.e.
• Decontamination is
recommended if the
resident is for elective
surgery.
• If Infection Control Team
Recommend
MRSA identified on
admission or following
screening
Nursing Diagnosis
Goal: Prevention and Control of MRSA
1. Encourage resident/significant other(s) to voice
concerns. Provide psychological support & information
to address concerns where possible or seek advice from
local Infection Control Team (ICT). Provide education on
hand hygiene & infection control to residents /
significant other(s), visitors & carers. Support with MRSA
information leaflets.
2. Use Standard Precautions & Contact Precautions in
providing care. Chemical disinfection of communal
equipment (e.g. commodes) is not required. Clean all
equipment with hot water & detergent after use.
3. MRSA colonised residents do not normally require
isolation & can participate in therapeutic & social
groups. In exceptional cases (e.g. tracheostomy with
frequent coughing) ICT advice should be sought before
decisions on isolation are made.
4. Monitor for signs of infection.
Goal: Sleeping arrangements: cohort MRSA Positive
Residents *(ward/unit) & provide standard and contact
infection control measures as outlined above
Goal: MRSA Decontamination-(5 day Protocol)
(Include all Infection Control measures as above)
5. Nasal carriage: Apply Mupirocin ointment as prescribed
(do not use for residents with NO MRSA nasal carriage
or for Mupirocin resistant MRSA).
6. Skin carriage: Wash daily head to toe (hair- 1st / 3rd
day) with Triclosan (Epi Wash®) or Chlorohexidine.
7. Throat carriage: Gargle with Chlorhexidine mouth
wash (Corsodyl®) 3 times daily as prescribed.
8. Wound carriage: use appropriate impermeable dressing
Nursing Care Goals & Planning
Refer to the Infection Control
Team & Resident’s doctor for
advice.
Goal not met -MRSA not
eradicated
• Resident/carer is aware of
appropriate infection control measures and have
been given leaflets on
MRSA (available from
www.hspc.ie ).
• Continue to provide appropriate infection control
measures (standard precautions).
NB Reassess MRSA status
if concerns arise.
Goal met MRSA carriage
eradicated
• Continue to provide standard and contact infection
control measures & monitor for signs of infection
Goal met- MRSA colonized
residents
Cohorting
Nursing Evaluation
Protocols for Care in the Control and Prevention of MRSA in HSE Older Persons Designated Centres
SAMPLE CARE PLAN
Topic Heading: MRSA Care Plan
PROBLEM / NEED IDENTIFICATION
Number: Page 1
Date
Signature
02/02/10 Margaret has MRSA skin and nasal colonization as identified by swab
results on the 30/01/10. Margaret with the multi-disciplinary team has
identified a need for decontamination.
Jane Murphy
GOAL SPECIFICATION
To prevent Margaret from developing MRSA infection and eradicate MRSA skin and nasal carriage
within 5 days. To control and prevent MRSA cross infection.
SPECIFIC INTERVENTIONS
Date
Signature
02/02/10 •
•
•
•
•
•
•
•
•
•
•
•
Margaret was very upset hearing that she had MRSA, her main concern
is that she is afraid of ‘passing it on’ to her family and fellow residents.
Provide Margaret with opportunities to discuss her worries and reinforce
information/education on MRSA.
MDT risk assessment carried out. Specific instructions; commenced on
5 day MRSA decontamination protocol.
Apply Mupirocin ointment to nasal cavity as prescribed. Method: ask
Margaret to blow her nose into a disposable tissue. Squeeze a pea sized
amount of Mupirocin onto a cotton bud and gently apply to inside of
nostril. Repeat for other nostril. Ask Margaret to gently press her nose
together to spread the ointment inside her nose.
Ensure Margaret has a daily shower using Triclosan, encourage Margaret
to wash her hair with Triclosan on the 1st & 3rd day.
Change Margaret’s day & night clothes, underwear & bed linen daily for
5 days.
Infection control contact precautions and standard precautions are to be
used in care delivery.
MRSA positive check list completed-update document following the 5day decontamination protocol.
Margaret is to be encouraged to participate in social activities
Monitor daily for signs of skin allergies to Triclosan and for signs &
symptoms of infection.
Re-screen for MRSA 48hours post last protocol day.
Communicate monitoring concerns promptly to Margaret’s
doctor/Infection Control Team.
Information/education sessions to be provided to Margaret & her
family on the importance of hand washing and the control & prevention
Jane Murphy
of infection. Resident Information Leaflets on MRSA given to Margaret
and her family.
EVALUATION OF CARE (based on goals specified)
Date
03/02/10 No skin allergies noted. Plan continued.
Signature
Jane Murphy
Discontinued Date: …..... / ……… / 20…… Signature: …………………………………………..
194
Suggested Further Reading:
Health Protection Surveillance Centre (2005) Guidelines for Hand Hygiene in Irish Health
Care Settings
http://www.hpsc.ie/hpsc/A-Z/Gastroenteric/Handwashing/Guidelines/File,1047,en.pdf
Health Protection Surveillance Centre (2005) The Control and Prevention of MRSA in
Hospitals and in the Community
http://www.hpsc.ie/hpsc/AZ/MicrobiologyAntimicrobialResistance/EuropeanAntimicrobi
alResistanceSurveillanceSystemEARSS/ReferenceandEducationalResourceMaterial/Saureu
sMRSA/Guidance/
References
1
SARI (2005) The Control and Prevention Of MRSA in Hospitals and in the Community, HSE
Health Protection Surveillance Centre
2
Health Protection Surveillance Centre (2005) Guidelines for Hand Hygiene in Irish Health
Care Settings
http://www.hpsc.ie/hpsc/A-Z/Gastroenteric/Handwashing/Guidelines/File,1047,en.pdf
3
HIQA (2009) National Quality Standards for Residential Care Settings for Older People in
Ireland
195
Appendix 1: MRSA Positive Resident Checklist
Forms should be completed on all residents who return a positive culture for MRSA and
checklist to be maintained in the resident’s Care Record
NAME
Dates Samples Sent
Site/Sites Positive
Mupirocin Resistance
MRN
DATE OF BIRTH
1st
2nd
(Circle As Appropriate)
If yes: High Level resistance
Low Level Resistance
Yes/No
Yes/No
Yes/No
Risk Assessment see protocol (Circle As Appropriate)
•
•
(i) Does resident require isolation
(ii) Does resident require cohorting
Yes/No
Yes/No
Is Decontamination
If Yes
indicated
Yes /No
Date commenced
Resident/Next Of Kin Informed
Yes /No
Information leaflet given
Yes /No
Action: Isolated / Cohorted / Other (Circle As Appropriate)
Any Further Action or comment:
196
Signature
WARD/UNIT
RAP 20: Feeding Tubes
Definitions:
A feeding tube is a medical device used to provide nutrition to residents who cannot
obtain nutrition by swallowing. The state of being fed by a feeding tube is called enteral
feeding or tube feeding. Placement may be temporary for the treatment of acute
conditions or lifelong in the case of chronic disabilities. A variety of feeding tubes are
used in medical practice. They are usually made of polyurethane or silicone. The diameter
of a feeding tube is measured in French units (each French unit equals 0.33 millimetres).
They are classified by the site of insertion and intended use.
Re-feeding syndrome: residents that have eaten nothing for more than 7 days are at
high risk of this phenomenon. ‘Re-feeding syndrome’ usually occurs within four days of
starting to feed again and can occur with parental, enteral and oral re-feeding. It is caused
by an intracellular loss of electrolytes, in particular phosphate due to starvation. Serum
phosphate concentrations of less than 0.50 mmol/l (normal range 0.85-1.40 mmol/l)
can produce the clinical features of re-feeding syndrome, which includes: rhabdomyolysis
(release of muscle fibre contents-myoglobin into the bloodstream resulting in kidney
damage), leucocyte dysfunction, respiratory failure, cardiac failure, hypotension,
arrhythmias, seizures, coma, and sudden death (Hearing, 2004).
Types of Feeding Tubes:
1. Nasogastric Tube
A naso-gastric (NG) feeding tube is passed through the nares (nostril), down the
oesophagus and into the stomach. It is generally not recommended for long term use.
2. Gastric feeding tube
A gastric feeding tube (or "G-tube," or "button") is a tube inserted through a small incision
in the abdomen into the stomach and is used for long-term enteral nutrition.
The most common type is the Percutaneous Endoscopic Gastrostomy (PEG) tube. It is
placed endoscopically: the resident is sedated, and an endoscope is passed through the
mouth and oesophagus into the stomach. The tube is kept within the stomach either by
a balloon on its tip (which can be inflated / deflated) or by a retention dome which is
wider than the tract of the tube.
Gastric tubes are suitable for long-term use; they last about six months, and can be
replaced through an existing passage without an additional endoscopic procedure.
3. Jejunostomy Tubes (J Tube):
Jejunostomy tubes are useful for residents with contraindications to gastrostomy tubes
e.g, gastrectomy, and bowel obstruction proximal to the jejunum. However, these tubes
do not pose less risk of tracheo-bronchial aspiration than gastrostomy tubes, as is often
thought. Jejunostomy tubes are easily dislodged and are not usually recommended for
long term use.
197
Indications for enteral nutrition include the following:
• Prolonged anorexia.
• Severe protein-energy under-nutrition.
• Coma.
• Liver failure.
• Inability to take oral nutrition due to head or neck trauma or neurological disorders
resulting in impaired gag reflexes.
• Critical illnesses e.g. burn injury, causing metabolic stress.
Other indications may include bowel preparation for surgery in seriously ill or seriously
undernourished resident’s, closure of entero-cutaneous fistulas, and small-bowel
adaptation after intestinal resection or in disorders that may cause malabsorption e.g.
Crohn's disease.
RAI Identifiers of Potential Risks:
Enteral Feeding F4
Risks/Complications associated with having a feeding tube
include:
1. Mechanical complications
• Tube blockage: this results from deposition within the tube and may be addressed by
following instructions under Flushing tubes.
• Tube displacement.
• Tube dysfunction/malfunction.
• Tube leakage.
2. Infective complications
• Infection- this can occur due to contamination of the feed or aspiration pneumonia.
3. Gastrointestinal complications
• Gastro - oesophageal reflux: this can lead to aspiration if not addressed.
• Diarrhoea: this is characterised by frequent loose, watery stools (3 or more episodes
in a day). It is rarely due to the feed type.
• Constipation: this is characterised by few bowel movements (absence of bowel
movement for longer than 3 days) with hard stools causing pain and discomfort.
Determine cause of constipation, refer to RAP: 9 Constipation. The enteral feed should
only be stopped if faecal impaction is suspected or the resident has overflowing
diarrhoea. If possible eliminate cause of constipation in conjunction with the resident’s
doctor and dietician re: feed regimen and/or need for medication (laxatives).
• Nausea/Vomiting: This may not be due to the feed type.
4.
•
•
•
198
Metabolic complications
Over/under hydration
Raised blood glucose levels.
Bio-chemical/electrolyte imbalances.
5. Drug/Nutrient interactions
Interactions between enteral feeds and drugs can occur. The bioavailability/
absorption of drugs may be affected by enteral feeding, so it is important to check
for this with the pharmacist before administering any medication via the enteral
feeding tube.
6.
•
•
•
•
Stoma Related complications
Overgrowth of granulation tissue.
Infection at stoma site
Stoma leakage.
Buried Bumper Syndrome (Buried bumper syndrome is a complication of PEG tubes
where the disc becomes buried in the wall of the stomach.
Preparation of the resident prior to transfer to an acute setting
for PEG insertion:
1. A multidisciplinary team meeting should be organised to discuss the resident’s
nutrition/hydration status and available options with the resident/significant
other/advocate. The decision for PEG tube insertion should be based on the
resident’s/significant other(s) wishes/ care preference where possible.
2. Nursing staff and the dietician must document a formal nutritional screening and
assessment using a validated tool e.g. MNA, MUST.
3. A PEG feeding regimen is drawn up by the dietician and must accompany the
resident on transfer to the hospital performing the procedure.
4. Prevention of “Re-Feeding syndrome” should be a priority.
5. Residents will need to fast for 12 hours prior to PEG insertion
Post PEG insertion:
1. On return to the Older Persons designated centre the resident is kept fasting as per
post operative instructions.
2. Assess the resident for signs and symptoms of pain or discomfort using a validated
tool (refer to RAP 16: Pain) and appropriately address pain/discomfort where present.
3. Ensure all equipment required i.e. feeding pump/appropriate feed/giving sets, etc, as
per dietician’s instructions are available.
4. PEG Feeding should not commence for the first 6-10 hours (refer to post-operative
sheet).
• Evaluate all enterally fed residents for risk of aspiration.
• Assure that the feeding tube is in the proper position before initiating feedings
(See section below titled: Procedure for checking correct positioning of an
enteral tube).
• Keep the head of the bed elevated at 30°-45° at all times during the
administration of enteral feedings.
• Check gastric residuals every 4 hours during the first 48 hours for gastrically fed
residents. After enteral feeding goal rate is achieved, gastric residual monitoring
may be decreased to every 6-8 hours in non-critically ill residents. However,
every-4-hours measurements are prudent in critically ill residents.
199
If the Gasrtic Residual Volume (GRV) is ≥ 250mL after a second gastric residual
check, a promotility agent should be considered. Contact the resident’s Doctor
and Dietician to discuss the plan of care. Document the referrals made on the
resident’s MDT referral record and in the resident’s narrative notes.
• A GRV ≥ 500mL should result in holding the enteral feed and reassessing
resident tolerance by the Doctor/Dietician to include a physical assessment, GI
assessment, evaluation of glycemic control, minimization of sedation, and
consideration of promotility agent use, if not already prescribed.
• Consideration of a feeding tube placed below the ligament of Treitz when GRVs
are consistently measured at > 500mL.
(American Society for Parenteral and Enteral Nutrition [2009]).
• Note: Aspiration of small bore tubes is not recommended. GRV of < 500mL
should be returned unless contra indicated by resident risk i.e. resident retching,
vomiting, complaining of nausea, etc. Following the first 48 hours, the frequency
of GRVs should be as per dietician’s instructions.
5. Site care: Following the initial tube insertion, a channel of scar tissue forms between
the gastric wall and the abdominal wall. This process takes between 10 -14 days.
During this time there is a risk of cellulitis and peritonitis. Always wash hands with
soap and water, dry with a disposable paper towel or use alcohol gel on visibly clean
hands before and after contact with the stoma site and feeding apparatus. Wear
gloves if in contact with body fluids and follow standard infection control precautions.
Discuss care and management with the resident, supporting and encouraging them
to manage their own care if possible.
•
200
Care Immediately postplacement (up to 48hrs )
PEG tube site Care (day 3
until stoma is healed).
Long term PEG tube site
care (after stoma site has
healed, 14 – 21 days).
• Treat the entry as a surgical
wound for the first 48hrs.
• Do not touch the site &
tube for 8-12 hrs after
placement.
• After 12 hours remove
dressing, observe site for
signs of swelling,bleeding or
infection.
• Cleanse site & fixation
device with sterile normal
saline using an aseptic
technique.
• Apply a thin dry sterile
dressing only if required to
absorb exudate.
Do not release the fixation
device.
• After 48hrs non-sutured
tubes must be rotated 360
degrees daily to avoid
infections related to buried
bumper syndrome.
• Tube should be pushed in
by 5mm & gently pulled
back to prevent buried
bumper syndrome.
• Tubes that are sutured
should be rotated following
removal of the suture.
• A clean technique using
sterile equipment e.g.
dressing pack with non
woven gauze should be
used until the tract has
healed.
• Do not release the fixation
device
• No dressings required
• Residents may shower but
should not have a plunge
bath until tract is healed
Ensure that daily PEG tube
observation chart is updated
(Appendix 1)
• Inspect the site daily.
• Wash with warm water and
rinse daily, dry thoroughly
with a clean dry towel.
• The fixation device should
be separated from the base
to allow further cleaning on
a daily basis.
• Ensure the tube is replaced
to the correct position in
relation to the fixation
device when cleaning is
completed
• Ensure the tube is secured
(tapped) without pressure to
the abdominal wall to
prevent friction and the
development of granulomas
at the stoma site.
• Apply a dressing if there is a
discharge.
• Do NOT apply antiseptic
creams to the site as they
may damage the tube.
Plunge baths are permitted
once the stoma site has
healed.
5. Checking the Balloon (For CORFLO Gastostomy tube only)
The balloon volume should be checked weekly and documented in the resident’s care plan.
Prior to the procedure the nurse should check the resident’s care plan to:
•
•
•
•
•
•
•
•
Establish the amount of water in the balloon.
Equipment required:
• 2x 10ml syringes one to withdraw the water and one with the correct amount of
sterile water to re inflate the balloon.
• Sterile Gloves.
• Sterile water.
Dispose of syringes in sharp disposal container.
Using a syringe to withdraw the contents of the balloon, while carefully holding the
tube in place to avoid displacement.
Observe the amount of fluid withdrawn and re insert the correct amount.
Observe the resident for any pain, discomfort or pressure around the site during and after
the procedure.
Report any concerns to the doctor.
Document that the procedure has been carried out in the narrative notes and
document the date of when the next weekly check is due.
Procedure for the administration of a Tube Feed:
Equipment required:
• Drip Stand/ attachment for bed, feeding pump, feed and giving set. Note: Feeding
pumps and drip stands must be cleaned daily with a detergent. They should be
disinfected where required with hypochlorite 1:1000 e.g. Presept when contaminated
with body fluids or when used by residents who are in source isolation.
• 50ml syringe, sterile water. Note: Syringes used for aspiration, flushing, administering
medication and bolus feeding are for ‘single use’ only. Therefore, they must be discarded
following use as per disposal of sharps guidelines. Syringes may be discarded into sharps
safe bin, 50ml syringes used for feeding may be discarded into household waste
(provided it is NOT contaminated with blood).
• Disposable Gloves / paper towel
• Sterile Scissors (if required)
• Waste disposable bag
• PEG observation chart
• Enteral feeding pumps should be serviced annually in line with the manufacturer’s
recommendations.
• Bottle openers if used should be dedicated for use with enteral feeding products
only. Prior to use clean with a mediswab and allow to dry. After use, wash in a
dishwasher or wash with hot water and detergent, dry with a paper towel. Store covered
in a clean place.
• Administration sets and feed containers are for single use and must be discarded after
each feeding session, maximum of 24 hours.
• Ready-to-use feeds can be given for a whole administration session, up to a maximum
of 24 hours. Please ensure hanging times are adhered to.
• Select a system that minimises the risk of contamination, use the minimum number of
connections and use giving sets with recessed spikes.
201
Procedure:
• Explain the procedure to the resident.
• Ensure that they have privacy when setting up the feeding regime.
• Check feeding regime as per dieticians regime in the resident’s care plan
• The head of the resident’s bed should be elevated at least 30 degrees while feeding in
order to prevent oesophageal reflux resulting in aspiration pneumonia. Do not lay the
resident flat after the feed is finished.
Administration of Feeds:
• Prior to preparing/setting up a feed, hands must be washed and dried thoroughly or
alcohol gel may be used on visibly clean hands. Hand hygiene is the single most
important procedure in the prevention and control of infection. Wear gloves if in contact
with body fluids and if the resident presents a risk for infection.
• Connect the feed container to the administration set using a non-touch technique. This
involves ensuring that no part of the equipment, which comes into contact with the
feed, be allowed to touch the hands, skin or clothing, etc. Prime the set and ensure
there are no kinks.
• The feed container should be clearly labelled with a grey enteral feeding tube, the date
and start time of the feed.
• Check the position of the fixation device daily, in relation to the markings on the tube
and adjust to the correct position if necessary. This position should be confirmed before
feeding is commenced to ensure that the tube has not been displaced.
• Prior to commencing the feed, explain the procedure to the resident and ensure that
there is a call bell within reach to enable them to call for assistance if required.
• Prior to feeding check for correct placement by aspirating the gastric contents.
Procedure for checking correct positioning of an enteral tube:
• Wash Hands as per infection control policy on hand hygiene.
• Apply non sterile gloves.
• Explain procedure to the resident.
• Using a sterile syringe (large tip) aspirate a small amount of fluid from the feeding port
with gentle suction.
• Place a drop of aspirate on pH indicator strips and check for an acidic reaction (wait for
approx 10 seconds)
• Match the colour change of the pH indicator strips with the colour code on the box to
determine the pH of the aspirate:
• A pH of 5.5 indicates correct gastric placement of tube and feeding can be
recommenced as ordered
• If the pH reading is 6 or above, consider repeating the test in one hour. Do not
commence feeding. If the repeat test remains high, seek medical advice.
Reasons for a high pH reading:
• Dilution of gastric aspirate by enteral feed, wait an hour to allow the stomach to empty
and pH to fall (most common reason).
• Resident is receiving antacids/H2 receptor antagonists and proton pump inhibitors may
have an unusually high pH. Timing of pH testing is crucial.
• Tube displacement outside of the stomach.
202
During administration:
• Ideally feeds should not be interrupted once they are in progress. If it is necessary to
disconnect the feed use a non-touch technique, flush the tube and cap the giving set
with a sterile cap or one supplied by the manufacturer with the set. Once the cap from
the distal end of the giving set has been removed from the giving set, it should be stored
in a clean covered container, at the resident’s bedside until required. Clean as per
manufacturer’s instructions and discard the cap after 24hours. A non-touch technique
should be used when reconnecting the giving set to the enteral tube.
• Avoid unnecessary handling of ports or connections as this increases the risk of
introducing bacteria into the system, from hands or the environment.
• Document the feed and volume on the resident’s fluid intake/output chart, stating the
time and date the feed was commenced.
Tube Flushing:
• Feeding tubes must be flushed with sterile water before and after feeding and before and
after administration of each medicine.
• Follow the dietician’s instructions on the feeding regimen to ensure that the resident’s
calculated fluid requirements are met.
Note: Sterile Water must be used during enteral feeding e.g. for flushing the tube,
reconstituting powder feeds, administering medication or for hydration. Use sterile water
only and discard any that may be remaining after 24 hours. Record the following information
on the bottle: the date and time when the bottle was opened. Do not decant the sterile
water into a non sterile container.
Flushing the tube is essential to:
• Reduce the risk of microbial colonisation of the surfaces of the enteral feeding tube.
• Prevent blockage - the tube should be flushed before and after feeding, before and after
drug administration, when more than one drug is being administered (flush with 510ml of water between each drug), if the feed is stopped / interrupted. MERCK
recommend flushing the tube every four hours to reduce the risk of blockage.
