“HCSL has been incredibly easy to navigate since we went live on the system on the 1st of October. Our team have people with varying levels of technology literacy and the ease of this system has meant that staff are more confident to use technology and see how it can help to improve time management by not having to double or triple up on written documentation.”
Manager
Alexander House Rest Home
Mattresses aren’t just something to lie on but if not maintained and cared for appropriately, also have the potential for causing harm.
As I travel a lot for work, I have the opportunity to test many different mattresses, all with varying degrees of comfort. This reminds me how difficult it must be for those who may be suffering painful joints to get a good night’s sleep. Appropriate mattresses are not only required to reduce pain from positioning discomfort but also reducing risk to residents. This include ensuring the mattresses are of a suitable standard and fit for purpose.
I’ve seen a number of mattresses which had hardened and torn linings and were well past being able to provide much comfort or an appropriate degree of pressure support. Some had masking tape used in an attempt to cover splits in the mattress cover. Others had holes in and were badly stained from exposure to body substances. As the residents in care are becoming frailer, with increasing acuity, the need for ensuring appropriate pressure support is crucial to preventing pressure injuries, maintaining comfort and maximizing the opportunity for good sleep.
There is the potential for old and in poor condition mattresses to be a potential source for infection transmission. For those of you operating newer facilities, this may not yet be an issue. For older facilities, part of stock and resource control should include mattress stock checks to verify they are in fact still fit for use. When conducting checks, determine the mix of mattress types you have and speak with your supplier about a replacement programme should this be necessary. As mattresses differ, so do beds and it’s important to make sure the mattress you use is appropriate for the particular bed type and size.
When reviewing your mattress stocks and purchasing new mattresses you might like to think about the following factors:
Harm prevention can also be supported with advances in technology such as Pressure Monitoring sensing devices to ensure appropriate pressure distribution. I’m not aware of anyone who can rent or lease out Pressure Mappers in NZ. However Cubro have one that they can bring onsite to facilities for training and education. Make contact with your supplier to see if they can assist if this could be useful for you.
Also remember that other devices used in beds should be checked as well to ensure they are still safe and appropriate for use eg; wedges, rolls, pillows, seat cushions, mattress covers (where these are appropriate for use), bed sensor monitoring pads. For reading on how to choose the best mattress option for your needs go here.
For more related information view here.
Article compiled by Gillian Robinson (RN, BN, Lead Auditor) for Healthcare Compliance Solutions Ltd.
The Draft Moving and Handling guidelines are currently being finalised with the view to be implemented from December 2017. Developed by Worksafe, they cover Health and Safety at Work Act 2015 (HSWA) duties and risk management for PCBUs in the health care industry and supersede the 2012 guidelines. There are a range of factors noted in these which need to be taken into consideration for those building new facilities or doing refurbishment of existing facilities. There is also a raft of information on Bariatric Care which is an increasing part of the services being provided in residential care.
The draft guidelines include the following:
Please note that there is not a complete consensus on the criteria for classifying a person as bariatric based on weight or Body Mass Index (BMI). However some examples include those people:
– with a body weight greater than 140 kilograms.
– with a BMI greater than 40 (severely obese), or a BMI greater than 35 (obese) with co‑morbidities.
– with restricted mobility, or is immobile, owing to their size in terms of height and girth.
– whose weight exceeds, or appears to exceed, the identified safe working loads (SWLs).
Health risks for bariatric clients
People who have been bariatric for a considerable time face chronic and serious health conditions, many of which should be considered before moving or handling them. Health conditions to take into account include:
– skin excoriation
– rashes or ulcers in the deep tissue folds of the perineum, breast, legs and abdominal areas
– fungal infection
– bodily congestion, including causing the leaking of fluid from pores throughout the body, a state called diaphoresis, which makes the skin even more vulnerable to infections and tearing
– diabetes
– respiratory problems
– added stress to the joints, which may result in osteoarthritis.
Planning for bariatric clients:
The planning process for bariatric clients in order to reduce moving and handling risks should include:
– admission planning
– client assessment
– communication
– room preparation
– mobilisation plan
– equipment needs
– space and facility design considerations
– planning for discharge.
Facility and equipment needs for bariatric clients
Health care and other facilities providing care for bariatric clients need to provide adequate spaces for these clients. Some considerations could include:
– ramps and handrails at entrances
– bariatric wheelchairs
– that the facility’s main entrance has sufficient clearance
– adequate door clearance and weight capacity in lifts
It must be remembered that the above comes from a draft but as drafts often end up being very close to the finished document, I felt it timely to share this information. To read more on Health and Safety in the Workplace go here.
HCSL are pleased to announce that from January 2018, you will be able to access clinical online tools for:
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Our eyes see what is familiar and what they expect to see. Are we good at picking up subtle changes through your assessment processes and acting on them appropriately? The ability to see the less than obvious is essential when responsible for clinical assessment as you won’t act on those things you haven’t noticed.