Equipment:
• A 30ml or larger syringe should be used, as the pressure from smaller syringes may cause
the tube to rupture.
• 50 mls of sterile water should be used to flush each time unless the resident is on a
restricted fluid intake.
• Non sterile gloves .
• Sterile Water.
Precautions required during Feeding:
• Feeds should be administrated at room temperature.
• Never force any feed through the tube.
• Feeding tube should be flushed with 50mls of sterile water before and after every feed.
• Feed reservoirs are for single use only. Giving sets should be changed every 24hrs, with
the time changed documented on the PEG observation sheet.
• If PEG feeding is the sole source of nutrition it should be administrated over 20 hours with
a fast period. This is to allow the gastric pH to fall and therefore reduce bacterial
overgrowth and potential infection.
• If the PEG is used for supplemental feeding this may take the form of overnight or bolus
feeding.
203
Bolus Feeding:
The resident’s nutritional needs and life style will determine their method of feeding i.e.
continuous feeding or bolus feeding. Bolus feeding is delivering a bolus of feed by a syringe
as a gravity feed, using a sterile 50ml syringe. Do not use the plunger of the syringe to force
the feed. Raise the syringe above the resident and allow it to siphon in slowly. Repeat this
process for the flushing of the tube. Some residents may prefer to use the pump to
administer their bolus feed. It is important to liaise with the dietician regarding planning of
an individual regime. The syringe must be discarded after single use. Document feeding
regime in the daily PEG observation chart.
After Feed Administration:
• Giving sets should be changed every 24 hours or as per manufacturer’s instructions.
• Always flush the enteral tube with sterile water at the end of a feed using a syringe.
• Document the procedure in the resident’s intake/output chart and complete the PEG
observation sheet
• Report any adverse reactions to the doctor and consult the dietician.
Replacement of a Gastrostomy Tube for residents with an already established
tract by an appropriately trained and competent healthcare professional.
Equipment Required:
• Clinically clean trolley, Sterile Dressing Pack, Sterile Gloves 2 pairs, Alcohol Gel
• Normal Saline 0.9% to cleanse stoma area
• Silicone Replacement Gastrostomy Tube
• Pre-filled syringe which comes in each initial pack, 5 mls for the 12, 14, 16 and 18fr
balloons. Only the 20fr & some specially requested 16fr will need 20mls of sterile water
• Syringe for obtaining gastric aspirate
• Water Soluble Lubricating Gel
• pH Indicator strips
• Small black bag for waste disposal
Procedure:
• Explain the procedure to the resident and gain verbal consent. Allow time to answer any
questions the resident/significant other(s) may have. Provide privacy.
• Wash hands and wear sterile gloves adhering to National SARI Guidelines.
• Using an aseptic technique, open inner cover of the dressing pack. Pour saline into the
receptacle. Open the replacement kit and contents and open the syringe from its outer
packaging and place it in the sterile field.
• Inspect the replacement tube prior to insertion. Using a syringe inflate the balloon with
5mls of sterile water. Remove the syringe and observe the balloon for a symmetrical
shape, if necessary roll the balloon gently between the thumb and the index finger to
achieve a uniform shape.
• Check the retention bolster to see that it slides up and down the shaft of the tube.
• Close the feeding port.
• Thoroughly cleanse the stoma area with normal saline 0.9%.
• Remove gloves and decontaminate hands with alcohol gel.
• Put on a new pair of sterile gloves.
• Lubricate the tip of the replacement tube with water soluble lubricant.
• Gently guide the lubricated tip of the replacement tube through the stoma, until the
entire balloon has passed through the tract and into the stomach.
• Hold the tube in position and inflate the balloon with the recommended amount of
sterile water.
204
•
•
•
•
•
•
•
•
•
•
Position the balloon against the stomach by pulling the tube up and away very gently
until resistance is felt.
Check for the correct placement by aspirating gastric contents with a syringe and testing
aspirate on pH indicator strip.
Wipe away any fluid or lubricant from the tube and stoma.
Inspect the stoma for gastric leakage; if there is leakage add an additional 1-2mls of
water until the leakage stops. Do not exceed the maximum volume of the balloon.
Remove gloves, dispose of waste and decontaminate hands.
Prior to the commencement of each feed, check for correct placement by aspirating
gastric contents with a syringe and testing aspirate on pH indicator strip. pH 5.5 or
below confirms stomach placement .
Document procedure in the resident’s narrative notes with details of the size of the tube,
the amount of water in the balloon and the date and time of the procedure, and a
confirmation of the correct tube placement via a pH indicator test. Schedule date for next
replacement if appropriate.
Adhere to An Bord Altranais guidelines on Recording Clinical Practice (2002).
If a resident complains of undue pain or displays non verbal signs of discomfort, stop the
procedure and refer to the Doctor immediately.
Never exceed the manufacturer’s recommendations on the maximum volume of sterile
water to be inserted into the balloon.
Specific Considerations for residents receiving enteral feeding:
All relevant baseline assessments and care plans should be reviewed as this is essential to
their ongoing management.
Document the following assessments on determination that enteral feeding is required and
when the resident’s condition changes.
Assess the resident’s:
1. Physical Care Requirements: These will incorporate:
1. The resident’s nutritional status and needs and how they should be managed.
This should incorporate their nutritional status e.g. weight/BMI, nutritional requirements
(as assessed by the dietician), swallowing status & recommendations: in
dysphagic/aphagic residents, following assessment by a Speech and Language Therapist.
The resident’s recommended nutritional intake including their oral intake (if permitted)
and tube feeding regime should be recorded. The quantity, frequency and consistency
of oral fluid and food allowed should be noted.These should be explained to the resident
and /or their significant other(s). Record all intake and output on a Fluid Balance
chart (In the first 48 hours post tube insertion, record gastric residual volumes
(GRVs) aspirated and returned. Record further GRVs as ordered by the dietician on
the intake/output chart).
2. Positioning: Residents requiring enteral feeding should be in a sitting position during
feeding to prevent aspiration, where possible. If this is not possible a semi-recumbent
position should be used. The person should be nursed at a 30° angle or more and this
position should be maintained for 30 minutes following feeding. Residents who are at
risk of aspiration should not have a continuous feed overnight.
3. Pain assessment and management Refer to RAP 16-Pain.
4. Communication Ability and how to best communicate with the resident, refer to RAP
1 Communication, Vision and Hearing.
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5. Equipment needs Consider what is needed to maximise the resident’s comfort,
privacy and dignity, and to facilitate the feeding regime i.e. pump type and serial
number.
6. Stoma care requirements: condition of stoma and surrounding site (peri-stomal
skin condition).
7. Tube details – date of insertion, make of tube, batch number, French gauge, length
of external tubing visible, and the volume of water in the retention balloon, if appropriate
and method of fixation. Record the date the tube is to be replaced.
8. Oral hygiene needs Refer to RAP 11: Impaired ability for Personal Care.
9. Medications prescribed; the method of administration and drug interactions require
consideration. Phenytoin interaction with enteral feeds is well described. It is
recommended that Phenytoin is given as a single dose where possible, and the enteral
feed is stopped two hours before and restarted two hours after administration.
Quinolone antibiotics are further examples of drugs that interact with enteral feeds. All
medication should be reviewed by the doctor and pharmacist for possible interaction
with the enteral feed. Any recommendations subsequently made should be documented
and implemented.
10. Monitoring requirements for potential complications with any details concerning
the resident’s clinical condition and/or any biochemical abnormalities.
2. Psychological Care Requirements: Consider the resident’s:
• Quality of life: residents on enteral feeding have various factors that can impede on
their quality of life. Mealtimes can be particularly difficult for residents; the smells of
food/cooking, watching others eating and missing being able to eat or drink can be
very distressing for the person. Time constraints in feeding can also present challenges
to the resident’s normal life-style, resulting in immobility and infringements of their
activities. Consideration should be given to the individual especially around the timing
of meals and planned activities for the person, to ensure the resident does not feel socially
excluded. Other factors include: disturbed sleep and a restricted choice of clothing.
• Preferences and dislikes should be accommodated especially for residents who can
tolerate and are permitted a small amount of food/fluid orally.
• Dignity, Respect and Privacy Requirements: establish from the resident/significant
other how the resident wishes their dignity, respect and privacy to be maintained.
• Decision making ability e. g. consider the resident’s advanced care directives or
wishes for withholding or withdrawing enteral feeding. Consider who can legally make
these decisions if the resident cannot or has not already done so. Refer to the Regional
DML Guidelines on Nutrition for further advice in this area.
• Information that the resident / their loved one and carers may request e.g. what are
the risks/complications associated with feeding tubes? How long is the resident expected
to need this type of feeding?
• Support Services that the resident/significant others may require e.g. what are the
ways that caregivers can best provide emotional/ psychological comfort to the
resident/their significant other(s)? Is there a need for additional resources such as
counselling services?
3. Social/cultural Care Requirements: Establish what the resident’s and their
significant other’s wishes are regarding tube feeding and how these can be respected
e.g. Food and eating are an important part of the social and emotional life of a person.
It is important to provide time and support to enable the resident to come to terms with
their nutritional regime and for the nurse/carer to be sensitive around general mealtimes.
It is important that where possible the resident is offered a choice of leaving the dining
area at meal times.
206
Multidisciplinary Team Referrals required:
Refer to the multidisciplinary team as appropriate to the resident’s assessment findings.
• Dietician: for further nutritional assessment, screening, and for review of the resident’s
feeding regime as appropriate e.g. in delayed gastric emptying, the volume of feed/fluid
administration will need to be reviewed, and altered accordingly.
• Speech and Language Therapist: for swallow reassessment and positioning advice
for safe feeding.
• Medical Doctor must review a resident if he/she shows signs of abdominal discomfort
or distension or signs of complications as outlined earlier.
• Dentist: to assess the resident’s oral health and to advise on appropriate mouth care.
A dental review should be carried out at a minimum on an annual basis.
• Pharmacist: to review medications prior to the commencement of enteral feeding and
to supply any liquid drug preparations necessary as an alternative to oral drug
medications that cannot be administered via the PEG tube.
• Infection Control Team: as required for recommendations and advice on specific
treatment e.g. MRSA detected at the stoma site.
• Consultant Specialist Care: as required.
• Counselling Services: as required.
• Pastoral Care Team: as required.
• Clinical Nurse Specialist: in relevant specialties e.g. wound care, stoma nurse
specialist as appropriate.
Record all referrals made on the MDT Referral Record and document the reason/outcome
of the referral in the narrative notes. Update care plans accordingly.
Personalised Care Planning:
The aim of care planning is to develop a single multidisciplinary (MDT) plan of personalised
care to address the prevention of risks and management of enteral feeding. The MDT
includes the resident/significant other(s), carers, nurses, doctors and allied health
professionals.
Problem/Need Identification:
Record the actual or potential feeding tube problem/need and its associated or related risk
factors. For example; “Mary has a very poor gag reflex following her CVA and is unable to
tolerate anything by mouth. A PEG tube was inserted on 07/03/2010 to address nutritional
and hydration needs.”
Goal Specification:
Record specific, measurable, realistic, and achievable MDT goals based on the assessment
findings of the resident’s needs. For example; ‘Mary will receive all her nutritional and
hydration needs and medication via her PEG tube without the development of any
complications.”
Specific Interventions:
These are the specific steps taken based on expected standards of care in addressing actual
or potential problems/needs. Document:
• What we need to do (specific interventions based on residents/significant other(s) care
choices where possible)
• What we need to monitor (on-going reassessments)
• What we need to communicate (back to the MDT)
• What/who we need to educate (to improve the problem/need)
207
1. Specific MDT interventions:
The following should be recorded:
a. Specific interventions to address the resident’s/significant(s) concerns,
preferences and care choices e.g. the resident may be deeply distressed at not being
able to eat or drink. Provide appropriate psychological support and assess the need for
onward referral for counselling /psychological supports if necessary.
b. MDT specific care instructions. This includes care instructions for addressing any
risks associated with the delivery and maintenance of the resident’s feeding regime and
nutritional care .e.g. Speech and Language Therapist instructions regarding positioning
of the resident for safe feeding; the specific instructions form the dietician, these should
be listed here or attached to the care plan. Refer the reader to the instructions.
c. Oral hygiene
d. Specialised equipment – Feeding solution, giving set etc. Refer the reader to the
resident’s Nutritional Care Plan.
e. Pain present – Refer the reader to the resident’s Pain Management Care Plan
f. Advanced Care Directives/Plans
2. Monitoring and ongoing assessment:
• It is essential that residents receiving PEG feeds are adequately monitored. Monitoring
should place emphasis on fluid balance, biochemistry and haematology and changes in
the resident’s clinical condition.
• Baseline bloods should be taken i.e. FBC, U&E, Serum Proteins, Serum Magnesium, and
Blood Sugars. These results should be documented and tracked in the resident’s medical
notes.
• It is important to check and document glucometer readings as instructed by the
dietician, as the resident can develop hyperglycaemia/ hypoglycaemia. If a blood sugar
reading is not within normal range it should be reported to the doctor.
• The resident should be monitored closely for both the outcome of the prescribed
nutritional support and for any potential side effects from the administration of a feed
e.g. intestinal obstruction and delayed gastric emptying; nausea, vomiting, constipation,
diarrhoea, aspiration, or side effects of medication. This should be managed accordingly
under medical supervision.
• The resident’s weight should be checked and documented prior to insertion of the
PEG tube. The resident should be weighed weekly to monitor any weight changes
associated with the tube feeding regimen. Any changes in their weight should be
reported to the dietician and the outcome documented in the resident’s narrative
notes.The care plan should be updated as appropriate.
• Abdominal discomfort and bloating may be caused by excessive air/gas in the stomach.
Venting or decompression (allowing air to escape) should be performed prior to each
feed or medication administration.
• The resident’s hydration status should be monitored and managed accordingly under
medical supervision. Observe for signs of dehydration e.g. dry mucous membranes;
sunken eyes; low/absent or concentrated urinary output; increase in urinary tract
infections; constipation; confusion; lethargy; muscle cramps; hypotension, tachycardia
& seizures. Record all intake and output on a fluid balance chart.
• Observe for signs and symptoms of aspiration, symptoms include coughing/choking,
wet/gurgly voice, alterations in breathing pattern e.g. shortness of breath, fever, acute
or increasing confusion, chest pain, and respiratory arrest. Some residents who aspirate
have no overt symptoms, they may just present with a low grade temperature i.e. silent
aspiration.
208
•
•
•
Monitor ongoing risk factors associated with co morbidities.
Update care plan as appropriate based on monitoring findings, resident’s satisfaction
and emerging identified needs.
Reassess the resident’s needs if there is any change in their overall condition.
3. Communication
Discuss and devise the resident’s care plan in conjunction with the resident/significant
other(s) where possible and based on the resident’s wishes. Communicate the resident’s
preferences and wishes to all those involved in the resident’s direct care.
Ensure any monitoring concerns identified are promptly communicated to all appropriate
members of the MDT and refer the resident to other healthcare professionals as needed.
4. Information/Education/Health Promotion for Resident, Significant Other(s)
and Carers
Provide education / information on the care of feeding tubes to residents, to promote self
care where possible. Provide education on the plan of personalised care to the
resident/significant other.
All carers should receive training appropriate to their role in providing care to residents on
enteral feeding.
Evaluation of Care:
The evaluation of the resident’s care should be based on the goals specified in their individual
care plan and must be evaluated when the resident’s condition improves or deteriorates and
at a minimum 3 monthly. The effectiveness of the care being provided should be evaluated
by checking to see if the goals of care are being met.
Please refer to the “Protocols of Care” flow chart and sample “Personalised
Care Plan” in documenting care planning and in providing care.
209
210
Nursing Assessment-Document
• Overall Risk Context
• Past medical history
• Co-morbidities
• Risk factors: aspiration
• Peri-stomal Skin assessment
• Pain Assessment
• Fluid balance Assessment
• Resident’s main concerns
• Resident’s goals
• Resident’s preferences
• Cognitive ability
• Communication abilities/deficits
• Resident’s cultural beliefs
• Resident’s religious beliefs
Further Assessments
• Assess ongoing needs
• Assess for signs & symptoms of
complications of enteral feeding
• Assess for the need of MDT referrals /
assessments /management
• Feeding tube care needs & ability to self
care
• Functional /Physical
/Cognitive/Emotional Ability/ Status
• Equipment needs
• Preferences /Likes/Dislikes
• Wound Care Requirements
• Quality of Life Concerns
• Dignity, Respect & Privacy Requirements
On admission, if resident’s condition changes &
at a minimum every 3 months
Nursing Assessment
1. Identify Physical,
Psychological,
Social & Spiritual
Care Needs
2. Devise Resident
Centred care plan
Need for Feeding
Tube Care Plan
Nursing Diagnosis
12.
13.
9.
10.
11.
6.
7.
8.
5.
Reassess if condition
changes.
Goals unmet or Condition
Changes
Goals met
• Resident/carer aware of appropriate preventative
measures & involved in
care decisions.
• Resident/carers have care
Plan for feeding tube care
1.
2.
3.
4.
The identified problem(s) / need(s)
The identified goals of care
The Specific interventions required
The management plan for any risks
identified.
The Care Plan for all identified problems
and goals
The MDT referrals required & made
Refer reader to relevant care plans
The identified appropriate specialised
equipment identified/required and
specialised care required
Symptom management
Monitoring requirements
Steps to prevent the development of
complications
The Resident’s preferences
Provide education to residents/significant
others & carers in care of Residents with
feeding tubes
Measure outcome against
specified goals
Nursing Evaluation
Implement an Enteral Feeding Care plan
Document:
Nursing Care Goals & Planning
Protocol of Care for Feeding Tubes in HSE Older Persons Designated Centres
SAMPLE CARE PLAN
Topic Heading: Feeding Tube Care
PROBLEM / NEED IDENTIFICATION
Number: Page 1
Date
Signature
01/01/10 Mary has a very poor gag reflex following her CVA and is unable to toler-
ate anything by mouth.
GOAL SPECIFICATION
Jane Murphy
Mary will receive all her nutritional and hydration needs and medication via her PEG tube without
the development of any complications”
SPECIFIC INTERVENTIONS
Date
01/01/10
Signature
Identify the type of feeding tube and stoma Mary has in place and the type of feeds
to be administered Gastrostomy Tube Details
Name of tube: ______________________________________________________
Size of tube: ___________ G/Fr
Measurement at skin: _________cm
Type of tube:
G-tube/PEG
J-tube/PEJ
Low Profile Stoma:
Yes
No
•
For stoma care refer to Wound Management Care Plan.
Identify the type of feeding that Mary requires
Method of feeding:
Gravity-drip
Pump
Syringe
Schedule of feeds:
Continuous
Intermittent
•
Refer to Mary’s Nutritional Care Plan for the feeding regime.
•
Identify the methods of gastric decompression to be used Venting / Decompression prior to
each feed.
•
Highlight the importance of positioning for the feeding regime. Tube feeds must only be
given when the Mary is sitting upright, standing, or half seated with the head raised 30° or
more. Never allow Mary to lie flat during a feed, and wait for 30 minutes or longer before
lying down.
Medication Administration
•
Most of Mary’s medications can be given via her PEG feeding tube. It is recommended that:
Liquid medication is used whenever possible (suspensions/elixirs). If a tablet must be
crushed, it must be ordered by the doctor and local policy followed.
•
Mary’s main concern(s) for her feeding tube care is that she will experience discomfort and
hunger and that her PEG tube will be accidentally dislodged while she is being moved. Offer
Mary plenty of reassurance and explain all procedures to her.
•
Pain Assessment/Management. Mary’s preferred method of pain control is to take oral
medication as she does not like needles. Explain to Mary that she can have her medication
given to her via her PEG tube and that she will not be left in pain. Refer to Mary’s Pain Care
Plan.
•
Dieticians Referral: Please see attached Feeding regime and recommendations from the
Dietician.
•
Speech & Language: Pease see attached recommendations from the SLT.
•
Monitoring: Monitor lab results as ordered by the Doctor.
•
Mary’s Weight and BMI are to be monitored on a weekly basis as per the attached
Dietician’s recommendations. Mary’s Blood sugars are to be monitored on a 4 hourly basis.
Observe for complications such as agitation, depression, mood disorders, self-extubation
(removal of the tube by the resident), infections, aspiration, misplacement of tube in trachea
or lungs, pain, and tube dysfunction/malfunction, tube obstruction, tube displacement,
tube leakage, over/under hydration, raised blood glucose levels, biochemical/ Electrolyte
Imbalances –Overgrowth of Granulation tissue, stoma leakage. Report monitoring concerns
to Mary’s doctor or other members of the MDT as appropriate.
•
Information sessions are to be provided to Mary & her family. Ongoing educational updates
are to be provided to Mary’s Carers and significant others. Any alteration in her care needs
must be communicated to all carers and significant others as per Mary’s wishes.
Jane Murphy
EVALUATION OF CARE (based on goals specified)
Date
Signature
Jane Murphy
02/01/10 Mary and her family report that they are very happy that Mary’s PEG tube/wound care
and feeding regime are being well managed and that she is content. They do not wish to
have any changes made in her care plan at this time and will notify staff in the event that
they wish any adjustments to be made to her plan of care. No complication to enteral
feeding noted.
Discontinued Date: …..... / ……… / 20…… Signature: …………………………………………..
211
Bibliography:
American Society for Parenteral and Enteral Nutrition (2009) Enteral Nutrition Practice
Recommendations, Journal of Parenteral and Enteral Nutrition, 33, 2:122-167.
An Bord Altranais (2000) Scope of Nursing and Midwifery Practice Framework, An Bord
Altranais, Dublin
Anderton A (1995) Reducing Bacterial Contamination in Enteral Tube Feeds British Journal
of Nursing Vol 4 no 7 pp 368-375
Arrowsmith, H., (1996) Nursing Management of Residents receiving gastrostomy
feeding, British Journal of Nursing 5(5) 268-273
Fieldhouse( 1995) Parental nutrition. British Journal of Nursing Vol 7 no 9 1998.
Cummins, C., Marshall T., Buris, A. (1997) PEG Feeding in the Enteral nutrition of
Dysphagic Stroke Professional Nurse Vol.13 No 1
NICE (2006) Nutritional Support for Adults, Oral Nutrition Support, Enteral Tube Feeding
and Parental Nutrition.
http://www.nice.org.uk/nicemedia/pdf/cg032fullguideline.pdf
Hearing, S. (2004) Refeeding syndrome Is underdiagnosed and undertreated, but
treatable. BMJ: 328(7445): 908–909.
Irish Nutrition & Dietetic Institute (2002) – ‘Nutrition support Reference Guide’
Irish Nutrition & Dietetic Institute (2007) – 'Home enteral feeding resource pack'
HSE SOP (2008) Management of Enteral Feeding Care in Older Persons Residential Care
Centres
http://hsenet.hse.ie/Hospital_Staff_Hub/mullingar/Policies,_Procedures_Guidelines_Midland_Area/Care_of_the_Older
_Persons/Regional_PPG's/ROP045_Guideline_Management_of_Enteral_Feeding_Care_in_Older_Persons_Residential_
Care_Centres.pdf
212
Sample Feeding Regime
To be completed by a Dietician or Medical Practitioner
FORMULA PREPARATION
Powder Formula
Thoroughly mix ____ cups, or ____ scoops of “___________________” powder with
____ mL of water in a large, clean container. Use a standard measuring cup and
follow the manufacturer’s instructions.
Ready-to-Use Formula
Shake the can or container well. Wipe the top of the container with a clean cloth
before opening, following the directions on the label. Use a standard measuring
device to measure the amount of formula required. Do not add water to ready-touse formulae.
FEEDING SCHEDULE
Continuous Feeding
Place ________ mL of formula in the feeding container every _______ hours.
Set the flow rate at:
Gravity: ________ drops/minute
Pump: ________ mL/hour
Give the feed for ______ hours, starting at _____:_____ and finishing at
_____:_____.
Give ________ mL of water every _______ hours.
Intermittent Feeding
Number of feeds per day:
__________________________________________________________________________
Time(s) of feeds:
__________________________________________________________________________
For each feed, place ______ mL of formula in the feeding container.
The feed should be given over _______ minutes, or _______ hours.
213
RAP 21: Palliative Care for all
Definitions:
Palliative Care is the care of residents with active, progressive, far advanced disease, for
whom the focus of care is relief, prevention and management of symptoms while
maintaining their quality of life. It is considered active Palliative Care management in
accordance with the resident’s and their carers’ wishes. When death appears imminent,
an end of life assessment and care plan is completed.
Palliative care is described by WHO as an approach that improves the quality of life of
people and their families facing problems associated with life threatening illness through
the prevention and relief of suffering. This is achieved by means of early identification,
impeccable assessment and treatment of pain and other symptoms that may be physical,
psychosocial and spiritual. The introduction of palliative care can be appropriate early in
the course of the disease and may be applicable with other therapies that are intended
to prolong life.
Levels of Palliative Care Services:
Level one – Palliative care approach
Palliative care principles should be practiced by all health care professionals. The palliative
care approach should be a core skill of every clinician at hospital and community level.
Many residents with progressive and advanced disease will have their care needs met
comprehensively and satisfactorily without referral to specialist palliative care units or
personnel. The palliative care approach aims to promote both physical and psychosocial
well-being. It is a vital and integral part of all clinical practice, whatever the illness or its
stage, informed by a knowledge and practice of palliative care principles.
Level two – General palliative care
At an intermediate level, a proportion of residents and families will benefit from the
expertise of health care professionals who, although not engaged full time in palliative
care, have had some additional training and experience in palliative care, perhaps to
diploma level. Such intermediate level expertise may be available in hospital or
community settings.
Level three – Specialist palliative care
Specialist palliative care (SPC) services are those services whose core activity is limited to
the provision of palliative care. These services are involved in the care of residents with
more complex and demanding care needs, and consequently, require a greater degree
of training, staff and other resources. SPC services, because of the nature of the needs they
are designed to meet, are analogous to secondary or tertiary health care services. SPC
services are those services with palliative care as their core speciality and which are
provided by an inter-disciplinary team, under the direction of a consultant physician in
palliative medicine. SPC services are available within primary care settings, acute general
hospital settings and specialist inpatient units.
214
RAI Identifiers of Potential Risks:
Section O
Decision to Adopt a Palliative Care Approach:
Chronic diseases and terminal diseases are the common reason for adopting a palliative
care approach. However, people with life-limiting, non-malignant diseases can experience
a range of physical and psychological symptoms throughout the course of their disease.
Their symptom burden has been shown to equal that of people dying with cancer. In
addition, their disease trajectory can be more complex and often of a much longer
duration. These aspects of non-malignant disease demonstrate the need for a palliative
care approach to be incorporated as part of their routine care.
Some life-limiting diseases that require particular consideration for palliative care include:
•
•
•
•
•
•
•
•
Dementia
Heart failure
Advanced respiratory disease such as COPD
Chronic kidney disease
Scleroderma
Motor neurone disease
Cardio-vascular accident
Multiple sclerosis
Further Assessments:
Palliative care responds to physical, psychological, social and spiritual needs, and extends
to support in bereavement. The goal of palliative care is to allow the highest possible
quality of life for both the resident and their family by identifying the resident’s needs in
relation to their
•
•
•
•
•
Physical Needs
Psychological Needs
Social Needs
Spiritual Needs
Family Support required
All relevant baseline assessments and care plans should be reviewed with a view to
maintaining the resident’s comfort, dignity and choice.
Document the following assessments on determination that Palliative care is required
and when the resident’s condition changes
Assess the resident’s
1. Physical Care Requirements – This will incorporate:
a) The resident’s symptoms as identified in Section O assessment and how best they
should be managed.
b) Palliative Care Needs – These should be explained to the resident and /or their
significant other.
c) Pain Management. Refer to RAP 16: Pain.
215
d) Communication ability and how to best communicate with the resident, their
significant other and carers. Refer to RAP 1: Communication, Vision and Hearing.
e) Equipment needs: consider what is needed to maximise the resident’s comfort,
privacy and dignity.
2. Psychological Care Requirements. These will include the resident’s:
a) Preferences and dislikes.
b) Dignity, Respect and Privacy Requirements. Establish from the resident/significant
other how they wish their dignity, respect and privacy to be maintained.
c) Decision making ability e.g. for resuscitation, advanced directives and who can legally
make these decisions if the resident cannot or has not already done so.
d) Information provision-that the resident, their loved one and carers may request e.g.
how long the resident is expected to live? What are the signs that death is
approaching?
e) Support Services that the resident their loved one and carers may require e.g.
ascertain the ways that caregivers can provide emotional comfort to the resident?
Consider what additional resources are needed and available. Provide information
about palliative care issues as appropriate to the resident’s wishes.
3. Social Care Requirements Family Issues and Interventions
a) Establish with the resident and their significant other(s) what their wishes are and
how these can be respected e.g. their desire for advanced care or specific aspects of
advance care options.
b) Conflict Resolution Ability and how to best resolve any conflicts that may arise or that
already exist.
4. Cultural Beliefs/Practices – ascertain how the resident and/or their significant
other would like these exercised
5. Any potential Legal implications e.g. Life support being withheld or withdrawn
6. Spiritual Care Requirements, Religious beliefs and wishes and how the
resident and/or their significant other(s) would like these incorporated into their
palliative care approach.
Referrals required:
Refer to the multidisciplinary team as appropriate to assessment findings.
•
•
•
•
•
•
•
•
•
216
OT/Physiotherapist referral required for specialised equipment needs assessments to
maximise functioning ability and comfort
GP/Medical referral for any medical concerns
Speech and Language referral to maximise communication abilities, etc
Rehabilitation Services (physiotherapy / OT therapy / Social Work Services) in order
to maximise physical abilities, promote independence and adapt to their condition
Specialist Palliative Care Teams for symptom management
Consultant Specialist Care as required
Counselling Services as required
Pastoral Care Team
Clinical Nurse Specialist in relevant specialties
•
•
Bereavement Counsellors
Alternative/Complementary Therapists for relief of physical symptoms and
psychological distress
Record all referrals made on the MDT Referral Record and document the reason and
outcome of the referral in the narrative notes. Update care plans accordingly.
Personalised Care Planning:
The aim of care planning is to develop a single multidisciplinary (MDT) plan of
personalised care to address the cause, symptoms or risks where possible. The MDT
includes the resident/significant other(s), carers, nurses, doctors and allied health
professionals.
Problem/Need Identification:
Record the actual or potential palliative care problem and its associated or related risk
factors. For example; “Mary is frightened that she will remain in pain”
Goal Specification:
Record: specific, measurable, realistic, and achievable MDT goals based on the resident’s
assessed needs. For example; ‘Mary will be free from pain as evidenced by Mary’s self
report during assessment at each interaction with Mary’.
Specific Interventions:
These are the specific steps taken based on expected standards of care in addressing
actual or potential problems in palliative care. Document:
• What we need to do (specific interventions based on residents/significant other(s)
care choices where possible)
• What we need to monitor (on-going reassessments)
• What we need to communicate (back to the MDT)
• What/who we need to educate (to improve the problem)
1. Specific MDT interventions:
The following should be recorded:
a. Specific interventions to address the resident’s/significant other(‘s) concerns,
preferences and care choices e.g. the resident may not wish to see anyone outside
of their immediate family.
b. MDT specific care instructions. This includes care instructions for addressing any
risks associated with the delivery and maintenance of the resident’s palliative care
e.g. Palliative Care Team instructions re: symptom management.
c. Specialised equipment – Syringe driver, prosthetics, etc. Refer the reader to the
resident’s Manual Handling & other care plans.
d. Pain present – Refer the reader to the resident’s Pain Management Care Plan.
217
e. Symptom Management. Record any intervention used to help relieve the individual’s
pain, discomfort or other negative experiences that arise as either a direct or indirect
result of their medical condition or the ageing process. This may include medication,
physical therapy, social activities, or spiritual support. It should be an integral element of
the care plan, focusing on identifying and managing the individual’s symptoms. It may
concentrate on managing pain or other psychosocial or physical problems that the
individual identifies as being significant to them. Person-centred symptom management
assesses and responds to the individual’s needs, taking account of the wider context
within which they live, their priorities, and the things that matter to them.
f. Resident’s/Significant other(‘s) understanding of their illness and prognosis
g. Resuscitation Status
h. Advanced Care Directives/Plans/wishes
i. Need for Counselling /psychological supports
2. Monitoring and ongoing assessment:
• Monitor the resident’s symptoms and assess the effectiveness of the interventions
implemented
• Monitor the resident’s pain using a validated tool. (Refer to RAP 16: Pain)
• Monitor the resident’s mental status
• Monitor the resident’s overall appearance and how comfortable they appear
• Monitor ongoing risk factors associated with co morbidities
• Update care plan as appropriate based on monitoring findings, the resident’s satisfaction
with the plan of care and on further identified needs
• Reassess the resident’s needs if there is any change in their overall condition
There are tools available to help audit and improve the quality of palliative care for
residents in the End of Life/terminal phase. Complete an End of Life assessment and
consider the use of The Liverpool Care Pathway (see template- Appendix 1). This
incorporates 11 goals covering care of the dying patient, as well as the use of education
and resources.
3. Communication
• Discuss and devise the resident’s care plan (based on their wishes) in conjunction with
the resident where possible and/or their significant other(s). Communicate the resident’s
preferences and wishes to all those involved in the resident’s direct care, with the
resident’s permission.
• Ensure any monitoring concerns identified are promptly communicated to all
appropriate members of the MDT and refer the resident to other healthcare professionals
as needed with the resident’s consent (where possible).
4. Information/Education/Health Promotion for Resident, Significant Other(s)
and Carers
• Provide education on palliative care approaches to residents/significant others/carers.
• Staff members need to be educated in relation to the provision of palliative care
approaches.
Evaluation of Care:
The evaluation of the resident’s care should be based on the goals specified in their individual
care plan and must be evaluated when the resident’s condition improves or deteriorates and
at a minimum 3 monthly. The effectiveness of the care being provided should be evaluated
by checking to see if the goals of care are being met.
Refer to the ‘Protocols of Care Flow Chart’ and Sample ‘Personalised Care Plan’
in documenting care planning and in providing care.
218
219
Overall Risk Context; Assess:
Past Medical History
Co-morbidities
Risks
Mobility
Skin Assessment
Pain Assessment
Incontinence Assessment
Resident’s main concerns
Resident’s goals
Resident’s preferences
Cognitive ability
Communication abilities/deficits
Residents cultural/religious beliefs &
requirements
Further Assessments
• Assess for signs & symptoms of palliative
care needs: Functional /Physical/
Cognitive/Emotional/Spiritual
• Specific MDT referrals/assessments as per
identified need
• Equipment Needs
• Preferences /Likes/Dislikes
• Personal Care Requirements
• Quality of Life Concerns
• Dignity, Respect & Privacy Requirements
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Document
On admission, if resident’s condition changes &
at a minimum every 3 months
Nursing Assessment
Assessment & Monitoring
Reassess when there is
a change in the
resident’s condition
No need for
Pallaitive Care
identified
1. Identify Physical,
Psychological,
Social & Spiritual
Care Needs
2. Devise Resident
Centred care plan
Need for Pallaitive
Care identified
Nursing Diagnosis
9.
10.
11.
12.
13.
6.
7.
8.
5.
1.
2.
3.
4.
The identified problem(s) / need(s)
The identified Goals of care
The Specific Interventions required
The Management plan for any risks
identified.
The Care Plan for all identified problems
and goals
The MDT referrals required & made
Refer reader to relevant MDT instructions
The identified appropriate
seating/lifting/specialised equipment
required
Symptom management
Any advanced directive/plans
The resident’s choice, preferences for care
The resident’s dislikes
Provide education to residents/significant
others & carers in palliative care
approaches
Implement a Palliative Care Care plan
Document:
Nursing Care Goals & Planning
Reassess if condition
changes.
Goals unmet or Condition
Changes
Goals met
• Resident/carer aware of appropriate preventative
measures & involved in
care decisions.
• Resident/carers have Care
Plan for Palliative Care
Measure outcome against
specified goals
Nursing Evaluation
Protocol for Palliative Care Approaches in HSE Older Persons Designated Centres
SAMPLE CARE PLAN
Topic Heading: Palliative Care
PROBLEM / NEED IDENTIFICATION
Number: Page 1
Date
Signature
01/01/10 Mary is frightened that the pain she has will have continue to get worse
and that she will note be able to cope
Jane Murphy
GOAL SPECIFICATION
Mary will be free from pain as evidenced by Mary’s self-report during assessment at each interaction
with Mary.
SPECIFIC INTERVENTIONS
Date
Signature
01/01/10 •
•
•
•
•
•
•
Mary’s main concern(s) for her palliative care is that she will remain in
pain as she is aware that she will need to be repositioned at a minimum
at two hourly intervals and she experiences a significant amount of back
pain on movement. Please refer to Manual Handling & Pain Care Plan.
Specialised equipment. Mary has poor hearing in her left ear and
needs to have her hearing aid in place at all times. Please refer to her Personal Care Plan.
Pain Assessment/Management. Mary’s preferred method of pain
control is to take oral medication as she does not like needles. Please refer
to her Pain Care Plan
Incontinence Mary is incontinent of urine and needs frequent
toileting/ attention. Please see Incontinence Care Plan
Information sessions are to be provided to Mary & her family. Ongoing
educational updates are to be provided to Mary’s Carers and significant
others. Any alteration in her care needs must be communicated to all
carers and significant others as is Mary’s wish.
Resuscitation status: Mary is not for active resuscitation as per her
own wishes. Please refer to resuscitation orders in Palliative Care assessment and ensure all care staff are aware of this decision and directive
Spiritual Care Needs. Mary is a practising Roman Catholic and would
like prayers said with her at night time or for her in the event that she
cannot say them herself. Mary received the Sacrament of the Sick (Jan 3rd Jane Murphy
2010)
EVALUATION OF CARE (based on goals specified)
Date
Signature
Mary
and
her
family
report
that
they
are
very
happy
that
Mary’s
pain
is
Jane Murphy
02/01/10
being well managed and that she is pain free. They do not wish to have
any changes made in her care plan at this time and will notify staff in the
event that they wish any adjustments to be made to her plan of care
Discontinued Date: …..... / ……… / 20…… Signature: …………………………………………..
220
Bibliography:
Department of Health and Children DOHC, Report of the National Advisory Committee on
Palliative Care. 2001
Irish Hospice Foundation, A Baseline Study on the provision of Hospice/Specialist Palliative
Care Services in Ireland. 2006: Dublin
World Health Organisation, Palliative Care, The Solid Facts, ed. E. Davies and I. J.
Higginson. 2004
The Marie Curie Palliative Care Institute Liverpool (MCPCIL) The Liverpool Care of the
Dying Pathway
The NICE clinical guidance on supportive and palliative care (CSG)
NICE Guidance on Cancer Services Improving Supportive and Palliative Care for Adults
with Cancer
www.who.int/cancer/palliative/en
Marie Curie Cancer Care Spiritual and Religious Care Competences for Specialist Palliative
Care
National End of Life Care Programme/University of Nottingham “Advance Care Planning:
A guide for Health and Social Care Staff”
221
222
As required subcutaneous medication written up as per protocol (eg. pain, agitation, nausea and vomiting, emergency orders,
Goal 2
Summary
GP and other key people in the primary care team are aware of patient's condition
Goal 11 Family/others express understanding of plan of care
Goal 10 Plan of care explained and discussed with patient/family
Goal 9
Family given relevant RACF, funeral and bereavement information
Goal 8
Communication with primary health care team
Identify how family/other are to be informed of patients impending death
Communication with family/other
Religious/spiritual needs assessed with patient/family
Goal 7
Goal 6
Insight into condition assessed
Goal 5
Religious/Spiritual Support
Ability to communicate in English assessed as adequate
Psychological Insight
when necessary, routine turning regimens/vital signs discontinued)
Discontinue inappropriate interventions (routine blood tests, antibiotics, subcutaneous fluids, not for resuscitation documented
Goal 4
Goal 3
Current medications (via appropriate route) assessed, nonessentials discontinued
Goal 1
respiratory tract secretions
Comfort measures
Goals
Appendix 1: The Liverpool Care of the Dying Pathway
RAP 22: End of Life Care
Please note that when ‘resident/significant other’ is referred to in the course of this
document, information to or from the resident’s significant other is made with the
resident’s consent or when the resident cannot communicate their wishes.
Definitions:
End of Life Care is defined here as the care provided to a person in their final stages of
life where death is imminent. It is considered to be the period of time marked by disability
or disease that is progressively worse until death.
Symptoms of imminent death may include an altered mental status, decreased
socialisation and withdrawal, decreased need for food and fluids, increased challenges in
controlling pain/increased need for analgesia, skin becomes cool to the touch, breathing
becomes laboured with rattling or gurgling sounds, involuntary movements (Myoclonus),
tachycardia, hypotension, etc.
End of life care involves:
Physical Care: effective symptom control/prevention such as: pain, discomfort,
agitation, fatigue, dyspnoea, respiratory tract secretions, constipation, nausea, vomiting
and/or loss of appetite, constipation, pressure ulcer prevention. Physical care further
includes personal care activities and activities of living which promote the resident’s
comfort, dignity and autonomy. It should also include empowering the resident by
discussing and agreeing their plan of care with them and/or their significant other where
the resident is no longer able to do so.
Psychological Care: assessing individual needs and providing referral to appropriate
supports e.g. social work services for counselling, etc. Psychological Care also includes the
provision of emotional support to the resident and those who care about them; giving
time to listen and understand their concerns and by expressing sympathetic presence
with the resident and their family/friends. Where desired by the resident, their family and
friends should be included in decisions about their care and provided with the necessary
information about their individual care plan.
Social Care: giving support and advice on practical matters such as getting their affairs
in order or onward referral of the resident to appropriate members of the multidisciplinary team where matters fall outside of the nurses’ scope of practice. Social care
also includes allowing the resident time and space to spend in private with their family
and friends e.g. the provision of appropriate accommodation such as a single room where
possible. Consideration should also be given to ensuring that staff understand how to
communicate sensitively and appropriately with the resident and their family so that
dignity, comfort and choice is always respected by staff members caring for the resident
and their family.
Spiritual Care: some people may have a need to explore thoughts about the meaning
of life, or concerns about what happens after death. Most people are likely to have
spiritual needs and some may also have practical things they need to do because of their
religious beliefs. A spiritual needs assessment should be undertaken to identify individual
needs.
223
RAI Identifiers:
Section P End of Life
Quality of Life Risk Factors:
Risk factors that may negatively impact on residents’ quality of life in their end of life days
may be associated with the impact/exacerbation of co-morbidities/disease progression
and related symptoms on the resident’s life, and unfulfilled/unmet psycho-social needs.
It should be noted that during the final stages of terminal care emphasis should not be
placed on actively treating symptoms that will not improve the resident’s quality of life.
The emphasis should be on comfort care. This will require focussed assessments of all the
various components.
Focussed Assessments:
The focus of assessment is to identify the resident’s/ significant other(s) needs so that
they/their loved one can be afforded a death with dignity in their place of choice with
whom they wish. Their dignity should be promoted and maintained at all times.
All relevant baseline assessment and care plans should be reviewed with the resident
and/or their loved one with a view to maintaining the resident’s comfort, choice and
dignity. Document the following assessments on determination that end of life care is
required and when the resident’s condition changes. All documentation should evidence
a person centred approach to care.
Assess the resident’s
1. Physical care requirements: this incorporates:
The resident’s symptoms and how they should be managed.
a) End of Life symptoms: these should be identified through RAI Section P End of Life
Assessment. Discuss symptoms identified and the resident’s/significant others wishes
in managing these symptoms. Provide appropriate advice where possible or refer the
resident/significant other to appropriate MDT members for advice/discussion.
b) Pain management: it should be noted that 25% of people, who die; die in pain.
A strong emphasis is required on pain assessment and management. Refer the reader
to RAP 16: Pain.
c) Communication Ability and how to best communicate with the resident, their
significant other and carers. Communication may include sensitive breaking of bad
news, respectful discussion about how the resident feels about dying, how the family
are coping with the resident’s imminent death, etc.
d) Equipment needs: consider what is needed to maximise their comfort, privacy and
dignity
2. Psychological Care Requirements: these will include the resident’s:
a) Wishes regarding their place of death and whom they would like to be present, as
far as possible.
b) Dignity, Respect and Privacy Requirements. Establish from the resident/
significant other how they wish their dignity, respect and privacy to be maintained.
c) Decision making ability e.g. for resuscitation, advanced directives and who can
legally make these decisions if the resident cannot or has not already done so.
224
d) Information provision-that the resident, their loved one and carers may request
e.g. how long the resident is expected to live? What are the signs that death is
approaching? What are the signs that the patient has died?
e) Support Services that the resident their loved one and carers may require e.g.
ascertain the ways that caregivers can provide emotional comfort to the resident?