On the 5th July I presented a full day seminar on a range of topics to Nurses working in aged care. During the day I made what should have been an obvious change but I have no doubt it wasn’t noticed by all. In the morning I wore a dress with a white jacket. In the afternoon I’d changed the dress for one of a different colour and pattern but retained the white jacket. I made the change during the lunch break.
When I entered the room after the lunch break three people commented straight away. I saw a small number of puzzled looks but those nurses didn’t say anything. Others didn’t seem to notice and didn’t make comment. We had three distinct groups. Those that notice and comment, those that notice but don’t comment and those that don’t notice and therefore don’t comment! Which are the nurses you’d feel safest with if it came to performing a clinical assessment on you on an ongoing basis day after day? Which differences would they notice and which wouldn’t get a second glance. Which changes would be commented on?
We need a mix of ‘detail’ thinkers and ‘big picture’ thinkers to see everything that occurs. Equally these two groups of people can complement each other. Working separately they will each only see part of what needs managing. Some over think and others don’t seem to think or reflect. Awareness of how the members of your nursing team work and think could be important in supporting you to minimise risk resulting from subtle changes occurring which may not have been addressed.
It may be beneficial to review personality types to see how your team are working separately or collectively to ensure the best outcome for residents in their care. This increased recognition of each others natural thinking styles may also enhance the ability of the team to understand each other and consciously support others differences. There are a raft of profiling tests however Myers Briggs has been around as a validated tool for a long time and may be a useful one for you and your team.
What subtle changes are occurring with your residents that you haven’t noticed? Did you see the white dress in the morning change to a black one in the afternoon? If not, what else are you not seeing that could expose someone to risk? Are any of your team seeing things but not saying anything because they don’t recognise it’s their responsibility or think someone else has commented?
When care planning, the goals or objectives developed for each aspect of care need to be measurable. This ensures you’re able to evaluate progress and determine whether the goal has been met or not. The concern is making sure an appropriate goal is set. While we look at this from a clinical perspective, we must always remember the resident as the central focus and director where they are able to provide input into what the care plan relays. People have choice within their capacity and sometimes as nurses, we may not agree with a choice made by our patients / residents in aged care.
When guiding weight management goals from a clinical perspective, Liz Beaglehole, Registered Dietitian has offered the below guide.
Ideal weight range in the care process:
Body mass index is still helpful in determining healthy weights for older adults. A healthy BMI range for adults over 65 actually shifts upwards as compared to adults. So a healthy BMI for older adults has been found to be BMI – 22 – 27kg/m2. A BMI above 32kg/m2 would suggest obesity, a BMI below 20 suggests underweight, and below 18.5 is malnourished.
To work out the BMI: (weight/height²). Example case: height = 1.5m and weight = 45kg
Example: weight = 45kg divided by 2.25 = BMI of 20kg/m². This is regarded as the lower end of ideal body weight and suggests the resident is underweight for optimal health.
An ideal body weight for some who is 1.5m tall would be a BMI range of 22 – 27 so a weight range of min 50kg up to around 60kg. Basically to work out ideal body weight just enter different weights into the BMI calculation until you get to the BMI of at least 22 and then again to a BMI of around 27.
The ideal body weight may differ to the GOAL weight. The goal weight may be something that is set when the BMI is outside the ideal range but some weight changes are desirable. The goal weight is more useful and practical as it considers the weight history of the resident and the ability to achieve changes in weight. For example, a resident may be underweight with a weight of 42kg (BMI= 18.6) but they have been this weight for the past year. Ideally they would gain weight to 50kg, but this is unrealistic. The goal weight therefore becomes either weight stabilisation at 42kg or a slight weight gain to 44kg. This would still mean the resident is underweight but is realistic in what can be achieved. If the initial goal weight is achieved, a second goal weight may be identified. This may be to stabilise weight at 44kg or to gain to 45kg. etc…
This can work for overweight residents too. Using the same example height of 1.5m. Someone who weighs 78kg has a BMI of 34.6, and is obese. However, realistic weight loss to within the ideal body weight range would suggest the resident would need to lose around 18 – 28kg, which is completely unrealistic and would never be suggested for aged care. A more realistic GOAL weight would be weight stabilisation and then some weight loss. 5% weight loss can improve many health outcomes and this would be a realistic target. Weight loss of 5% is still around 4kg, which is possible but still difficult.
Article contributed by: Liz Beaglehole (NZ Registered Dietitian), Canterbury Dietitians
A very common adverse clinical outcome for residents is unintentional weight loss. It can contribute to a decline in general health, energy, about to heal in relation to skin / wound care and increase the risk of accidents.