Consider what additional resources are needed and available. Provide information
about end of life issues as appropriate to the resident’s wishes.
3. Social Care Requirements Family Issues and Interventions
a) Establish with the resident and their significant other(s) what their wishes are and
how these can be respected e.g. their desire for advanced care or specific aspects of
advance care options.
b) Conflict Resolution Ability and how to best resolve any conflicts that may arise
or that already exist.
4. Cultural Beliefs/Practices and how the resident and/or their significant other
would like these exercised.
5. Any potential Legal implications e.g. Life support being withheld or withdrawn.
6. Spiritual Care Requirements Religious beliefs and wishes and how the
resident and/or their significant other would like these incorporated into their end of
life care.
Referrals required:
Refer to the multidisciplinary team as appropriate to their assessment findings.
•
•
•
•
•
•
•
•
•
OT/Physiotherapist referral required for specialised equipment needs assessments to
maximise functioning ability and comfort
GP/Medical referral for any medical concerns
Speech and Language therapist Referral to maximise communication abilities etc
Palliative Care Teams for complex pain management beyond the scope of the team
Consultant Specialist Care as required
Counselling Services as required
Pastoral Care Team
Clinical Nurse Specialist in relevant specialties
Bereavement Counsellors
Record all referrals made on the MDT Referral Record and document the reason/outcome
of the referral in the narrative notes. Update care plans accordingly.
Personalised Care Planning:
The aim of care planning is to develop a single multidisciplinary (MDT) plan of
personalised care to address the cause, symptoms or risks where possible along in
conjunction with the resident’s expressed wishes and preferences. The MDT includes the
resident/significant other(s), carers, nurses, doctors and allied health professionals.
225
Problem/Need Identification:
Record the actual or potential end of life care problem and its associated or related risk
factors. For example, ‘Mary is frightened that she will die in pain’.
Goal Specification:
Record specific, measurable, realistic, and achievable MDT goals based on assessment of
the resident’s needs. For example; ‘Mary will die comfortably and peacefully free from
pain’.
Specific Interventions:
These are the specific steps taken based on expected standards of care in addressing
actual or potential End of Life problems/needs. Document:
• What we need to do (specific interventions based on residents/significant other(s)
care choices where possible)
• What we need to monitor (on-going reassessments)
• What we need to communicate (back to the MDT)
• What/who we need to educate (to improve the problem/need)
1. Specific MDT interventions:
The following should be recorded:
a. Specific interventions to address the resident’s/significant(s) concerns,
preferences and care choices e.g. the resident may not wish to see anyone
outside of their immediate family.
b. MDT specific care instructions. This includes the care instructions for addressing
the resident’s identified problems or needs in their end of life days, this section should
make reference to:
• Symptom Management. Any intervention used to help relieve the individual’s
symptoms or negative psycho-social well-being should be detailed here or refer the
reader to the resident’s appropriate care plan e.g. pain present - Refer the reader
to the resident’s Pain Management Care Plan for the Palliative Care Team instructions
regarding pain management /syringe driver etc.
• Resident’s/Significant other(s) understanding of illness and prognosis.
• Resuscitation status
• Advanced Care Directives/Plans
• Counselling /Bereavement supports/interventions
2. Monitoring and ongoing assessment:
• Monitor the resident’s mental status for signs of distress, anxiety and diminishing
ability to communicate verbally
• Monitor the resident’s pain using a validated tool
• Monitor the resident’s symptoms and manage accordingly in line with the
resident’s/significant others expressed wishes
• Monitor the resident’s overall appearance and how comfortable they appear
• Monitor ongoing risks associated with co morbidities e.g. constipation, etc
• Update care plan as appropriate based on monitoring findings and resident’s
satisfaction with care and emerging identified needs
• Reassess the resident’s needs if there is any change in their overall condition
226
There are tools available to help audit and improve the quality of residents’ End of Life
care. The Liverpool Care Pathway template (Appendix 1) incorporates 11 goals covering
care of the dying resident, as well as use of education and resources.
3. Communication
Discuss and devise the resident’s care plan and their wishes sensitively in conjunction with
the resident where possible and/or their significant other. Communicate the resident’s
preferences and wishes to all those involved in the resident’s direct care.
Ensure any monitoring concerns identified are promptly communicated to all
appropriate members of the MDT and refer the resident to other healthcare professionals
as needed.
4. Information/Education/Health Promotion for Resident, Significant Other(s)
and Carers
Provide education on diagnosis, current phase of illness, attitudes, actions, awareness and
advice to residents/significant others/carers as appropriate.
All carers should receive training in dealing with the dying resident and/or their
significant other and in the breaking of bad news as appropriate to their role. Staff need
to be educated in relation to what procedures need to be adhered to following the
death of a Resident and where their individual responsibilities lie i.e. who does what?
Evaluation of Care:
The evaluation of the resident’s care should be based on the goals specified in their individual
care plan and must be evaluated with the resident when the resident’s condition improves
or deteriorates and at a minimum 3 monthly. The effectiveness of the care being provided
should be evaluated by checking to see if the goals of care are being met and that this in
turn is having a positive impact on the resident and their significant other.
Please refer to the Protocols of Care Flow Chart and Sample Personalised Care
Plan in documenting care planning and in providing care.
227
228
• Overall Risk Context
• Past Medical History
• Co-morbidities
• Risk factors
• Mobility
• Skin Assessment
• Pain Assessment
• Resident’s main concerns
• Resident’s goals
• Resident’s preferences
• Risk Assessments
• Cognitive ability
• Communication abilities/deficits
• Incontinence Assessment
• Residents cultural , religious needs
Further Assessments & ongoing
• Assess for signs & symptoms of
imminent death
• MDT referrals & assessments
• End of Life Care Needs
• Functional /Physical
/Cognitive/Emotional Ability/ Status
• Equipment Needs
• Preferences /Likes/Dislikes & wishes
• Personal Care Requirements
• Quality of Life Concerns
• Dignity, Respect, Choice & Privacy
Requirements
Nursing Assessment-Document
On admission, if resident’s condition changes &
at a minimum every 3 months
Nursing Assessment
1. Identify Physical,
Psychological,
Social & Spiritual
Care Needs
2. Devise personalised
care plan
Need for End of Life
Care identified
Nursing Diagnosis
Implement an End of Life Care plan
Document:
The identified problem(s) / need(s)
The identified abilities of the resident
The identified resident’s goals of care
The Specific Interventions required in the
management/prevention of risks identified.
5. Symptom management: refer reader to
relevant care plans
6. Complete Care Plans for all identified
problems with goals based on the
resident’s wishes, choice, comfort &
preferences
7. The MDT referrals required & made
8. Advanced directive/plans
9. Monitoring interventions required
10. Communication interventions required
11. Provide education to residents/significant
others & carers in care of the dying and
breaking bad news as appropriate.
1.
2.
3.
4.
0
Nursing Care Goals & Planning
Reassess if condition
changes & update care
plan accordingly.
Goals unmet or Condition
Changes
Goals met
• Resident/carer aware of interventions & are involved
in care decisions.
• Resident/carers have Care
Plan on End of Life Care
• Outcomes are evaluated
based on the specified
goals
Measure outcome against
specified goals
Nursing Evaluation
Protocol of Care for End of life Care in the DML, HSE Older Persons Designated Centres
SAMPLE CARE PLAN
Topic Heading: End of Life Care
PROBLEM / NEED IDENTIFICATION
Date
Number: Page 1
Signature
01/01/10 Mary is frightened that she will die in pain
Jane Murphy
GOAL SPECIFICATION
Mary will die comfortably & peacefully free from pain
SPECIFIC INTERVENTIONS
Date
Signature
01/01/10 •
•
•
•
•
•
•
Mary’s main concern(s) for her end of life care is that she will die in
pain. Mary’s experiences a significant amount of back pain on movement.
Please refer to Manual Handling & Pain Care Plan. She is also concerned
about her catheter being accidentally dislodge while being moved. Please
refer to continence & Manual Handling care plan
Pain Assessment/Management. Mary’s current preferred
method of pain control is to take oral medication as she does not like
needles. Please refer to her Pain Care Plan
Specialised equipment. Mary has poor hearing in her left ear and
needs to have her hearing aid in place at all times. Please refer to her
Personal Care, care plan
Mary is at high risk of developing pressure ulcers: refer to Mary’s
Pressure Ulcer Prevention care plan
Information sessions are to be provided to Mary & her family by a staff
member. Ongoing educational updates are to be provided to Mary’s
Carers and significant others in accordance with Mary’s expressed wishes.
Any alteration in her care needs must be communicated to all carers and
significant others.
Resuscitation status: Mary is not for active resuscitation as per her
own wishes. Please refer to resuscitation orders in her medical notes and
ensure all care staff are aware of this decision and directive
Spiritual Care Needs Mary is a practising Roman Catholic and would
like prayers said for her in the event that she cannot say them herself. She
has indicated specifically which prayers she would like said. Please see
Jane Murphy
attached list. Mary has been anointed (Nov 3rd 2009)
EVALUATION OF CARE (based on goals specified)
Date
02/01/10
Time
Signature
Mary and her family report that they are happy that Mary’s level of pain Jane Murphy
is controlled and constantly reviewed. They do not wish to have any
changes made in her care plan at this time.
Discontinued Date: …..... / ……… / 20…… Signature: …………………………………………..
229
Bibliography:
HIQA (2009) National Quality Standards for Residential Care Settings for Older Persons,
Health Information and Quality Authority
HSE NMPDU (2009) End of Life Care Guideline
Department of Health (2008) End of Life Care Strategy
Department of Health October (2004) The NHS Knowledge and Skills Framework (NHS
KSF) and the Development Review Process
The Marie Curie Palliative Care Institute Liverpool (MCPCIL) The Liverpool Care of the
Dying Pathway
National Institutes of Health State-of-the-Science Conference: Statement on Improving
End-of-Life Care. 6-8 December 2004. 4 November 2006.
The NICE clinical guidance on supportive and palliative care (CSG)
NICE Guidance on Cancer Services Improving Supportive and Palliative Care for Adults
with Cancer Executive Summary
Common core competences and principles for health and social care workers
working with adults at the end of life
http://consensus.nih.gov/2004/2004EndOfLifeCareSOS024html.htm
http://www.skillsforcare.org.uk/publications/publications_c.aspx
www.who.int/cancer/palliative/en
Marie Curie Cancer Care Spiritual and Religious Care Competences for Specialist Palliative
Care
National End of Life Care Programme/University of Nottingham “Advance Care Planning:
A guide for Health and Social Care Staff”
Institute for Health Research Lancaster University (2008) Advanced care planning in care
homes for older people; A survey of current practice International observatory on end of life
Care
230
231
As required subcutaneous medication written up as per protocol (e.g. pain, agitation, nausea and vomiting, emergency orders,
Goal 2
Summary
GP and other key people in the primary care team are aware of patient's condition
Goal 11 Family/others express understanding of plan of care
Goal 10 Plan of care explained and discussed with patient/family
Goal 9
Family given relevant RACF, funeral and bereavement information
Goal 8
Communication with primary health care team
Identify how family/other are to be informed of patients impending death
Communication with family/other
Religious/spiritual needs assessed with patient/family
Goal 7
Goal 6
Insight into condition assessed
Goal 5
Religious/Spiritual Support
Ability to communicate in English assessed as adequate
Psychological Insight
when necessary, routine turning regimens/vital signs discontinued)
Discontinue inappropriate interventions (routine blood tests, antibiotics, subcutaneous fluids, not for resuscitation documented
Goal 4
Goal 3
Current medications (via appropriate route) assessed, nonessentials discontinued
Goal 1
respiratory tract secretions
Comfort measures
Goals
Appendix 1: The Liverpool Care of the Dying Pathway
Appendix 1
Integrated Minimum Dataset and Resident Record
Chart Layout
232
Chart Layout
Doc 1 DML Cover Page and Index 1 - Care Plan Instructions
Doc 2 Signature Bank
Doc 3 Index 2 - Guidelines for Completing Personal Details and Assessments
Doc 4 Consent for Photography
Doc 5 Section A: Personal Details
Doc 6 Section B: Missing Persons Profile
Doc 7 Section C: Initial Admission Assessment & Discharge Potential
Doc 8 Section D: Communication, Mood & Behaviour
Doc 9 Section E: Breathing and Circulation
Doc 10 Section F: Nutrition and Hydration
Doc 11 Section G: Continence and Elimination
Doc 12 Section H: Mobility and Safety
Doc 13 Section I: Personal Care, Controlling Body Temperature, Self Image
Doc 14 Section J: Skin Condition, Pressure Ulcer Prevention and Wounds
Doc 15 Section K: A Key to Me
Doc 16 Section L: Personal Calendar of Important Dates
Doc 17 Section M: Meaningful Activities Assessment
Doc 17.1 Meaningful Activities Care Planning- Planned Activity Level
Doc 17.2 Meaningful Activities Care Planning- Exploratory Activity Level
Doc 17.3 Meaningful Activities Care Planning- Sensory Activity Level
Doc 17.4 Meaningful Activities Care Planning- Reflex Activity Level
Doc 18 Section N: Sleep and Rest
Doc 19 Section O: Palliative Care
Doc 20 Section P: End of Life
Doc 21 Index 3 - Nursing Assessment Tools
Doc 22 Vital Signs, Weights, BMI, Urinalysis Chart
Doc 23 Index 4 - Guidelines on completing the: MDT Referral Record, Care Plans, Daily
Flow Charts and Narrative Notes
Doc 24 Multidisciplinary Referral Record
Doc 25 Out Patients Appointments
Doc 26 My Day, My Way
Doc 27 Care Plan Template
Doc 28 Daily Flow Chart of Care
Doc 29 Daily Flow record of Care
Doc 30 Narrative Notes
Doc 31 3 Monthly Reviews
Doc 32 Readmission (Respite) Form
233
Appendix 2
Resident Assessment Instruments
234
DML Integrated Minimum Data
Set & Resident Care Record 2010
Affix Residents’ Photograph
This Care Record belongs to:....................................................................
Medical Records Number (MRN): ......................................................
Ward/Unit:...............................................................................................
Room:......................................................................................................
Bed Number: ...........................................................................................
Allergies (Food [bananas, nuts, avocado, kiwi], Latex [balloons, rubber
gloves, plasters, etc], Medications, Dressings: ....................................
................................................................................................................
(If a latex allergy is suspected / present complete a latex screening assessment)
Private
and
Confidential
Access allowed for the Resident, their Significant Other
(as permitted by resident) and the Healthcare Team only.
HSE Print (01) 626 3447
Ordering Code DML 01
Index 1
Specific Instructions for Using this Care Record
1.
Writing must be legible.
2.
Write in black ink.
3.
Nurses must sign entries using their name as entered on the Register of Nurses and
Midwives maintained by An bord Altranais (ABA, 2002).
4.
Signatures must be legible. Sign your name in the Signature Bank Form. The signature
bank should be updated on a 6-monthly basis.
5.
Resident’s name and medical records number must be on all nursing documentation, and
should be transcribed correctly. Ensure you have the correct chart / record before you
begin writing.
6.
Chart promptly as soon as possible after you make an observation or provide care, when
details are fresh in your memory.
7.
Entries must be in chronological order.
8.
Use appropriate spelling and grammar. Write clear, concise, factual, non-judgmental
sentences.
9.
Date and time all entries. Broad times, e.g. 8am – 8pm or ‘nocte’ are not acceptable. Use
the 24-hour clock as it precisely identifies the time of day.
10. Full titles/names to be given to residents and personnel on all documentation e.g. instead
of writing Dr. informed, document the doctor’s name.
11. Avoid the use of abbreviations. If necessary, use hospital-authorised abbreviations as
identified in the individual facility’s Abbreviation Policy.
12. Entries made in error should be bracketed and have a single line drawn through them so
the original entry is still legible. Errors should be signed and dated (ABA, 2002).
13. No attempt should be made to alter the entry in error. Erasure fluid should never be
used.
14. If you need to make an addition to the nursing record, date and time the entry and write
‘late entry’ beside it. Do not leave any blank spaces or spare lines in nursing records.
15. Avoid using terms or phrases that can be open to misinterpretation or that are unclear
such as: some, a lot, enough, every so often, now and then, etc.
16. Avoid phrases as in ‘resident is comfortable’- instead describe his/her comfort.
17. Accepted grading systems should only be used. Urinalysis results (+++) are an example of
official grading system. (ABA, 2002). Pitting oedema can be described with the 1+, 2+,
3+, 4+ following the guideline at the end of the Breathing & Circulation Assessment.
Symbols like ++, , < > are not acceptable in nursing documentation. Use terms such as
mild/moderate/severe, increased/decreased as appropriate.
18. Read your notes to ensure they are accurate. Read your colleague’s entries.
19. Strict adherence to the principle of confidentiality must be maintained in relation to all
nursing records.
20. Any delegated recording in any document of the care record must be countersigned by a
registered nurse.
HSE Print (01) 626 3447
Ordering Code DML 01
Addressograph Label
or complete the following
Ward/Unit: .......................................................
Name: ......................................................
D.O.B.: .....................................................
MRN: ........................................................
Date Commenced: …… /…… / 20……
Page no.: .............
Signature Bank
Date
HSE Print (01) 626 3447
Print Name
Initials
Signature
Witnessed by
Ordering Code DML 02
Addressograph Label
or complete the following
Ward/Unit: .......................................................
Name: ......................................................
D.O.B.: .....................................................
MRN: ........................................................
Date Commenced: …… /…… / 20……
Page no.: .............
Signature Bank
Date
HSE Print (01) 626 3447
Print Name
Initials
Signature
Witnessed by
Ordering Code DML 02
Index 2
Guidelines on Completing
PERSONAL DETAILS and ASSESSMENTS
The Assessment Sections are broadly based on the Activities of Living
Model:
A. Personal Details – to be completed on or within 2 hours of admission.
B. Missing Person Profile – to be completed on or within 2 hours of admission.
C. Initial Admission Assessment and Discharge Potential – to be completed on or
within 2 hours of admission.
Important:
attach a copy of the resident’s medication prescription
D. Communication, Mood and Behaviour.
E. Breathing and Circulation.
F.
Nutrition and Hydration.
G. Continence and Elimination.
H. Mobility and Safety.
I.
Personal Care / Controlling Body Temperature / Self-Image.
J.
Skin Condition / Pressure Ulcer Prevention and Wounds.
K. A Key to Me (Personal History Profile) – complete 5 days following admission.
L. Personal Calendar of Important Dates.
M. Meaningful Activities – complete 5 days following admission.
N. Sleep and Rest / Spiritual Needs.
O. Palliative Care.
P.
End of Life.
Guidelines on Completing the Documentation. (This documentation is completed using resident’s self-report assessment)
1.
Ensure the resident’s privacy is maintained when sharing personal information.
2.
Explain the nursing assessment process to the resident and their significant other. Clarify
that assessments may take up to 2 hours to complete. Make arrangements with the
resident and their significant others if the assessment process is to be staggered.
3.
Complete Personal Details and Initial Admission Assessment on or within two hours of
admission.
HSE Print (01) 626 3447
Ordering Code DML 03
4.
A photocopy of the resident’s medication prescription must be maintained with
the Initial Admission Assessment. The Initial Admission Assessment will help prioritize
assessments that need to be completed immediately and those which can be deferred to
within the 7-day period.
5.
Three photographs of the resident should be taken with resident’s consent on admission.
These are to be attached to the Prescription Sheet, Resident’s Care Record and the
Missing Person’s Profile. If a resident refuses to have their photograph taken, this needs
to be documented in the narrative notes.
6.
An explanation should be provided to the resident and their significant other on the
necessity of undertaking specific detailed nursing examinations. For example, when
undertaking an examination of the resident’s skin, pressure areas and feet; shoes, socks
and clothes must be removed and the skin inspected. It is not sufficient merely to ask the
resident. It is therefore vital that an explanation is provided and the resident’s dignity is
maintained during examination.
7.
Ensure that each part of every form is completed; do not leave any blank spaces.
8.
Ensure appropriate tick box is recorded.
9.
Be specific when recording information. For example, in the Nutrition and Hydration
Assessment under Food Likes, be specific when recording likes / dislikes e.g. ‘likes all
food but particularly likes sausage, beans and chips, etc’. Do not write statements that
provide little information such as ‘likes all food’ or ‘no preferences’.
10. Be cognisant of the potential of the resident tiring during the assessment process. It may
be more appropriate to complete the assessments within several short sessions.
11. The Meaningful Activities Assessment should not be completed before day 5 so that an
overall assessment of the resident’s cognitive and functional ability and need may be
obtained.
12. Activities of Living Assessments should be evaluated at least three-monthly using the
Three-Monthly Review form or sooner if there is a change in the resident’s condition.
Acknowledgements
The DML Documentation Sub Group would like to acknowledge & thank the following for permission to use and
/ or adapt their care planning documentation: St. Mary’s Hospital (Phoenix Park), The HSE Midlands, The HSE
South, NMPDU, Jackie Poole and Birr Community Nursing Unit.
HSE Print (01) 626 3447
Ordering Code DML 03
Addressograph Label
or complete the following
Ward/Unit: ...................................................
Name:...................................................
Nurse’s Signature: .........................................
D.O.B.:..................................................
Date Commenced: …… /…… / 20……
MRN:.....................................................
Page no.: .............
Consent for Photography
I hereby confirm that I give consent for photographs to be taken for the purposes of
identification in my:
•
Prescription Sheet
•
Care Record
•
Missing Person’s Profile
•
Wound Assessment/Management:
Yes Yes Not applicable Yes Yes No No No No Consent given by/on behalf of the Resident (signed): ……….............…………..................…
I understand that photographs of my wound have educational value. I consent to my wound
photographs being used for educational purposes and to be shown to appropriate
professional staff. I understand that efforts will be made to conceal my identity during
educational session, but full confidentiality is not guaranteed.
Yes No Not applicable Consent given by/on behalf of the Resident (signed): …………………..............................…
I confirm that the purpose for which the photographs will be used has been explained to me
in terms, which I have understood. Refusal to consent will in no way affect my right to
medical or nursing care
Consent given by/on behalf of the Resident (signed): ………............……….....…..…………
Print Name: ………………………………………………………..........….................…………
Date: ………………………………………………………………...........…........……......……...
HSE Print (01) 626 3447
Ordering Code DML 04
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
Nurse’s Signature: ..............................................
D.O.B.:.......................................................
Date: ……… /……… / 20………
MRN: .........................................................
Page no.: .............
Section A: PERSONAL DETAILS
1.
21. Next point of contact:
Legal Name:
……………......…………….........................….....
Name: …………….......……………….....…………
2.
Likes to be known as: …......………………....…..
Address: …….......………………….....…….………
3.
Address: …………………......……...…..…....……
………….......……………………………….......…..
……………......…………….........................….....
Telephone No: ….......……………...………………
4.
Telephone No: ………......…………...….....…..…
Relationship: …...…………….......…...……………
5.
Religion: ……………......…..………..…….....……
Contact at night:
6.
Date of Birth: …… /…… /20….....
7.
8.
Age: ………………......………..…………..........… 23. Does the resident wish to manage their own
finances:
Yes
No
Marital Status: ……………......……..……….....…
9.
Occupation: ……….......…......…..…………….....
22. Ward of Court:
10. 1st Language: ………...……..…......……......……
Yes1
11. Does the resident want/need an interpreter
No
12. Date of admission: …… /…… /20…......
(day/month/year)
13. Time of admission: (24 hr. clock) ......….….….....
14. Admitted from: …………………......…......…...…
15. Type of admission: …………….........…......……..
16. Admitted under the care of:…….......…….....…..
……………......…………….........................….....
17. Significant other aware of admission:
Yes
No
18. Accompanied by: ……......…………......…………
19. Who is to be contacted first?
Address: ……………......…….………….....………
……………......…………….........................….....
Telephone No: ..………......………………........…
Relationship: .……………......…………….....……
Yes
Yes
No
No
If No - record the name of the resident’s
appointed financial representative: ….......………
24. G.P: ………………………………….......….....……
Telephone No: .…………….........………...………
Address: .…….......………………………..………..
25. Public Health Nurse: ….......……………….………
26. Health Centre: ………….......……………...………
Telephone No: ….....…….......……...……….…….
27. Medical Card No: …….......………………….…….
28. P.P.S. No: ………….......………………………....…
29. Health Insurance: …….......………….………….…
30. How much information do you want to be
told regarding your care?
all
none
would like to have a significant other present
unable to express wishes 1
when being told
Name: ………………......…………….....…………
Contact at night:
Yes
No
20. Next point of contact:
31. How much information is given to
Significant other(s)?
all
none
must be consulted each time information is
unable to express wishes 1
given
Name: ……………………......………………....…. 32. Name(s) of person/people permitted to
Address: ...………………......………….…….…....
receive information: ……...............…………..
……………......…………….........................….....
………………………….......……………….......…..
Telephone No: …......……..……………........…… 33. What is the extent of family involvement?
(specify):…..………….......…........…………………
Relationship: ……......…………………………...…
Contact at night:
HSE Print (01) 626 3447
Yes
No
………….......……………………………….......…..
Ordering Code DML 05
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
Nurse’s Signature: ..............................................
D.O.B.:.......................................................
Date: ……… /……… / 20………
MRN: .........................................................
Page no.: .............
34. Admitting Doctor informed of admission:
Yes
No Date & Time: …......……………..
54. Resident’s Property List completed:
Yes No
35. Doctor’s Name: …………..........…………..…… 55. Valuables Sent to:
Administration office:
36. Health History: ...............................................
Yes No
Yes No
……………....…………….........................….......... 56. Home
(with whom): ………....……….......…….....………
……………....…………….........................…..........
……………....…………….........................…..........
Signature: ………...………….......…………………
……………....…………….........................….......... 57. Resident informed:
……………....…………….........................….......... 58. Relatives informed:
Yes No
Yes
No
……………....…………….........................….......... 59. MRSA: Positive19 Negative ……………....…………….........................…..........
……………....…………….........................…..........
Unknown19
Date confirmed: ……… /……… /20………
N/A Yes No
37. Respite form:
N/A Yes No
38. Nursing letter:
N/A Yes No
39. Doctor’s letter:
N/A Yes No
40. Prescription:
41. Reviewed by Psychiatry
of Later Life?
N/A Yes No
42. Home Situation/Support Network:
Lives Alone
With Spouse/ Partner
With other (specify) ……….......……….………
43. Type of accommodation: ………......…………….
Yes No
44. Meals on Wheels:
Yes No
45. P.H.N. visits:
60. C. Diff.: Positive Negative Unknown
No4
Date confirmed: ……… /……… /20………
61. Flu Vaccine:
Yes
No4
Date received: ……… /……… /20………
62. Pneumococcal Vaccine: Yes
Date received: ……… /……… /20………
63. Communicable Diseases: ……..........…………
64. Care Plan required for Communicable Diseases:
Yes
No
concerns for admission14:
65. Resident’s understanding of reason/
………….......…………………………......…........
46. Day Care:
Yes No
………….......…………………………......…........
Yes No
………….......…………………………......….......
48. Physiotherapy:
47. Occupational therapy: Yes No
Assistive Devices:
49. Hearing Aid:
Yes1 No
Left Right
Yes No
50. Spectacle(s):
number of pairs ......................
51. Dentures:
upper
lower
52. Walking Frame:
Yes No
partial
Yes10 No
………….......…………………………......…........
66. Significant other’s understanding/
concerns over admission: ……......…………..
………….......…………………………......…........
………….......…………………………......…........
………….......…………………………......…........
67. Information obtained from: .……….......…...……
68. Date: ……… /……… /20………
69. Time :(24 hr. clock) …………………
70. Referred to Social Worker: Yes
53. Other: .................................................................. 71. Referred to Interpreter:
HSE Print (01) 626 3447
Yes
No
No
Ordering Code DML 05
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
Nurse’s Signature: ..............................................
D.O.B.:.......................................................
Date: ……… /……… / 20………
MRN: .........................................................
Page no.: .............
Section B: MISSING PERSON PROFILE
(to be reviewed in 3 months and re-written in 6 months)
Name: …………………………….......…..................................
Date of Admission: ……… /……… /20……..
Known as: ……………………………...........…… D.O.B...……….. Age on Admission: .…………………………..
Previous Home Address: ………………………..........……………………........................................................…
………......…………………...............………………………………………………………………………………………
Is this resident likely to attempt to leave the unit without staff knowledge?
Yes No
If Yes, where is the resident most likely to attempt to go: ...............................................................................
………......…………………...............………………………………………………………………………………………
What disability does this resident have that would increase their vulnerability, whilst absent from this unit
e.g. hearing, sight, cognitive impairment? ......................................................................................................
Has this resident got a history of leaving the unit without staff knowledge?
Is a care plan required for an unanticipated absence of this resident?
Description
Male
Female
Yes No
Yes No
Photograph
Height: …………….................……… Weight: …………………… kg
Build: ....................…………………………………………………………
Hair Colour and Style: ……………..................………….....……………
Eye Colour: ..................…………………………………..............………
Outstanding features: ......…..................……………………………......
…………….................……..………………………………………………
Yes No (specify) ……………...........……………………………………........
Glasses:
Yes No (specify) ……………...........……………………………………........
Hearing Aid:
Yes No (specify) ……………...........……………………………………........
Mobility Aid:
Communication problems:
Yes No (specify) ……………...........……………………………………........
In the event that the resident is missing; complete the following:
LAST KNOWN DETAILS
Reported absent at: ……………………………………………...........………………...… (use the twenty-four hour clock)
Last seen at: ……………………………………………………………………...............… (use the twenty-four hour clock)
Clothing description: ………………………………………………....................................…………………...........
……………………………………………………………………………………...........……………………………...…
Location where he/she was last seen: …………………………………………..............................……….............
He/she is alert
He/she is confused
HSE Print (01) 626 3447
Yes
Yes
No
No
He/she is agitated
He/she may be aggressive
Yes
Yes
No
No
Ordering Code DML 06
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
Nurse’s Signature: ..............................................
D.O.B.:.......................................................
Date: ……… /……… / 20………
MRN: .........................................................
Page no.: .............
Section C: INITIAL ADMISSION ASSESSMENT
Must be completed on or within two hours of admission
1.
BMI5,10: ….……......…
Admitting Observations: BP: ..….... / …......
O2 Sat: ……….…
Wt: …….….. kg
Temperature: …........
Pulse: …........
Respiration: …........
Blood Sugar: ….......……...........................
Urinalysis: ……………………….……........................................................................................................................
2.
3.
4.
5.
Resident introduced to the staff on duty: Yes No
Resident/Significant other given the CNM’s name and contact details: Yes No
Information Handbook given: Yes No
The resident/significant other given a brief introduction/tour of the environment: Yes No
If ‘No’ is ticked for any item(s) above, the reason must be documented in the Admission Notes
Resident’s Assessments:
If ‘no’ is ticked, there must be a full assessment carried out following the completion of this form
6.
7.
8.
9.
1, 14
No 5, 14
No 6, 14
No 5, 12
No 5, 12, 13, 14, 17
No 10, 12, 15, 14
No 11, 15, 14,
No 11, 15, 14
No 2, 14, 17
Can verbally communicate without any difficulties ................................................. Yes No
Able to eat without any difficulties ......................................................................... Yes
Able to drink without any difficulties ...................................................................... Yes
Weight has been stable for the past 6 months ........................................................ Yes
10. Skin has been inspected and is intact and healthy ................................................... Yes
11. Able to mobilise independently .............................................................................. Yes
12. Able to maintain hygiene independently ................................................................ Yes
13. Able to dress independently ................................................................................... Yes
14. Able to sleep without any problems ....................................................................... Yes
If ‘yes’ is ticked, there must be a full assessment carried out following the completion of this form
10 No
Has dietary restrictions ....................................................................................... Yes 5, 14 No
Has difficulty with urinary management ............................................................. Yes 7, 10, 12, 14, 17 No
Has difficulty with bowel management ............................................................... Yes 8, 9, 10, 12, 14, 17 No
Has problem with breathing ............................................................................... Yes 4, 5, 14, 17 No
Has behaviours that challenge ............................................................................ Yes 2, 15, 14, 17 No
Has pain ............................................................................................................. Yes 16, 14, 17 No
15. Has fallen in the past year ................................................................................... Yes
16.
17.
18.
19.
20.
21.
22. Any additional issues that require immediate attention: ………………………............…………...............…..
…………………………………………………………………….............……………………………………………………..........…
HSE Print (01) 626 3447
Ordering Code DML 07
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
Nurse’s Signature: ..............................................
D.O.B.:.......................................................
Date: ……… /……… / 20………
MRN: .........................................................
Page no.: .............
23. Affix a copy of current medication prescription/list current medications:
24. Is the resident prescribed psychotropic drugs: Yes
10,17,18
No
(Examples of psychotropic drugs include antipsychotics, antidepressants, antianxiety/hypnotics, mood
stabilisers such as Haloperidol [Serenace], Olanzapine [Zeprexia], Citalopram [Cipramil], Diazepam
[Valium]; Alprazolam [Xanax], Carbamazepine [Tegretol], Lithium Carbonate [Camcolit or Priadel])
25. List 24. List non-prescribed medicinal products that the resident is currently taking:
…………………………………………………………………...........……………………………………………………
…………………………………………………………………...........……………………………………………………
…………………………………………………………………...........……………………………………………………
…………………………………………………………………...........……………………………………………………
26. Doctor informed of non-prescribed medicinal products:
27. Discharge potential:
Within 1 month:
Within 1-3 months:
Yes
No
Yes
No
Yes
No
No
Discharge Status uncertain-not planned:
HSE Print (01) 626 3447
Yes
Yes
No
Ordering Code DML 07
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
Nurse’s Signature: ..............................................
D.O.B.:.......................................................
Date: ……… /……… / 20………
MRN: .........................................................
Page no.: .............
1.
Section D: COMMUNICATION 1, MOOD AND BEHAVIOUR 2, 3
15. Time of the day behaviour is exhibited2:
Speech: Clear Incoherent1, 18
Morning
Afternoon
Evening Other1, 2
Previously seen by a:
N/A
Speech & Language Therapist
Yes No
If yes, please attach written instructions to care plan
2.
Yes1, 2 , 3, 14, 15, 16, 17, 18
16. History of behaviours that challenge:
17. Physical: Yes No
Describe (i.e. slurred, indistinct): …..........……….... 18. Verbal:
…………….............……………………………….....
3.
1, 2, 3, 5, 6, 7, 8, 10, 14, 15, 16, 18:
Comprehension: Any difficulty understanding what
is being said
No specific time
Night
(specify) …...................……..............………...……
No
Yes No
If yes, describe: ……..........……….........……………
…..………....................……………...………………
19. What triggers behaviour: .…..….......………………
…..………....................……………...………………
…………….............………………………………..... 20. What interventions decrease behaviour:
4.
needs/wants1, 2, 3, 5, 6, 7, 8, 10, 14,
…..………....................……………...………………
Expression: Any difficulty expressing their
15, 16, 18:
(specify) ..……........…...........…........………………
Uses communication aids: Yes1 No If yes,
specify …................................................………….
…..………....................……………...………………
…………….............……………………………….....
6.
Hearing: Normal
Impaired1, 2, 15 left
Uses hearing aid: Yes1
8.
Vision: Normal Impaired1, 10, 15 Blind
left
Spectacles: Distance
Varifocals
No
right
both
Reading
None
10. Disease of the eye: Yes No
If yes, specify: (Glaucoma, Cataracts, etc.)
…………….............……………………………….....
Confused10, 18, 2, 3
11. Cognitive / Emotional State:
Alert
Orientated
Semi Comatosed18 Deep Coma
Anxious14
Tearful14,16
Low mood 14,16, 2
Content
No 1, 2, 3, 15, 16, 17, 18
12. MMSE: Score: …… /30 Date: ….../…../20…..
13. Restless: Yes
14. Agitated: Yes
HSE Print (01) 626 3447
…..………....................……………...………………
If yes to any above, refer to Doctor/OT for a FULL
Mental State Examination 22. Pain: Yes 2,
right
7.
9.
Yes
If yes, specify: ….…….…......................……………
…………….............……………………………….....
5.
phobias/depression: Yes2, 3, 18
21. History of delusions/hallucinations/fears or
No1, 2, 3, 15, 16, 17, 18
No
Unsure2, 16 Difficult to assess2, 16
3, 14, 15, 16, 17
Unable to verbalise1, 16
If yes to any above, complete a pain assessment chart 23. Resident’s / Significant Other’s concerns14
…..………....................……………...………………
…..………....................……………...………………
24. Information obtained from: …...............………….
…..………....................……………...………………
25. Referral required for:
CNS:
Audiology:
Optician:
SLT:
Doctor:
Yes
No
Yes
No
Yes
Yes
Yes
No
No
No
26. Care Plan required for:
Communication:
Yes
Behaviour that challenges: Yes
No
No
Ordering Code DML 08
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
Nurse’s Signature: ..............................................
D.O.B.:.......................................................
Date: ……… /……… / 20………
MRN: .........................................................
Page no.: .............
Section E: BREATHING & CIRCULATION4
1.
Character of Breathing:
7.
Yes4
Rhythm: .…………….........……………..……………
Yes4
Pursed Lipped
Abdominal Breathing
No
No
Quit……………… years ago
Speaking Yes No
Cough: Yes4
Mobilizing Yes No 8.
Yes No
Sleep Yes No
…..…………………............……………...........……
No
Frequency ...…….........……………………...………
When? …….........….....………………………………
Other: …..….............................…………………
Productive cough: Yes No
…..……….........……………………………………….
Sputum: Amount: ….....….… Colour: ….......……
Colour:
Specimen sent: Yes No
Skin: …............................………………………….…
Date: …. /…. /20.…
Nail Bed: …........................………………………….
Ineffective Cough: Yes No
Mucous Membrane: …...................………………… 9.
Lower Extremities: Colour: .….........……………
Yes4, 14, 16, 17
Difficulty associated with breathing:
Exertion
Expiration
Yes
Yes
Yes
Yes
No
No
Left - warm cool4, 12 cold4, 12
Temperature to touch:
Right - warm
cool4, 12 cold4, 12
Oedema: Yes4, 12 No, if yes:
No
No
left
No
1+ 2+ 3+ 4+
right 1+ 2+ 3+ 4+
Tracheostomy: Yes4 No
Lying down
6.
Expresses wish to stop smoking Yes No
Changes in breathing pattern when4, 5:
Inspiration
5.
………/day
Support required Yes No Details:
Drinking Yes No
4.
Yes4
…..……….........……………………………………….
Eating
3.
Smokes: Never
No. of years smoking ……...…….……………
Other: ..…...............………………………………
2.
Smoking History:
10. Resident’s / Significant Other’s concerns
14:
Date: .…/.… /20.…
…..…………………............……………...........……
If yes, requires Separate Care Plan
…..…………………............……………...........……
Equipment: Nebuliser
(see prescription sheet)
Continuous O2
Pacemaker
Humidified O2 >4 litres
Yes
Yes
Yes
Yes
No
No
No
No
11. Information obtained from: .……........……………
…..…………………............……………...........……
12. Referral required for:
Doctor:
Physiotherapy:
Yes No
Breathing and Circulation
Yes No
Other, specify: .…………............………………… 13. Care Plan required for:
………...……………….........…………………………
2mm or less = 1+ Oedema
Slight pitting
No visible distortion
Disappears rapidly
HSE Print (01) 626 3447
2-4mm= 2+ Oedema
Slightly deeper pit
No readable detectable distortion
Disappears in 10-15 seconds
Yes No
4-6mm = 3+ Oedema
Pit is noticeably deep
May last more than 1 minute
Extremity looks fuller & swollen
6-8mm = 4+ Oedema
Pit very deep
Last as long as 2-5 minutes
Extremity is grossly distorted
Ordering Code DML 09
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
Nurse’s Signature: ..............................................
D.O.B.:.......................................................
Date: ……… /……… / 20………
MRN: .........................................................
Page no.: .............
Section F: NUTRITION 5 & HYDRATION 6
1.
2.
Recent Unexplained Weight Loss:
Yes2, 3, 5 , 12 No
Previously seen by a:
Speech & Language Therapist Yes No
Dietician
Yes No
If yes, please attach written instructions to care plan
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Diet:
Normal Yes No Diabetic Yes No
High Protein Yes No Renal Yes No
Enteral feeding: Yes20 No
If yes, see Care Plan
Modified: Yes5, 6, 14 No specify:
…........................................................……………
Other: Yes No specify: …........…....……
…........................................................……………
Fibre (must have >1500mls fluid each day)
Yes No
Thickened Fluids:
Yes No
(If yes6, 14) syrup custard set
Food fortification required: Yes No
Oral nutritional
supplements required:
Yes No
Normal fluid intake: (approx.) ……….........… mls
Preference of Serving Size (Food Portion Size)
Small Medium Large Extra-Large
Preferred Beverage: (specify) ……............….…
…........................................................……………
…........................................................……………
Food Allergies: (specify) ……........……....………
…........................................................……………
Food Likes: …………………...…........……………
…........................................................……………
…........................................................……………
Food Dislikes: …………..………........……………
…........................................................……………
Level of Assistance:
Independent Verbal Cues Set Up
Minimal Assistance14 Total Assistance5, 6, 14
Details: ………........……....…………………………
…........................................................……………
Willing to share a table with other
residents at mealtimes: Yes No
Where does the person like to eat?
…........................................................……………
Requires position for safe swallowing:
Yes No (e.g. Upright, chin tilt, etc)
…........................................................……………
HSE Print (01) 626 3447
21. Any signs/symptoms of dehydration: (e.g.
dry mucous membranes; sunken eyes; low/absent
or concentrated urinary output; increase in
urinary tract infections; constipation; confusion;
lethargy; muscle cramps; hypotension &
tachycardia).
Yes2, 3, 5, 6, 7, 9, 12, 14, 18
No
Specify: ....….…………….…………........…………
…..............……………………………………….......
22. Any difficulty in swallowing:
Yes4,5, 6, 14 No
If yes, tick the box:
Coughing/choking
Throat clearing
Residue in mouth
Recurrent chest
Holding food in mouth
infection
Hoarse/gurgly voice after swallowing
Alterations in breathing pattern
Other: (specify) ........……….…….........…………
23. Influencing Factors:
None
Constipation2, 9
Nausea/Vomiting2, 3, 5, 6,18
Flatulence
Depression2
Diarrhoea 3, 5, 6 Heartburn
Pain/Discomfort2 Anxiety2
Absent Gag Reflex
Other: (specify) ……..………………………
24. Resident’s/Significant Other’s concerns14
…..............……………………………………….......
…..............……………………………………….......
…..............……………………………………….......
25. Information obtained from: ...…........…......………
…..............……………………………………….......
26. Assessments completed:
Oral Cavity
Yes No
Assistance required with Oral Care:
Yes11 No
Nutritional Risk
Yes No
27. Referral required for:
Dentist
Yes No
Dietician
Yes No
Speech & Language
Yes No
Doctor
Yes No
28. Care Plan required for:
Oral Care Plan
Yes No
Nutrition/Hydration
Yes No
PEG Care
Yes No
Ordering Code DML 10
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
Nurse’s Signature: ..............................................
D.O.B.:.......................................................
Date: ……… /……… / 20………
MRN: .........................................................
Page no.: .............
Section G: CONTINENCE & ELIMINATION 7, 8
1.
Influencing Factors: (i.e. mobility, bowel surgery,
to urinary infections, prostatic symptoms) 8, 9
Continent:
Specify: ……....……........…………………....…………
…...……….................…………………………….....
Crohn’s Disease, carcinoma obstetric history or prone
2.
Continent Day Time: Yes No6, 7,
10, 12, 14
Occasional Incontinence: Yes No
If incontinent, continence promotion programme
Yes No
initiated
Incontinence Wear required:
Yes No
Conveen
Usual pattern: ..……........................……………….
Constipated2, 3, 7, 8, 9, 14, 18 Loose Stool8
11. Individual Reported Symptoms:
Micturition:
Continent Night Time: Yes No6, 7, 10, 12, 14
3.
Yes No8, 10, 12, 14
10. Faecal Elimination:
Incontinence pad
Discomfort
Flatulence
Uses Laxatives (type) .……...........………………
Changes in bowel pattern
No symptoms
12. Stoma: Yes 14 No
Type: colostomy ileostomy ileo-conduit
Appliance type: .………......….......…………………
Size: .…......…...………………………………………
Size: …......………… 13. Level of Assistance required for Stoma Care:
Night wear: ….……….…
Size: …......…………
Independent Minimal Assistance 14
Individual Reported Symptoms:
Total assistance14
Day wear: .……….......…
4.
Frequency Yes No
Burning Yes No
Discomfort Yes No Urgency Yes No
Stress
Retention
5.
Yes No Nocturia Yes No
Yes No18 Other Yes No
7.