Ensuring adequate nutritional intake relevant to the health status for each resident is ultimately the responsibility of Registered Nurses. There has been the perception in some instances that it’s normal to lose weight as people age. While there is an increased tendency to lose weight, it should not be considered normal.
If unintentional weight loss is detected, ensure thorough multi-disciplinary clinical assessment and development of specific short term care plan to define strategies to meet the specified care plan goal. Offering more frequent high energy (high calorie) and high protein snacks and drinks between main meals and instigating the recording of all food and fluid intake should be part of this plan (unless contraindicated). The dietitian can best help guide you through the best nutritional support for each individual resident and their circumstances at the time.
Unintentional weight loss or the undesirable decline in total body weight over a specified period of time is common however should not be ignored as ‘part of ageing’. Sarcopenia (muscle loss in the elderly) is also common however not inevitable and should be addressed through a targeted exercise and balance programme. Light body weight in the elderly have been shown to have a detrimental effect on the resident ability to function and on their general quality of life.
Unintentional weight loss of 3 -5 percent (or greater) in 30 days (or 10 percent in 180 days) must be monitored more closely and a short term care plan must be developed to promote weight loss cessation and implementation of weight management practices. RN’s must ensure they review regular weight monitoring records to identify progressive changes and respond to adverse patterns.
Residents that have been determined to be in later stages of palliative care or receiving terminal cares should be excluded from the need for close monitoring and related care planning related to trying to reverse unintentional weight loss. This is at the discretion of the Registered Nurse in consultation with the Doctor and next-of-kin / advocate / whanau. Discussions will also be had with the resident and the Medical Practitioner regarding the extent or type of tests, investigations and interventions that are desirable. These must be clearly documented in the Care plan evaluation and interventions recorded in the long term care plan and Doctors consultation notes.
Ensure the specific instructions (interventions) are recorded in the care plan for staff to implement on a consistent basis. Ensure these are reviewed at each weight monitoring event (time-frame specified in care plan) and adjust interventions according to weight monitoring outcomes.
If after two weeks of weekly monitoring the weight has not stabilized or started to increase, consult a Dietitian to review the resident and provide recommendations. Ensure any recommendations are followed as directed.
Treat any underlying cause and continue monitoring of weight until it has reached optimum levels in accordance with care plan goals. Return to monthly monitoring of weight at this stage. Those on special diets must be monitored more closely than those residents that are independent with eating and drinking or those that have no identified difficulties which may lead to increased potential for unintentional weight loss.
Case Study:
An 84 year old female resident (Mrs A) with a diagnosis of chronic heart failure and early dementia was noted to be experiencing progressive weight loss. Staff indicated she was able to physically feed herself but often refused to eat, pushing the meal tray away from her. She was able to express her needs to the extent of saying she didn’t want her meal. Staff recorded this in the progress notes however no investigation was done to identify the cause of her refusal to eat. Her weight had reduced at that point to 38kg having had an admission weight of 48kg only six months previously. Staff noted Mrs A was often sleepy during the day and expressed their belief her dementia was advancing. A new Clinical Nurse Lead (CNL) sat down and talked with Mrs A to discover that her mouth wasn’t sore and her dentures were well fitting. There appeared to be no difficulty with her ability to eat or swallow. The CNL consulted with the dietitian to support the assessment process. It was decided that a staff member would sit with Mrs A and gently talk with her as the staff member offered small spoonfuls of food. Mrs A obliged with eating with no resistance or protest and seemed to enjoy her meal. Progressively day after day her intake increased and she seemed to be sleeping less. She had more energy and within a period of one week had shown an 800 gram weight gain. Staff continued with supporting Mrs A with assisting her with her meal and within 6 weeks her weight had increased from 38kg to 41kg. At that time she was no longer sleeping most of the day and had resumed feeding herself. Short term care plans were instigated at the start of this process and more detailed long term care planning and regular assessment was also documented. Family input had been sought to gain a greater understanding of Mrs A’s previous eating patterns and she was able to talk about the foods she enjoyed having with her family. Asking questions about a context such as family meals assisted the staff in gaining more information than if they’d simply asked Mrs A what her favourite foods were. Giving a direct answer to a specific question wasn’t easy for Mrs A however she was able to talk about family meal times which proved a valuable source of information for nursing staff in supporting her. At the end of an 8 week period Mrs A had more energy, was interacting more with others, was sleeping less during the day,appeared happier and was enjoying her meals. She was no longer refusing to eat. It stands to reason that when a person is lacking nutrients, they may actually lose the energy needed to feed themselves. Getting the basics right is a good place to start.
HCSL is still the only New Zealand provider that, along with our software offer fully customised (Site by Site) up to date. New Zealand compliant policies & procedures, so you don’t have to update, edit or create them yourselves.