Continence Assessment required:
Yes No
Level of Assistance required for Toilet Use:
Independent
Minimal Assistance Total Assistance
8.
Equipment/Aids Used:
Bedpan Yes No
Toilet
If yes, document details in the Narrative Notes
Contact details: ..……………………….......……..…
Commode at bedside
Catheter: Yes No
Independent
Minimal Assistance
Total Assistance
16. Resident’s/Significant Others concerns14:
…...……….................…………………………….....
…...……….................…………………………….....
17. Information obtained from: …..….......……….....…
…...……….................…………………………………
Urinal Yes No
Yes No Grab rails Yes No
Raised toilet seat
9.
Yes No
admission:
(specify) ...…..…….......……………………………… 15. Level of assistance required for hand
washing
How is desire to use toilet communicated:
………………...........................................................
6.
14. Instructions from Stoma Nurse prior to
Yes No
Yes No
…...……….................…………………………….....
18. Referral required for:
Continence Specialist:
Doctor:
Stoma Nurse:
Dietician:
Specify type of catheter: ...………........…....……… 19. Care Plan required for:
Reason for insertion: ……...........……………...……
Continence & Elimination:
Product type: ......….....….. Size: ….....………
Stoma:
Date last changed: ……… /……… /20………
Catheter:
HSE Print (01) 626 3447
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Ordering Code DML 11
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
Nurse’s Signature: ..............................................
D.O.B.:.......................................................
Date: ……… /……… / 20………
MRN: .........................................................
Page no.: .............
Section H: MOBILITY & SAFETY 10
1.
Mobility Status:
6.
Independent
Falls risk: Yes10, 18 No
Score…………………
Requires supervision/prompts to mobilise
independently 10, 14, 15
Minimal Assistance (1 person)7, 8, 9,
Total Assistance7, 8,
7.
Other (specify) …………………………………..
2.
8.
Safety System Required:
Bed Rails: Yes No
Safety Belt: Yes No
……………………………………………….............
Hoist:
Yes No
Devices Used:
Monitoring System: Yes No
Crutches: Yes No Tripod: Yes No
………......………………………………….…………
Cane: Yes No Zimmer frame: Yes No
Other (specify):.………...…………………………
If using bed rails or safety belt, complete a Risk
Other (specify)…………..………………………..
Assessment and document the rationale for use in the
……………………………………………….............
Narrative Notes with a review date • Visual Status: Yes1, 10
Do the following factors affect mobility:
No
No
• Medication: Yes10, 17, 18 No
• Pain:
• Dizziness:
Yes16
No
Yes10, 17,18 No
• Amputation:
Yes No
• Fracture: Yes No Arthritis: Yes No
• Hemi paresis: Yes No
9.
Risk of mobility / safety discussed with:
Resident:
Family/ Significant other:
Left Right
• Fatigues: Yes18 No Time of day: …....…
10. Resident’s / Significant Other’s concerns14:
………......………………………………….…………
11. Information obtained from: .………………..……...
………......………………………………….…………
12. Referral required for:
• Appropriate footwear: Yes No10
Safety Status:
OT:
Impaired10, 15
Good
Yes2, 3, 16 No
Influencing factors affecting safety:
Psychological:
Nervous:
Anxious:
Smoker:
Yes14
Yes14
Yes
Yes No
Document details in the Narrative Notes Doctor:
Safety awareness:
Yes No
………......………………………………….…………
• Contracture(s): Yes No
5.
Yes No
Call Bell: Yes No Hip Protectors: Yes No
• Aural Status: Yes1
4.
Moving and Handling Risk Assessment
……………………………………………….............
Grabber: Yes No Wheelchair: Yes No
3.
Date: ……/… /20………
completed:
10, 12 , 14, 15
9, 10, 12, 14, 15
Falls Risk Assessment completed: Yes No
No
Physiotherapy:
13. Care Plan required for:
Mobility & Safety
Restraint
Yes No
Yes No
Yes No
Yes No
Yes No
No
No
Other (specify): .…….……………………………
HSE Print (01) 626 3447
Ordering Code DML 12
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
Nurse’s Signature: ..............................................
D.O.B.:.......................................................
Date: ……… /……… / 20………
MRN: .........................................................
Page no.: .............
Section I: PERSONAL CARE/CONTROLLING BODY TEMPERATURE/SELF-IMAGE 11
Personal Cleansing & Dressing
13. Hair Care: Assistance required: Yes11 No
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Level of Assistance required:
Independent
Minimal Assistance11, 14
Total Assistance 11, 14
Associated factors:
Cognitive impairment:
Yes11, 14 No
Hemiparesis: Yes 11, 14 No left right
Amputation:
Yes11, 14 No
Specify ..………………………………………………
Involuntary movement:
Yes11, 14 No
Other (specify) …….….………………..…………
Preferences for intimate care: None Female
Male
Preferences for: Bath Shower Bed bath
History of sensitivity to hygiene products
No
(e.g. creams, soaps etc.)
Yes13
Specify ……....……………………………………..…
Personal clothes clearly labelled:
Yes No
Carer informed of laundry arrangements: Yes No
Carer will take laundry home for washing: Yes No
Controlling Body Temperature
Assistance required in choosing clothing appropriate
to current temperature:
Yes11 No
Able to communicate feeling hot or cold:
Yes No 1
Likes blanket on knees while in chair: Yes No
Socks (non-slip soles) preferred in bed: Yes No
Eye Care
Eye Care needed:
Yes
No
Assistance required:
Yes11 No
Specify ……....……………………………………..…
………………........…………………………………
………………........…………………………………
Ear Care
Assistance required:
Yes11 No
Yes
No
Hearing Aid1: Left
Right
Yes
No
Usual cleaning schedule for de-waxing hearing aid:
Specify ……....……………………………………..…
………………........…………………………………
………………........…………………………………
Nail Care: Assistance required: Yes11 No
………………........…………………………………
………………........…………………………………
HSE Print (01) 626 3447
Hairstyle preferred: (comment) ………….…………
Would like to attend a hairdresser: Yes No
Beard: Yes No
Moustache: Yes No
Hair removal/shaving preference:
Wet shave:
Yes No
Electric Razor:
Yes No
Hair removal cream
Yes No
14. Foot Care: Assistance required: Yes11 No
Associated Factors: (e.g. Diabetic, PVD, Neuropathy)
Specify: ….….…………………………………………
Right
Left
Dry skin13:
Yes No Yes No
Cracks & fissures:
Yes No Yes No
Calluses/Corns:
Yes No Yes No
Toe nails ingrown/long: Yes No Yes No
Hammer/Overlapping
toes:
Yes No Yes No
Wounds12, 13:
Yes No Yes No
If wound is present, complete a wound care chart 15.
16.
17.
18.
Uses preventative/protective foot wear: Yes No
Specify: ….….…………………………………………
………………........…………………………………
Self Image
Altered body image (e.g. amputation) Yes14 No
Specify: ….….…………………………………………
………………........…………………………………
Preferred clothes or colours (specify) .…….………
………………........…………………………………
Resident’s/Significant other’s concerns 14
(e.g. Privacy, dignity)…………………………………
………………........…………………………………
Information obtained from: …......…………………
………………........…………………………………
Referral required for:
Audiologist
Yes No
Doctor Yes No
Orthotics
Yes No
O.T. Yes No
Vascular Consult Yes
No Chiropody Yes
19. Care Plan required for:
Personal Care:
Yes
Eye/Ear Care:
Yes
Foot Care:
Yes
No
No
No
No
Ordering Code DML 13
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
Nurse’s Signature: ..............................................
D.O.B.:.......................................................
Date: ……… /……… / 20………
MRN: .........................................................
Page no.: .............
Section J: SKIN CONDITION/ WOUNDS13 & PRESSURE ULCER PREVENTION12
1.
Intact
Yes No5, 13 Moist Yes No
Healthy Yes No13
Dry
Yes No13
Bruising Yes No
Rashes
Skin Condition:
Scars
Yes No
6.
N.B. Remove all dressings on admission. A wound
assessment/ management chart and a pain
Yes No
assessment chart must be completed on admission.
Wound present: Yes5, 13, 14, 16, 17 No
All residents with wounds require a dietetic referral.
Yes No
If yes, is this area blanchable? Yes No12
Area of redness
On antibiotics for wound infection: Yes No
Other skin conditions noted 13 (specify)
Date commenced: ..……….………………..………
Type (specify): ..………………………………………
12, 13, 14, 16, 17
……….……...............………………………………
Skin not intact
No. of courses of antibiotics in last 6 months ……
Wound Location/s:.…………....……………………
Pressure Ulcer Risk Assessment5, 12:
(complete a wound assessment/ management chart)
2.
Tool used (specify) ……….....……………...……….
Score: …...……
3.
………………………...………………………………
Duration of wound: .…..……………………………
7.
Risk Level: ……...………………
Yes No
Category of Pressure Ulcer: .……….....……………
If yes, please specify equipment needed for:
(Use EPUAP/NPUAP (2009) Classification to Categorise
Bed: ………......…………..………………….………
Chair: …….....…………...………………..…………
Heels: …......……………………………………….…
8.
Repositioning Assessment:
Level of assistance required:
Independent
Independent but requires prompts 12
Minimal Assistance (1 Person)12
Total Assistance12
Frequency of repositioning required: (specify)
………………………...………………………………
9.
Information obtained from: .….............................
………………………...………………………………
10. Referral required for:
Yes No
Dietician
Yes No
Podiatrist
Yes No
Doctor
Yes No
Physiotherapist
Yes No
Bed: ……......……………………….………..………
Tissue Viability Nurse
Incontinent: Yes7, 12, 13 No
Occupational Therapist
Vascular Consult
If yes; state cleansing and barrier creams/products
(Leg/Foot ulcers- unknown cause)
Chair: ……......………………….……………………
5.
(malodour, pain16, etc): .…………….....…..……
………………………...………………………………
pressure): …….....……………………………...……
4.
Resident’s / Significant Other’s concerns14
Pressure Ulcers)
Resident’s equipment (e.g. static, alternating
……….……...............………………………………
Yes5, 12, 13, 14, 16, 17 No
Pressure Ulcer Present:
History of Previous Pressure Ulcer: Yes12 No
Pressure Relieving/Redistributing Devices
required:
Wounds:
Yes No
Yes No
required (Sudocrem is not recommended. CREST, 1998): 11. Care Plan required for:
Pressure Ulcer Prevention/Management Yes No
……….……...............………………………………
……….……...............………………………………
HSE Print (01) 626 3447
Wound
Yes No
Ordering Code DML 14
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
Nurse’s Signature: ..............................................
D.O.B.:.......................................................
Date: ……… /……… / 20………
MRN: .........................................................
Page no.: .............
Section K: A Key to Me 14
(Adapted from the Pool Activity Level (PAL) Personal History Profile© Poole [2008])
Childhood
1
Where were you born?
2
What are your family members’ names?
3
Where did you grow up?
4
Which schools did you attend?
5
What was your favourite subject?
6
Did you have any family pets?
What were their names?
Adolescence & Adulthood
7
When did you leave school?
8
Any special teenage memories?
9
Did you have any special training?
(e.g. college, apprenticeship)
10 What did you work at?
11 What special memories do you
have of workdays?
12 Do/did you have a partner?
Partner’s name/occupation?
13 Where and when did you meet?
14 Where and when did you marry?
15 What did you wear?
What flowers did you have?
16 Where did you go on honeymoon?
17 Where did you live?
18 Any children- what are their names?
HSE Print (01) 626 3447
Ordering Code DML 15
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
Nurse’s Signature: ..............................................
D.O.B.:.......................................................
Date: ……… /……… / 20………
MRN: .........................................................
Page no.: .............
Adulthood
19 Any grandchildren- what are their names?
20 Did you have any special friends?
What are their names?
21 When and where did you meet?
22 Are they still in touch?
23 Did you have any pets?
What were their names?
Retirement
24 When did you retire?
25 What are your hobbies and interests?
26 What are the biggest changes for you?
Likes and Dislikes 15
27 What do you enjoy doing now?
28 What do you like to read?
29 Do you like to celebrate your birthday?
30 What is your favourite time of year?
31 What is your favourite colour?
32 What kind of music do you like?
33 Is there anything that you definitely
do not like to do?
34 Do you have any special routines
to your day?
35 Do you want people to help you
with anything?
36 Do you want people to leave you to
do anything on your own?
37 What are you good at?
38 Is there anything else you would like
to tell us about you?
HSE Print (01) 626 3447
Ordering Code DML 15
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
Nurse’s Signature: ..............................................
D.O.B.:.......................................................
Date: ……… /……… / 20………
MRN: .........................................................
Page no.: .............
Section L: PERSONAL CALENDAR OF IMPORTANT DATES
Which dates are important to you e.g. birthdays, Christmas, dates that make you feel happy and
sad 14 or dates that you like to celebrate
January
July
February
August
March
September
April
October
May
November
June
December
HSE Print (01) 626 3447
Ordering Code DML 16
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
Nurse’s Signature: ..............................................
D.O.B.:.......................................................
Date: ……… /……… / 20………
MRN: .........................................................
Page no.: .............
Section M: MEANINGFUL ACTIVITIES ASSESSMENT 15
Pool Activity Level (PAL) Checklist ©
The term meaningful activity includes Activities of Living & leisure activities that promote quality
of life, self-esteem, pleasure, comfort, education, creativity & independence. Each registered nurse
assessing a resident is accountable for designing, co-ordinating & implementing an individualised
Meaningful Activity Programme to meet the resident’s psychological and social needs.
Completing the checklist: For each activity, the statements refer to a different level of ability. Tick the
statement that represents the resident’s ability in each activity. Assessment centres on 4 levels of ability &
suitable meaningful activities: P= Planned, E= Exploratory, S= Sensory & R= Reflex. There should be only
one tick for each activity. If in doubt about which statement to tick, choose the level of ability that represents
the average performance over 5 days. Make sure you tick only on one statement for all of the activities.
1.
2.
Risk Assessment for Meaningful Activities
4.
Mobility Status Independent
Supervised
Minimal assistance Total assistance
Falls Risk:
Yes
No
Safety Awareness: Poor Intermittent Good
Risk of Wandering: Yes No
Mental Test Score: ..……………………..………………..
Alarm System: Yes No specify: .…….……………
On-site Activities:
Yes No
1:1 assistance needed:
Requires assistance as part of a group: Yes No
Off-site Activities: 1:1 assistance needed: Yes No 5.
Requires assistance as part of a group: Yes No
Bathing/Washing
• Can bathe/wash independently, sometimes
with a little help to start
• Needs soap put on flannel & one-step at
a time directions to wash
• Mainly relies on others but will wipe own
face & hands if encouraged
• Totally dependent & needs full assistance
to wash or bathe
P
E
S
R
6.
3.
Getting Dressed
• Plans what to wear, selects own clothing
from cupboards; dresses in correct order
• Needs help to plan what to wear but
recognises items & how to wear them; needs
help with order of dressing
• Needs help to plan and with order of dressing,
but can carry out small tasks if someone
directs each step
• Totally dependent on someone to plan,
sequence & complete dressing; may move
limbs to assist
HSE Print (01) 626 3447
P
E
S
R
Eating
• Eats independently & appropriately
using correct cutlery
• Eats using a spoon &/or needs food
to be cut up into small pieces
P
E
• Only uses fingers to eat food
S
• Relies on others to be fed
R
Contact with Others
• Initiates social contact & responds to
needs of others
• Aware of others & will seek interaction,
but may be more concerned with own
needs
• Aware of others but waits for others
to make the first contact
• May not show an awareness of the
presence of others, unless in direct
physical contact
Group Work Skills
• Engages with others in a group activity,
can take turns with the activity/tools
• Occasionally engages with others in a
group, moving in and out of the group
at whim
• Aware of others in the group and will
work alongside others although tends
to focus on own activity
• Does not show awareness of others in
the group unless close 1:1 attention is
experienced
P
E
S
R
P
E
S
R
Ordering Code DML 17
7.
8.
Communication Skills
• Is aware of appropriate interaction, can chat
coherently and is able to use complex
language skills
• Body language may be inappropriate and
may not always be coherent, but can use
simple language skills1
• Responses to verbal interaction may be
mainly through body language:
comprehension is limited 1
• Can only respond to direct physical contact
from others through touch, eye contact or
facial expression1
P
9.
E
S
R
Practical Activities (craft, domestic chore,
gardening)
• Can plan to carry out an activity, hold the
goal in mind and work through a familiar
sequence; may need help solving problems
• More interested in the making or doing than
in the end result, needs prompting to
remember purpose, can get distracted
• Activities need to be broken down &
presented one step at a time, multi-sensory
stimulation can help to hold attention
• Unable to “do” activities, but responds to
the close contact of others & experiencing
physical sensations
10.
P
E
S
R
Use of Objects
• Plans to use and looks for objects that
are not visible: may struggle if objects
are not in usual/familiar places
(toiletries in a cupboard below washbasin)
• Selects objects appropriately only if in
view (i.e. toiletries on a shelf next to
washbasin)
• Randomly uses objects as chances
upon them, may use inappropriately
• May grip objects when placed in the
hand, but will not attempt to use them
P
Looking at a Newspaper/Magazine
• Comprehends and shows interest in
the content, turns the pages and looks
at headlines and pictures
• Turns the pages randomly, only
attending to items pointed out by others
• Will hold and may feel the paper, but
will not turn the pages unless directed
and will not show interest in the content
• May grip the paper if it is placed in the
hand but may not be able to release
grip or may not take hold of the paper
P
E
S
R
E
S
R
Total amount of ticks in each box below:
Planned
TOTAL:
Exploratory11
Sensory11
Reflex11
Now, select the appropriate ‘Meaningful Activities Programme - Residents Activity level Profile’ to act
as a general guide to engaging with the resident in a variety of meaningful activities.
Then, complete an individualised ‘Meaningful Activities Programme’ to act as a specific guide to
facilitating personal activities.
HSE Print (01) 626 3447
Ordering Code DML 17
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
Nurse’s Signature: ..............................................
D.O.B.:.......................................................
Date: ……… /……… / 20………
MRN: .........................................................
Page no.: .............
Meaningful Activities Programme-Residents Activity Level Profile
Pool Activity Level (PAL) Profile ©
Planned Activity Level
Likely Abilities
Can explore different ways of carrying out an activity.
Likely Limitations
May not be able to solve problems that arise.
Can work towards completing a task with a tangible
result.
May not be able to understand complex sentences.
Can look in obvious places for any equipment.
May not search beyond the usual places for
equipment.
Method of engagement
Activity objectives
To enable…………………………………………… to take control of the
activity and to master the steps involved.
Position of tools
Ensure that equipment and materials are in their usual, familiar places.
Verbal directions
Explain task using short sentences by avoiding using connecting phrases
such as “and”, “but”, “therefore”, or “if”.
Demonstrated directions
Show ………………………………………… how to avoid possible errors.
Working with others
…………………………………… is able to make the first contact & should
be encouraged to initiate social contact.
Activity characteristics
There is a goal or end product, with a set process, or “recipe”, to achieve it.
An element of competition with others is motivating.
Suitable Activities (based on knowledge of the person’s life history ‘A Key To Me’)
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
HSE Print (01) 626 3447
Ordering Code DML 17.1
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
Nurse’s Signature: ..............................................
D.O.B.:.......................................................
Date: ……… /……… / 20………
MRN: .........................................................
Page no.: .............
Planned Activity Level
Activity:
DRESSING
• Encourage ......................................................... to plan what to wear and to select own clothes from the
wardrobe
• Encourage ......................................................... to put on their own clothes, be available to assist if required
• Point out labels on clothing to help orientate the back from the front
• Encourage ......................................................... to attend to grooming such as brushing hair, putting on
make-up, cleaning shoes
Activity:
BATHING
• Encourage ......................................................... to plan when they will have the bath, to draw the water and
select toiletries from the usual cupboard or shelf. Ensure a slip resistant bath mat is in the bath and on the
floor
• Encourage ......................................................... to wash their own body, be available to assist if required
• Encourage ......................................................... to release the water afterwards, and to wipe the bath
Activity:
DINING
• Encourage ......................................................... to select when and what they wish to eat
• Encourage ......................................................... to prepare the dining table and to select the cutlery,
crockery and condiments from the usual cupboards or drawers
• Encourage ......................................................... to clear away afterwards
Note: Consideration of National Infection Control Guidelines and HSE Health & Safety
Guidelines is required in undertaking the above.
HSE Print (01) 626 3447
Ordering Code DML 17.1
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
Nurse’s Signature: ..............................................
D.O.B.:.......................................................
Date: ……… /……… / 20………
MRN: .........................................................
Page no.: .............
Meaningful Activities Programme-Residents Activity Level Profile
Pool Activity Level (PAL) Profile ©
Exploratory Activity Level
Likely Abilities
Can carry out very familiar tasks in familiar
surroundings.
Likely Limitations
May not have an end result in mind when starts a
task.
Enjoys the experience of doing a task more than the
end result.
May not recognise when the task is completed.
Can carry out more complex tasks if they are broken
down into 2-3 step stages.
Relies on cues such as diaries, newspapers, lists and
labels.
Method of engagement
Activity objectives
To enable…………………………………………… to experience the
sensation of doing the activity rather than focusing on the end result.
Position of tools
Ensure that equipment and materials are in the line of vision.
Verbal directions
Explain task using short simple sentences. Avoid using connecting phrases
such as “and”, “but”, or “therefore”.
Demonstrated directions
Break the activity into 2-3 steps at a time.
Working with others
Others must approach …………………………………… and make the first
contact.
Activity characteristics
There is no pressure to perform to a set of rules, or to achieve an end result.
There is an element of creativity and spontaneity.
Suitable Activities (based on knowledge of the person’s life history ‘A Key To Me’)
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
HSE Print (01) 626 3447
Ordering Code DML 17.2
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
Nurse’s Signature: ..............................................
D.O.B.:.......................................................
Date: ……… /……… / 20………
MRN: .........................................................
Page no.: .............
Exploratory Activity Level
Activity:
DRESSING
• Encourage discussion about the clothing to be worn for the day: is it suitable for the weather or the occasion,
is it a favourite item.
• Spend time colour matching items of clothing and select accessories.
• Break down the task into manageable chunks: help lay the clothes out in order so that underclothing is at
the top of the pile. If the person wishes to be helped, talk ......................................................... through the
task: “put on your underclothes” “now put on your dress and cardigan”.
• Encourage ......................................................... to check (his/her) appearance in the mirror.
Activity:
BATHING
• Ensure a slip resistant bath mat is in the bath and on the floor.
• Break down the task into manageable chunks: suggest that ......................................................... fills the
bath, then when that is accomplished suggest that he or she gathers together items such as soap substitute
(e.g. Silcock base®), shampoo, flannel, and towels.
• When ......................................................... is in the bath, suggest that (he/she) washes and rinses (his/her)
upper body, and when that is accomplished, then suggest that (he/she) washes and rinses (his/her) lower
body.
• Ensure that bathing items are on view and that containers are clearly labelled.
• Have attractive objects around the bath such as unusual bath oil bottles or shells and encourage discussion
and exploration of them.
Activity:
DINING
• Store cutlery and crockery in view and encourage ......................................................... to select own tools
for dining.
• Offer food using simple choices.
• Create a social atmosphere using table decorations, music, and promote conversation.
Note: Consideration of National Infection Control Guidelines and HSE Health & Safety
Guidelines is required in undertaking the above.
HSE Print (01) 626 3447
Ordering Code DML 17.2
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
Nurse’s Signature: ..............................................
D.O.B.:.......................................................
Date: ……… /……… / 20………
MRN: .........................................................
Page no.: .............
Meaningful Activities Programme-Residents Activity Level Profile
Pool Activity Level (PAL) Profile ©
Sensory Activity Level
Likely Abilities
Is likely to be responding to bodily sensations.
Can be guided to carry out single step tasks.
Can carry out more complex tasks if they are broken
down into one step at a time.
Likely Limitations
May not have any conscious plan to carry out a
movement to achieve a particular end result.
May be relying on others to make social contact.
Relies on cues such as diaries, newspapers, lists and
labels.
Method of engagement
Activity objectives
To enable…………………………………………… to experience the effect
of the activity on the senses.
Position of tools
Ensure that ……………………………… becomes aware of equipment and
materials by making bodily contact.
Verbal directions
Limit requests to carry out actions to the naming of actions and objects
e.g. “lift your arm”, “hold the brush”.
Demonstrated directions
Show ………………………………………… the action on the object. Break
the activity down into 1 step at a time.
Working with others
Others must approach…………………………………… and make the
first contact. Use touch and …………………’s name to sustain social
contact.
Activity characteristics
The activity is used as an opportunity for a sensory experience. This may
be multi-sensory and repetitive.
Suitable Activities (based on knowledge of the person’s life history ‘A Key To Me’)
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
HSE Print (01) 626 3447
Ordering Code DML 17.3
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
Nurse’s Signature: ..............................................
D.O.B.:.......................................................
Date: ……… /……… / 20………
MRN: .........................................................
Page no.: .............
Sensory Activity Level
Activity:
DRESSING
• Offer a simple choice of clothing to be worn.
• Spend a few moments enjoying the sensations of the clothing: feeling the fabric, rubbing the person’s finger
up and down a zip fastener, or smelling the clean laundry.
• Break down the task into one step at a time: “put on your vest” “now put on your pants” “now put on your
stockings” “now put on your dress”.
Activity:
BATHING
• Prepare the bathroom and run the bath water for .........................................................
• Make the bathroom warm and inviting - play music, use scented oils, have candles lit on a safely out of
reach shelf. Ensure a slip resistant bath mat is in the bath and on the floor.
• Break down the task into one step at a time and give ......................................................... simple directions:
“rub the soap substitute (e.g. Silcocks Base®) on the cloth, rub your arm, rinse your arm, rub your chest,
rinse your chest......”.
Activity:
DINING
• Serve food so that it presents a variety of colours, tastes and textures.
• Offer ......................................................... finger foods, encourage (him/her) to feel the food.
• Offer ......................................................... a spoon, place it in (his/her hand) and direct (him/her) to “scoop
the potato” “lift your arm” open your mouth”.
Note: Consideration of National Infection Control Guidelines and HSE Health & Safety
Guidelines is required in undertaking the above.
HSE Print (01) 626 3447
Ordering Code DML 17.3
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
Nurse’s Signature: ..............................................
D.O.B.:.......................................................
Date: ……… /……… / 20………
MRN: .........................................................
Page no.: .............
Meaningful Activities Programme-Residents Activity Level Profile
Pool Activity Level (PAL) Profile ©
Reflex Activity Level
Likely Abilities
Can make reflex responses to direct sensory
stimulation.
Can increase awareness of self, and others, by
engagement of senses.
May respond to social engagement through the use
of body language.
Likely Limitations
May be in a subliminal or subconscious state.
May have difficulty organising the multiple sensations
that are being experienced.
May become agitated in an environment that is over
stimulating.
Method of engagement
Activity objectives
To arouse…………………………………………… to a conscious awareness
of self.
Position of tools
Stimulate area of the body being targeted e.g. stroke
…………….........................…………’s arm before placing it in a sleeve
Verbal directions
Limit spoken directions to movement directions i.e. “Lift”, “Hold”, “Open”.
Demonstrated directions
Show ………………………………………… the action on the object. Break
the activity down into 1 step at a time.
Working with others
Maintain eye contact, make maximum use of facial expressions, gestures
and body posture for non-verbal conversation. Use social actions which
can be imitated e.g. smiling, waving, shaking hands.
Activity characteristics
The activity is in response to direct selective sensory stimulation.
Suitable Activities (based on knowledge of the person’s life history ‘A Key To Me’)
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
HSE Print (01) 626 3447
Ordering Code DML 17.4
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
Nurse’s Signature: ..............................................
D.O.B.:.......................................................
Date: ……… /……… / 20………
MRN: .........................................................
Page no.: .............
Reflex Activity Level
Activity:
DRESSING
• Prepare the clothing for ........................................................., ensure the dressing area is private and that
a chair or bed at the right height is available for sitting.
• Talk through each stage of the activity as you put the clothing onto .........................................................
Use a calm tone, speak slowly and smile to indicate that you are non threatening.
• Stimulate a response in the limb being dressed by using firm but gentle stroking. Ask
......................................................... to assist you when necessary by using one word requests: “lift” “stand”
“sit”.
• At the end of dressing, spend some time brushing ......................................................... hair using firm
massaging brush strokes.
Activity:
BATHING
• Prepare the bathroom and run the bath water for ........................................................., put in scented bath
products (lavender will aid relaxation).
• Ensure that the bathroom is warm and inviting, and feels secure by closing the door and curtains and
providing a slip resistant bath mat in the bath and on the floor. Clear away any unnecessary items which
may be confusing.
• Use firm, massaging movements when washing and rinsing ......................................................... Wrap
(him/her) securely in a towel when (he/she) is out of the bath.
Activity:
DINING
• Use touch on ......................................................... forearm to make contact, maintain eye contact, and
smile to indicate the pleasure of the activity.
• Place
a
spoon
in
.........................................................
hand.
Close
your
hand
over
......................................................... and raise the spoon with food on it to (his/her) mouth.
• As the food reaches ......................................................... mouth say “open” and open your own mouth to
demonstrate. Touch ......................................................... lips gently with the spoon.
Note: Consideration of National Infection Control Guidelines and HSE Health & Safety
Guidelines is required in undertaking the above.
HSE Print (01) 626 3447
Ordering Code DML 17.4
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
Nurse’s Signature: ..............................................
D.O.B.:.......................................................
Date: ……… /……… / 20………
MRN: .........................................................
Page no.: .............
Section N: SLEEP AND REST17
SLEEP and REST
1. Usual Sleep Environment
Type of bed: ……………….…….…..………………
Type of bedding: …………….………………………
Sleep attire preferred: ………………………….……
Shared bedroom
Sleeps alone
Shared bed
Light on
Light off
Door opened
Door closed
Quiet
Noise (type) .…..……
……………………………………………........………
2. Temperature preference:
Warm
Cool
Other ………...……………………………………
3. Preferred time to get up: ……………………………
4. Preferred bed time: ………………….………………
5. Pre-Sleep Routine: (describe) .…….…………………
……………………………………………........………
……………………………………………........………
6. Hours of sleep per night: ……………………………
7. Do you need assistance to get into bed?
Yes No
If yes, specify: ………......…………….………………
……………………………………………........………
……………………………………………........………
8. Resident’s Perception of Own Night-time
Sleep2, 3, 17: (tick as appropriate)
Good
Mood on waking
Difficulty going to sleep Refreshed on waking
Restless
Disturbed sleep
Early morning wakening Requires medication
Other (specify) .….………………………….……
……………………………………………........………
SPIRITUAL NEEDS
SPIRITUAL NEEDS
11. Religion: .…………………..…………………………
Yes No
12. Wish to partake in services:
13. Informed of services available:
Yes No
14. Do you need assistance to access services?
Yes No
If yes, specify: .………..………………………………
* If resident is unable to communicate wishes, ask
significant other*
15. Any specific spiritual beliefs, requirements, or
daily practices (dress, diet, place to meditate, daily
prayers, etc):
...............................................................................
...............................................................................
...............................................................................
16. Name of Spiritual Advisor:.…………………………
Contact details/ number: ....…............……………
...............................................................................
...............................................................................
...............................................................................
17. If Roman Catholic, has the resident received the
Sacrament of the Sick:
Yes No
18. Resident’s /Significant Other’s concerns14 .……
...............................................................................
Date received: ……… /……… /20………
...............................................................................
...............................................................................
...............................................................................
...............................................................................
19. Information obtained from:.…….....………………
Note: Early morning wakening, difficulty going to
...............................................................................
sleep, tired/low mood on waking - assess for
...............................................................................
Depression using a validated tool e.g. HADS
20. Referral required for:
Disturbed sleep pattern:
Doctor (Sleep and Rest)
Yes2, 3, 10, 14, 17, 18 No
Spiritual Advisor:
Associated factors:
21. Care Plan required for:
None
Anxiety Depression18
Sleep and Rest
Apprehension Boredom Pain16
Spiritual Needs
Confusion
Snoring Sleep Apnoea
Muscle cramps Lack of activity
Other (specify) ………………...…………………
10. Daytime Rest: (no longer than 2hours) Yes No
9.
Yes No
Yes No
Yes No
Yes No
Time: ..…………….....……………………….………
HSE Print (01) 626 3447
Ordering Code DML 18
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
Nurse’s Signature: ..............................................
D.O.B.:.......................................................
Date: ……… /……… / 20………
MRN: .........................................................
Page no.: .............
Section O: PALLIATIVE CARE 21
Palliative Care is the care of residents with active, progressive, far advanced disease, for whom the focus of
care is relief, prevention and management of symptoms while maintaining quality of life. It is considered active
Palliative Care management in accordance with the resident’s and their carers’ wishes. When death appears
imminent, an end of life assessment and care plan is completed. However residents’ wishes regarding their end
of life days should be completed as appropriate to the individual.
1.
2.
Decision to move to a palliative
the following there must be an Assessment and Plan of
By: .…..……….....……………………………..
Care to alleviate the symptom)
..……….....…..................................………
Reddened Pressure Areas/Wound
Date: ……… /……… /20………
Dry / sore mouth
This decision was discussed with:
Dehydration
Significant Other
MDT
Date: …../..… /20..…
Nausea / vomiting
Date: …../..… /20…..
Weight loss / Anorexia
Date: ..… /..…/20..…
Constipation
Drowsiness
Awareness of Prognosis:
Yes No
Resident :
Significant other :
4.
Fatigue
Insomnia
Yes No
MDT at Case Conference :
Yes No
For CPR :
For blood tests / procedures:
On-Site
Off-Site
Yes No
Yes No
10.
Antibiotic therapy :
I.V.
Yes No
Oral
Artificial Nutrition:
Artificial Hydration:
Yes No
Yes No
Level of Consciousness:
Alert
7.
8.
9.
Yes No
Orientated Confused
Semi-Comatose
11.
Deep Coma
12.
HSE Print (01) 626 3447
Yes12, 13 No
Yes5
No
Yes5
No
Yes6
Yes5
Yes6, 9
Yes
Yes4
Yes
Dyspnoea/Cough/Noisy breathing Yes4
Depression / low mood / anxiety Yes
The following issues were discussed
with the Resident /Significant Other &
5.
Frequent Palliative Care Symptoms21: (If yes to any of
approach to care was taken:
Resident
3.
6.
No
No
No
No
No
No
No
No
Pain:
Yes16
No
• Syringe pump:
Yes
No
Break through pain /comfort/palliative
medications prescribed:
Yes
No
Current medications reviewed by MDT: Yes
No
Psychosocial care:
• Resident’s concerns14:
Narrative Note pg……
• Significant Other’s Concerns: Narrative Note pg……
Resident’s wishes:
• Visit by Priest/Religious person
Yes
No
• Visit by Solicitor/Legal Advisor
Yes
No
• To be Alone
Yes
No
• Family involvement in decisions: Narrative Note pg….
• Place of Death:
Narrative Note pg ….
• Funeral Arrangements:
Narrative Note pg….
Referral required for:
Specialist palliative care service
Yes No
MDT
Yes
No
Counselling Services
Yes
No
Religious Advisor
Yes
No
Chaplaincy Team
Yes
No
Care Plan commenced: ……… /……… /20………
Ordering Code DML 19
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
Nurse’s Signature: ..............................................
D.O.B.:.......................................................
Date: ……… /……… / 20………
MRN: .........................................................
Page no.: .............
Section P: END OF LIFE ASSESSMENT 22
1.
Resident aware of his/her condition: Yes No
2.
Emotional status: Client expresses –
Fear
Anxiety
Anger
Depressed
Resident’s wish:
Alone
Friends
Others
With Family
Unable to express
Cafeteria/Kitchen/Refreshment facility
Bereavement Counselling
Resident’s preferred Religious, Spiritual and
Religious symbols and rituals e.g. altar, candle, Bible
Anointing / Sacrament of the Sick
11. Person to contact in the event of
the resident’s condition changes:
………………………………………………….
Visit by Priest / Religious Advisor
………………………………………………….
Frequent Palliative Care Symptoms: (If yes to any
………………………………………………….
of the following, there must be a plan of care to alleviate
………………………………………………….
the symptoms)
• Pain:
Yes16 No
• Syringe driver:
Yes
No
• Dry/Sore Mouth:
Yes5 No
• Reddened Pressure Areas/Wound: Yes12,13 No
• Dehydration:
• Nausea and Vomiting:
• Constipation:
• Weight Loss/Anorexia:
• Insomnia:
• Fatigue:
Yes6 No
Yes5 No
Yes9 No
Yes5 No
Yes
No
Yes4 No
Yes
No
• Dyspnoea/Cough/Noisy Breathing: Yes4 No
• Depression/Low Mood/Anxiety:
Resident’s wish regarding their place of death:
Wish to go to home Single Room
No preference
7.
Information obtained from: .………………...
Family room
Cultural practices:
6.
9.
No
10. Significant other aware of:
......…………......…………………………………………
5.
Yes
………………………………………………….
Specific wishes: .……………………………..……………
4.
Significant other aware of resident’s
condition:
Acceptance
Other: .……..…………………………………………
3.
8.
12. Resident’s concerns14:
………………………………………………….
………………………………………………….
………………………………………………….
………………………………………………….
………………………………………………….
………………………………………………….
………………………………………………….
………………………………………………….
………………………………………………….
13. Significant other’s concerns:
………………………………………………….
………………………………………………….
………………………………………………….
Resident’s wish regarding care after death:
………………………………………………….
Personal Dress: ………………...…………………………
………………………………………………….
…………….………………………………………………
………………………………………………….
Jewellery: …………………………………………………
…………….………………………………………………
Wish to go to home
Wish to remain in church over night
HSE Print (01) 626 3447
Ordering Code DML 20
Index 3
Nursing Assessment Tools
On admission the following assessments must be recorded for all residents:
• A pressure ulcer risk assessment with the score documented.
• A nutritional risk assessment using a validated screening tool with a BMI recorded.
• An oral cavity assessment
• A falls risk assessment
• A manual handling assessment
• Vital Signs, Weights, BMI, Blood Sugar & Urinalysis
Additional assessments which may need to be carried out include:
(This list is not intended to be exhaustive)
• Pain Assessment
• Dependency Scale
• Assessment for the use of restraint
• Wound Assessment and Management chart
• Behavioural and Mental State Checklist
• Dementia Care mapping
• Bed rails Assessment
• Continence Assessment
HSE Print (01) 626 3447
Ordering Code DML 21
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
D.O.B.:.......................................................
Page no.: .............
MRN: .........................................................
Vital Signs, Weights, BMI, Blood Sugar and Urinalysis
DATE/TIME TEMP PULSE
HSE Print (01) 626 3447
RESP.
B.P.
WEIGHT BMI
BLOOD URINALYSIS
SUGAR
NURSE
SIGNATURE
Ordering Code DML 22
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
D.O.B.:.......................................................
Page no.: .............
MRN: .........................................................
Vital Signs, Weights, BMI, Blood Sugar and Urinalysis
DATE/TIME TEMP PULSE
HSE Print (01) 626 3447
RESP.
B.P.
WEIGHT BMI
BLOOD URINALYSIS
SUGAR
NURSE
SIGNATURE
Ordering Code DML 22
Index 4
Guidelines on completing: the Multidisciplinary Referral Record, ‘My Day,
My Way’, ‘A key to Me’, a resident’s ‘Personal Calendar of Important
Dates’, Care Plans, Daily Flow Charts and Narrative Notes
Multidisciplinary Referral Record
• All referrals to the Multidisciplinary Team (MDT) must be recorded on the
Multidisciplinary Referral Record
• The Multidisciplinary Referral record should be updated each time an MDT referral is
made and a narrative note written. The accompanying narrative note should accurately
record the time, date, method/mode of referral and the reason for the referral
• All significant observations on a resident's condition that are made to members of the
MDT by nursing staff must be recorded in the nursing Narrative Notes
• Care plans should be updated to reflect the MDT decisions
‘My Day, My Way’, ‘A key to Me’ and a ‘Personal Calendar of Important Dates’
The importance of getting to know the resident as a unique person is the cornerstone to
providing personalised care. ‘My Day My Way’, ‘A key to Me’ and the resident’s ‘Personal
calendar of important dates’ were developed to help staff get to know the resident as an
individual. These ‘getting to know the resident’ exercises can be carried out before a resident is
admitted to the unit, when they are admitted as part of their admission procedure or now as
part of their ongoing assessment.
• My Day, My Way can be completed with the resident, by a family member, care staff
or named nurse
• It is important to note that the document ‘A Key to Me’ is not designed to be used in
an interview format but to be completed by all staff as they interact with the resident
through the activities of daily living, i.e. washing, dressing, chatting, etc. Staff may find
it useful to fill in the form as they learn the information through chatting with the
individual, their family and their visitors
• These living documents should be kept in the resident’s care plan which is accessible to
the resident and all staff
• They should be updated as part of the ongoing evaluation of the residents care and life
choices
• All new staff should familiarise themselves with these documents
Care Plans
Care plans must be discussed, agreed and drawn up with the involvement of the Resident or
their Significant Other and recorded under the following headings
• Problem identification - Any residents needs or problems identified are recorded in this
section
• Goal specification - The goals or aims of care are recorded. Goals must be realistic,
obtainable and measurable, for successful evaluation of care
HSE Print (01) 626 3447
Ordering Code DML 23
• Specific Interventions - The interventions recorded should provide sufficient
information to provide appropriate care
• Evaluations of Care are based on measurable outcome criteria as outlined in the
Goal specification. Evaluation must be documented on the flow chart as a NN
(Narrative Note) and a narrative note must be written. All care plans must be evaluated
at least three monthly using the Three Monthly Care Plan Review form or sooner if the
residents condition indicates, using the Evaluation Section on the Care Plan Template.
All Care plans are to be re-written six monthly irrespective of change to the resident’s
condition
Note: If the resident or their significant other is unable or unwilling to participate in care
planning, a narrative note must be recorded.
Daily Flow Records of Care
Daily flow records of care are recorded:
• During the morning (M), evening (E) and night (N). Times; M= 08.00-12.00, E=
12.01=20.00 N=20.01-07.59
• Accurately record the appropriate code as outlined on the Daily Flow Chart of Care
Narrative Notes
Narrative notes should be accurately recorded and updated:
• Following Daily Assessment if any changes occur
• When significant observations on a resident's condition are made
• When referrals are made to the multidisciplinary team. The reason for the referral
requested should be recorded
• MDT reviews/ case reviews or family meetings should be recorded
• When care changes due to new medical treatments/requirements e.g. when IV or
Subcutaneous fluids or enteral feeding are commenced
• When PRN medication is administered and the reason for/outcome of the PRN
medication administration
• When the resident’s condition improves or deteriorates
• When problems/needs identified, are resolved
• Following evaluation of the specific resident’s need/psycho-social wellbeing
• Following evaluation, updating or changes to care plans
• Refer to Index 1 for further instructions on recording the Narrative Notes
Note: Where HCA’s are filling in documentation as part of nurse/HCA delegation of tasks e.g.
recording Food/Fluid charts, Flow Charts of Care, etc, it is recommended that the HSE National
Guidelines on Delegation are followed and that nurses co-sign the documents.
HSE Print (01) 626 3447
Ordering Code DML 23
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
D.O.B.:.......................................................
Page no.: .............
MRN: .........................................................
MULTIDISCIPLINARY REFERRAL RECORD
REFERRAL
DATE
REFERRED
TO
HSE Print (01) 626 3447
REFERRED
BY
Page number of Narrative
Notes where the reason for
the referral must
be documented
REVIEW
DATE
REVIEWED
BY
Ordering Code DML 24
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
D.O.B.:.......................................................
Page no.: .............
MRN: .........................................................
MULTIDISCIPLINARY REFERRAL RECORD
REFERRAL
DATE
REFERRED
TO
HSE Print (01) 626 3447
REFERRED
BY
Page number of Narrative
Notes where the reason for
the referral must
be documented
REVIEW
DATE
REVIEWED
BY
Ordering Code DML 24
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
D.O.B.:.......................................................
Page no.: .............
MRN: .........................................................
Out Patients Appointments
DATE
APPOINTMENT TYPE
DATE OF
E.g. Wound, Vascular, Cardiac, Orthopaedic APPOINTMENT
HSE Print (01) 626 3447
CONSULTANT/
NURSE
LOCATION
SIGNATURE
Ordering Code DML 25
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
D.O.B.:.......................................................
Page no.: .............
MRN: .........................................................
Out Patients Appointments
DATE
APPOINTMENT TYPE
DATE OF
E.g. Wound, Vascular, Cardiac, Orthopaedic APPOINTMENT
HSE Print (01) 626 3447
CONSULTANT/
NURSE
LOCATION
SIGNATURE
Ordering Code DML 25
Addressograph Label
or complete the following
Ward/Unit: .........................................................
Name:........................................................
Nurse’s Signature: ...............................................
D.O.B.:.......................................................
Date: ……… /……… / 20………
MRN: .........................................................
Page no.: .............
My Day, My Way 14
I would like to share with you what is important to me when caring for me
What makes me happy?
What makes me unhappy?
HSE Print (01) 626 3447
Ordering Code DML 26
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
D.O.B.:.......................................................
Page no.: .............
MRN: .........................................................
CARE PLAN
(to be reviewed in 3 months and re-written in 6 months)
Topic Heading ……………………………………………………………
This Care Plan has been discussed, agreed and drawn up with the involvement of the Resident or their
Significant Other: Yes No Signed…………………………………… (Resident/Significant Other)
(If the resident/significant other is unable or unwilling to participate a narrative note must be recorded)
PROBLEM / NEED IDENTIFICATION
Date
Number: ....................
Signature
GOAL SPECIFICATION
SPECIFIC INTERVENTIONS
Date
HSE Print (01) 626 3447
Signature
Ordering Code DML 27
Addressograph Label
or complete the following
Ward/Unit: ........................................................
Name: .......................................................
D.O.B.:.......................................................
Page no.: .............
MRN: .........................................................
SPECIFIC INTERVENTIONS (Continued)
Date
Signature
EVALUATION OF CARE (based on goals specified)
Date
Signature
Discontinued Date: …..... / ……… / 20…… Signature: …………………………………………..
HSE Print (01) 626 3447
Ordering Code DML 27
HSE Print (01) 626 3447
Ordering Code DML 28
1.
2. Pain
Continence & Elimination
Snacks given
Fluids given
8.
9.
1.
2.
3.
0. Bowels not opened.
(If the resident is
independent, the nurse must
ask the resident)
6. Stoma care given
4.
5.
Bristol Stool Chart in
7. Bed rails in place
brackets & add sm., med., or
and checked as
lg
per care plan
Safety
6. Monitoring
systems in place
& checked as per
care plan
5. Mobilising as per
care plan
4. Total Assistance
required,
interventions
implemented as
per manual
handling care
plan
3. Minimal
Assistance
2. Mobilising with
Supervision /
prompts / aids
Mobility
1. Independent
Mobility & Safety
6.
Activities &
Location
7.
1. Self-caring
a) Shover
b) Bath
c) Wash
d) Shave
8.
1. Pressure Areas On-site
intact &
1. Meaningful
healthy
activities as
per care plan
2. Pressure ulcer
2. In bed
present, care
3. Bedside
2. Asisted care
implemented
4. Dayroom
a)Wash
as per care
5. Therapy
b)Shover
plan
6. Bingo
c)Bath
3. Pressure
7. Cooking
d)Bed Bath
ulcer/wound
8. Music therapy
e)Shave
present
9. Sing along
3. Refused personal
(wound chart 10. Out door
care-record in
recorded)
activities
narrative note
11. Exercise
4. Wound care
session
Care Attended:
carried out as
12. T.V.
4. Oral Hygiene:
per wound
13. Reading
a) Independent
chart
14. Butterfly
b) Assisted
5. Repositioned
Moments
see
(see chart)
5. Perineum care
repositioning
15. Others
chart
6. Eye Care
(record NN)
6. Heels offloaded Off-site
7. Ear Care
as specified in
8. Finger Nail Care
11. Trips/Tours
care plan
12. Special event
9. Toe nail Care
13. Out with
10. Foot Care
significant
other for part
11. Hair Care
of the day
12. Skin Care
Skin
Condition/
Pressure Ulcer
Prevention
& Wounds
If the colour of the urine is 5 or greater for more than two days, commence Fluid Monitor Chart
12. Refused
meal/feed
11. Refused fluids
10. Nil by mouth
Supper record
(%) taken
Food
fortification
provided
Urinary Elimination
1. Incontinent of urine. Insert
corresponding number in
brackets to urine colour &
Dietary
record daily to assess for
modification
dehydration & add sm.,
provided as per
med., or lg
dietician’s/SLT
2. Continence promotion
orders
attended to as per care plan
Enteral feeding
instructions
Recorded on
3. Continent of urine
Fluid
Insert corresponding number
Monitoring
in brackets to urine colour &
Chart
record daily to assess for
Breakfast record
dehydration
(%) taken
4. Catheter care given. Insert
Lunch/Dinner
corresponding number in
record (%)
brackets to urine colour &
taken
record daily to assess for
dehydration
Tea/Evening
Meal record
Bowel Elimination
(%) taken
5. Insert number from the
Nutrition &
Hydration
7.
6.
5.
4.
a) Alert
2.
b) Orientated
c) Confused
d) Semi-comatosed
e) Deep Coma
f) Anxious
g) Low Mood
3.
h) Tearful
i) Content
j) Restless/
Agitated
1. Cognitive/
Emotional State:
Narrative
Any complaints or
notes must
signs of pain?
be written if a) Yes
there is any b) No
cause for
concern for
If yes,
the resident complete a Pain
and/or a
Assessment
change in
Chart
their
condition
Insert
NI when
there is no
interaction.
Insert
NN when a
Narrative
Note is
written.
When
recording on
the Daily
Record of
Care:
Communication
Personal Care/
Controlling
Body
Temperature/
Self-Image
DAILY FLOW CHART OF CARE
7. Visited by
Spiritual
Advisor
6. Prayers
5. Attended
Mass/
Religious
Service
Spiritual Needs
4. Disturbed
Sleep pattern,
care given as
per care plan
3. Restless
2. Eyes open and
restful
1. Eyes closed &
restful
Sleep & Rest
Sleep & Rest/
Spiritual Needs
HSE Print (01) 626 3447
Ordering Code DML 29
M
E
N
M
E
N
M
E
N
M
E
N
M
E
N
Date
Communication
Nutrition &
Hydration
MRN: .........................................................
D.O.B.:.......................................................
Name:........................................................
Addressograph Label
or complete the following
Continence &
Elimination
Mobility &
Safety
Personal Care/
Controlling
Body
Temperature/
Self-Image
Skin
Condition/
Pressure
Ulcer
Prevention &
Wounds
DAILY FLOW RECORD OF CARE
Activities
Sleep
& Rest /
Spiritual
Needs
Page no.: .............
HCA’s
Signature
Nurse’s
Signature
Ward/Unit: ..................................................
HSE Print (01) 626 3447
Ordering Code DML 29
M
E
N
M
E
N
M
E
N
M
E
N
M
E
N
Date
Communication
Nutrition &
Hydration
MRN: .........................................................
D.O.B.:.......................................................
Name:........................................................
Addressograph Label
or complete the following
Continence &
Elimination
Mobility &
Safety
Personal Care/
Controlling
Body
Temperature/
Self-Image
Skin
Condition/
Pressure
Ulcer
Prevention &
Wounds
DAILY FLOW RECORD OF CARE
Activities
Sleep
& Rest /
Spiritual
Needs
Page no.: .............
HCA’s
Signature
Nurse’s
Signature
Ward/Unit: ..................................................
Addressograph Label
or complete the following
Name: .......................................................
Ward/Unit: ......................................................
D.O.B.:.......................................................
MRN: .........................................................
DATE &
Time
(24 Hour
clock)
Topic
Heading
HSE Print (01) 626 3447
Page no.: ................
Narrative Notes
Signature
&
Grade
Ordering Code DML 30
Addressograph Label
or complete the following
Name: .......................................................
Ward/Unit: ......................................................
D.O.B.:.......................................................
MRN: .........................................................
DATE &
Time
(24 Hour
clock)
Topic
Heading
HSE Print (01) 626 3447
Page no.: ................
Narrative Notes
Signature
&
Grade
Ordering Code DML 30
Three-Monthly Reassessment
Date: ……… /……… /20………
Resident’s Name: …………………....…....……… MRN: ……………....…………… Ward/Unit: …..….......……………………
Yes No
Resident/Significant other participated:
If No, document in Narrative Notes
Resident/Significant other signature: .……………....………………....……........…………....………………....………………....…
Using the Resident Assessment Instruments (RAIs) listed below, are any changes noted from the resident’s
last assessment? Record:
No
NN=Narrative Note written below
CP= Care Plan initiated
Please ✓(tick) in appropriate box
No NN CP
No NN CP
No NN CP
Communication, Mood /
Behaviour
Skin Condition,
Pressure Ulcer Prevention /
Wounds
Meaningful Activities
Breathing / Circulation
Nutrition / Hydration
Mobility / Safety
Personal Care
A Key To Me
Psychosocial Well-Being
Sleep / Rest
Palliative Care
Continence / Elimination
Reassessments completed: Nutritional
Continence
Observations: Temp:
°C, BP:
/
Blood Sugar
Oral
Pain
Pressure Ulcer Risk
mmHg, Pulse:
/min,
Resp:
Falls
Manual Handling
/min, Weight:
Kgs
, Urinalysis:
Referrals sent: Occupational Therapy
Physiotherapy
Speech & Language Therapist
Nutrition
Tissue Viability Nurse
Audiology
Activities
Other: ………........………………………
MDT Referral Record updated and Narrative Note written in the main record
Narrative Notes on Assessment Findings
All Care plan’s reviewed and care plan initiated/ rewritten for the following problems/needs:
Topic Heading
Problem/need
(Describe the resident’s need/identified problems in the resident’s own words,
where possible)
Nurse’s Signature:
HSE Print (01) 626 3447
Ordering Code DML 31
Three-Monthly Reassessment (continued)
Date: ……… /……… /20………
Resident’s Name: …………………....…....……… MRN: ……………....…………… Ward/Unit: …..….......……………………
Resident/Significant other participated:
Yes No
If No, document in Narrative Notes
Resident/Significant other signature: .……………....………………....……........…………....………………....………………....…
Topic Heading
Problem/need
(Describe the resident’s need/identified problems in the resident’s own words,
where possible)
Nurse’s Signature:
HSE Print (01) 626 3447
Ordering Code DML 31
Respite Readmission Form
Resident’s Name: ……………........…...........…..…… MRN: ……………........……… Ward/Unit: …….......……………………
Date of Readmission: ……… /……… /20………
Time: ……......…………………
Admitted from: …………..............………………………… Accompanied by: …………………………………………………….
Medications with resident: Yes (see Prescription) No
Aids: Hearing aid:
left
right
Dentures:
upper
lower
Walking Frame
Wheelchair Mattress
7. Valuable List completed: Yes No
Glasses: number of pairs ……..............…………
partial
Cane
Other: …………..…………………………………
Activity of Living
Any changes noted from last assessment? NN=Narrative Note written CP= Care Plan initiated
Please ✓(tick) in appropriate box
No NN CP
No NN CP
No NN CP
Communication, Mood /
Behaviour
Skin Condition,
Pressure Ulcer Prevention/
Wounds
Meaningful Activities
Breathing / Circulation
Mobility/Safety
Psychosocial well being
Nutrition/ Hydration
Personal Care
Sleep/Rest
Continence/Elimination
A Key To Me
Palliative Care
Observations: Blood Pressure:
Blood Sugar:
Pulse:
O2 Sat:
Skin Integrity: Intact
See Narrative Note
See Wound Care Plan
Temperature:
BMI:
Respirations:
Weight:
Urinalysis:
kgs
Referrals sent: Occupational Therapy
Physiotherapy
Nutrition
Audiology
Activities
Speech & Language Therapist
Tissue Viability Nurse Other: ………........………………………
MDT Referral Record updated and Narrative Note written
Reassessments completed: Nutritional Oral Pressure Ulcer Risk Falls Manual Handling Continence
Admitting Nurse’s Signature:
Discharge Form
Resident’s Name: ……………........…...........…..…… MRN: ……………........……… Ward/Unit: …….......……………………
Date of discharge: ……… /……… /20………
Time: ……............…………………
Discharged to: …………..............………………………… Accompanied by: …………………………………………………….
Medications with resident: Yes No
Aids: Hearing aid:
Valuable List returned: Yes No
left
right
Glasses: number of pairs ……..............…………
Dentures:
upper
lower
Walking Frame
Wheelchair Mattress
partial
Cane
Other: …………..…………………………………
Skin Integrity: Intact
See Narrative Note
10. IV discontinued: Yes
Not applicable
Discharge Letter sent: Doctor’s letter
Yes
Not required
Nurse’s letter
Yes No
Referrals: Public Health Nurse
Community Health Team
General Practitioner
Other: .....................................................................................
Prescriptions sent: Yes No
Significant other given information on the resident’s status at discharge: Yes
Further details in Narrative Notes: Yes
Discharging Doctor:
No (see Narrative Notes)
No Next Planned Admission Date: ………….....………………….
Time:
Admitting Nurse’s Signature:
HSE Print (01) 626 3447
Ordering Code DML 32
Appendix 3
Documentation Audit Tools
297
MINI Clinical Audit of Care Record
Name of Auditor: _________________ Ward/Unit ______________ Date: __/__/20___
Yes
Are the following completed:
Name
Ward/Unit
On each page
MRN
Front &Back
Completed and Up-to Date as per guidelines:
Pain Assessment
Pressure Risk Assessment
Nutritional Risk Assessment
Oral Cavity Assessment
Falls Risk Reduction Assessment
Manual Handling Assessment
Weights
Is there a care plan written when indicated by the RAI assessments
MDT Referral Record up-to-date
Three Monthly Reassessments
Narrative Notes:
Give a clear picture of the resident’s progress
All entries are: Signed
Dated
Timed using the 24 hour clock
Care Plans:
Is there evidence of resident and / or significant other
involvement in care planning?
Care Plans are written within the last six months
Resident’s Problem written
Goal is measurable, obtainable & realistic
Interventions provide sufficient information to provide care
The flow charts are without gaps, using the appropriate codes
Totals
Not
No Applicable
Score
%
Comments: _________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Scoring: Number of ‘yes’ ticked divided by the number answered (23 (total number of questions) minus the number
of ‘not applicable’ ticked) then multiply this number by 100 and this will give you the percentage
Sample: 16 (total yes) ÷ 23 = 0.69 x 100= 69% compliance
Full Audit of Care Plan to be carried out 6 monthly
HSE Print (01) 626 3447
Ordering Code DML 33
HSE Print (01) 626 3447
Ordering Code DML 34
Number of Care Records Audited:
Documentation Particulars
1
2
Audit Date:
Total Scores for N/A
Total Scores for Yes
14. A Pressure Ulcer Risk Assessment has been completed within the last three months
13. The Resident Assessment Instruments are signed
12. The Resident Assessment Instruments are dated
11. There is evidence that all Resident Assessment Instruments have been assessed
10. The Initial Admissions Assessment is completed within two hours of admission
9. The Personal Details Form is signed
8. The Personal Details Form is dated
7. The Resident’s vital signs have been recorded on admission
6. The Personal Details Form is timed within two hours of admission time
5. The Personal Details Form is completed without omissions
4. The resident’s medical record number is on every page of the record
3. The resident’s name is on every page of the record
2. Every staff member who has documented in the care record has signed the Signature Bank
1. All documentation is in black ink
Auditor Name:
Ward/Unit:
3
4
5
Chart Score
6
Methodology: Please insert 1 for Yes, if the item is found in the resident’s care record. Record 0 for No, the item is not present or
N/A (Not applicable)
Care Record Audit Tool
HSE Print (01) 626 3447
Ordering Code DML 34
Total Scores for N/A
Total Scores for Yes
34. A Manual Handling Assessment has been completed within the last three months
33. There is evidence that the Care Plan is updated when the Continence Assessment Score changes
32. The Continence Assessment is signed
31. The Continence Assessment is dated
30. A Continence Assessment has been completed within the last three months
29. There is evidence that the Care Plan is updated when Oral Cavity Assessment Score changes
28. The Oral Cavity Assessment is signed
27. The Oral Cavity Assessment is dated
26. An Oral Cavity Assessment has been completed within the last three months
25. There is evidence that the Care Plan is updated when the Falls Risk Assessment score changes
24. The Falls Risk Assessment is signed
23. The Falls Risk Assessment is dated
22. A Falls Risk Assessment has been completed within the last three months
21. There is evidence that the Care Plan is updated when the Nutritional Assessment score changes
20. The Nutritional Assessment is signed
19. The Nutritional Assessment is dated
18. A Nutritional Assessment has been carried out within the last three months
17. There is evidence that the Care Plan is updated when the Pressure Ulcer Risk Assessment Score changes
16. The Pressure Ulcer Risk Assessment is signed
15. The Pressure Ulcer Risk Assessment is dated
Documentation Particulars
1
2
3
4
5
Chart Score
6
HSE Print (01) 626 3447
Ordering Code DML 34
54. All narrative notes are written as the care is given
53. The flow charts are complete without any gaps
52. The nursing interventions state when it will be done
51. The nursing interventions state how often it will be done
50. The nursing interventions state how it will be done
49. The nursing interventions state what will be done
48. The goals are realistic
47. The goals are obtainable
46. The goals are measurable
45. The goals of care are aimed to solve/ alleviate /help the resident cope
44. Resident’s identified needs/problems are written as a resident problem
Total Scores for N/A
Total Scores for Yes
43. There is evidence that the Activities Assessment is completed within seven days
42. There is evidence that the Activities Assessment has commenced after five days
41. Each section of the Care Plan provides information to provide individualised care
40. All problems identified have a corresponding care plan
39. There is evidence of the resident/significant other involvement in care planning
than at three-monthly intervals (Standard 11.6: The residents care plan – HIQA)
38. All Care Plans are updated as indicated by the resident’s changing needs and no less frequently
37. The Manual Handling Plan is completed
36. The Manual Handling Assessment is signed
35. The Manual Handling Assessment is dated
Documentation Particulars
1
2
3
4
5
Chart Score
6
HSE Print (01) 626 3447
Ordering Code DML 34
Documentation Particulars
1
2
3
4
evidence to support this
Total Scores for N/A
Total Scores for Yes
72. Restraint that requires removal is being removed every two hours and there is documentary
71. The use of restraint is re-assessed every 24 hours by two nurses
70. The decision to use restraint has been made by at least two members of the Healthcare Team
69. The Restraint Assessment is completed in full (with corresponding documentation in notes)
5
Chart Score
Has the resident been identified as requiring restraint If yes: answer 69 – 72: If no mark with N/A
68. All student nurses’ / healthcare assistants’ entries have been co-signed by a registered nurse
67. There is evidence that the resident is reviewed after referral to Multidisciplinary Team
66. The Multidisciplinary Referral Record is current
65. Members of the healthcare team are identified by name
64. Errors are corrected according to policy
63. All symbols / grading used is An bord Altranais approved
62. All abbreviations used are from the approved list
61. Entries are made without gaps / lines between entries
60. All entries are in chronological order
59. All entries are signed
58. All entries use the twenty-four hour clock
57. All entries are dated
56. All written records are legible
55. All narrative notes are factual
Documentation Particulars
6
HSE Print (01) 626 3447
Ordering Code DML 34
1
Chart Score
2
3
4
5
A minimum of 20% of the Care Records or (a minimum of 4 care records) must be randomly selected to undertake an audit.
Total Scores for N/A
Total Scores for Yes
80. Would you be confident to take over this resident’s care using the care plan without a handover
79. Care records are updated according to policy
78. The reassessments are signed
77. The reassessments are dated
(i.e. Pressure ulcer Risk Assessment, Weights, Nutritional Assessment)
76. Reassessments are done according to local Policy
75. The Infection Care Plan is discontinued once the infection is cleared
74. There is evidence that the interventions from the care plan have been implemented
73. An Infection Care Plan is iniated once the infection is noted
Has the resident been identified as having an infection; If yes answer 73 – 75: If No mark with N/A
Documentation Particulars
6
HSE Print (01) 626 3447
Ordering Code DML 34
Chart 2
References:
An bord Altranais (2002) Recording Clinical Practice: Guidance to Nurses and Midwives, An bord Altranais
Payne, A.M. (2005) Nursing Care Plan Policy, St. Mary’s Hospital Policy Committee
Chart 1
Audit Scores
Chart 3
Chart 4
The target score is 100%
= 80% compliance for chart 1
56
70(Total questions 80 – 10 ‘N/A’) X 100
Chart 5
For Example
Total number of ‘Yes’ scores in chart 1 = 56
Total number of questions answered in chart 1 = 80
Total number of ‘Not Applicable’ questions in chart 1 =10
Chart 6
To score the audit, first total the number for ‘Yes’ scores on each page. Then add the ‘Yes’ totals from each page
together, to give the total ‘Yes’ scores for each chart audited. Next total the number of ‘Not Applicable’ scores using the
same format. For each chart subtract the total number of ‘Not applicable’ scores from the total number of audit
questions (80 questions).
The audit is scored by the following formula:
Total number of ‘Yes’ scores per chart, divided by the Number of questions answered, minus ‘Not Applicable’ answers
X 100
Appendix 4
Guidelines for completing
“My Day My Way”
298
“My Day My Way “
Towards Developing Person Centred Care for Our Residents
The Importance of getting to know the person not just the resident and what is
important to them in their daily care is kernel to the concepts underpinning PCC. How
can we help staff be more person- centred in their care for the individual person?
As part of a National Older Persons Centred Care Programme an innovative way “My
Day My Way” was developed by participants.
• This getting to know me exercise can be carried out before a resident is
admitted to the unit, when they are admitted as part of their admission
procedure or now as part of their ongoing assessment.
• This can be completed with the resident by a family member care staff named
nurse.
• It should be kept in the residents care plan which is accessible to all staff.
• It should be reviewed and updated as part of the ongoing evaluation of the
residents care.
• All new staff should familiarise themselves with the plan
HSE Print (01) 626 3447
My Day
My Way (Example )
I would like to share with you what is important to me when caring for me
Name: Mary Kelly
Suite: Sandymount
What makes me Happy ?
• I like to put my own makeup on in the morning please don’t rush me. If you
leave the mirror and the makeup bag I will work away at it. I am not in a hurry.
• I love to get fresh air every day, if you can assist me to go to the garden.
• I love a lie in on a Saturday morning I always did it at home. If you can put my
radio on and put RTE 1. I love the chat on the radio.
• I don’t like to eat my meals with other people. Please let me sit on my own to
have my meals. I eat better that way.
What Makes me Unhappy?
• Tea. I hate tea, always have and I am not going to change now, please let staff
know that.
• Trousers, I have never worn a pair and I would prefer not to at this stage of my
life.
• Loud music and the TV on at the same time. If you bring me in to the day
room, keep the noise level down please!
• Not to be consulted when planning my care. I hate when people talk over me
like I am not there!
HSE Print (01) 626 3447