short term care plans

 by Gillian Robinson

Critical thinking – the foundation of good nursing practice

There are lots of ‘trendy’ words in each work environment but one of the most important concepts which appears to be increasingly missing particularly in aged care nursing is that of critical thinking and reflective practice. Critical thinking is the core foundation of good nursing practice.

It is essential to evaluate what is occurring clinically for those in care and regularly reviewing what is being done for each individual resident along with what else needs to be done in order to provide the best care. The skills of critical thinking may not be instinctive for example for those nurses coming from a schooling system which promotes ‘rote’ learning and deters from challenging senior staff.  To question another may be seen in some settings as disrespectful however in the field of clinical care, to challenge and question is essential.  The attributes of those who critically think and reflect on nursing practice and care outcomes use evidence-based practice (EBP) guidelines including current EBP policies and procedures to form decisions.

Some of the skills of critical thinking are more important than others and certainly the ability to reflect while communicating with other members of the team is essential to safe and person centred care.  The nurse who has developed critical thinking skills is able to interpret, understand and explain the meaning of information. This can be event based or data based eg; reading lab result forms. Investigating possible interventions based on the information at hand and analysing which will achieve a desired outcome is also part of reflecting and critically evaluating a clinical scenario.  Assessing the value of information to determine it’s relevance, reliability and credibility in relation to a particular clinical presentation is also necessary.

There are potential barriers to optimising clinical outcomes by clinical staff when a pre-determined bias or fixed mind-set are applied to a set of data or resident clinical presentation. It’s only in the bringing together of information through evaluation, analysis, communicating, referencing EBP guidelines and a growth mind-set that care can be optimised.

Click here to read more on critical thinking.

 

 

in News
 by Gillian Robinson

Audit Tips for Clinical Documentation

Clinical documentation and clinical management relate to section 1.3.1 to 1.3.8 of the Health and Disability Services Standards and are referred to in section D5.4 of the ARRC.  There are key reference documents which provide reference at residential care facility level which should be used in conjunction and addition to your organisation policies and procedures.  These reference documents include:

 

  • Age Related Residential Care (ARRC) contract
  • NZS 8134:2008 Health and Disability Services Standards
  • Clinical best practice (EBP) guidelines – eg; Lippincott
  • The Code of Health & Disability Consumers Services Rights 1996

 

Clinical documentation errors of any type noted during audits will result in partial attainments at best.  This is an indication there could be risk associated with gaps in service. In a previous article about medication management we noted that even a single signature missing off an administration signing sheet was enough for the auditor to assign a partial attainment finding.

 

Below are some of the common compliance gaps which relate to clinical documentation:

   
General compliance

gaps

Missed signatures off notations.

Not dated.

Not signed by the author with a full signature.

No designation written with signature.

Not legible.

Inconsistent structure of resident files.

Unclear or unsecured archiving of documents.

Privacy breaches due to clinical documents placed in a situation that allowed unauthorized viewing.
Initial assessments

including InterRai

Not completed within time-frames defined in ARRC.

Baseline recordings at time of admission not recorded.

Assessment outcomes not used as a basis of care planning to link assessment to goals and interventions.

Additional detailed assessments not reviewed in a timely manner eg; six monthly to coincide with InterRai reassessments.

Failure to re-assess for each period of admission eg; respite care.
Clinical risk

Assessment not describing risk.

Risk not reflected in care plan interventions.

Lack of risk reviews.

Level of risk noted in interRai assessments not included in care planning
Progress notes

Not recorded in on a shift by shift basis.

Lack evidence of regular registered nurse input.

Writing beyond the bottom line of the page.

Failure to put resident identifiers on each side of each page (this applies to other clinical documents as well).

Lack evidence of interventions being implemented.

Lack evidence of RN response to clinical symptoms reported by care staff.

Lack of evidence of rationale for PRN medication administration or the resulting effect.
Short Term

Care Plans

Not developed for changes in clinical status eg; increased pain; infection; wounds, change in medication (to allow evaluation of effectiveness).

24 hours plans not developed for residents displaying behaviours of concern (challenging behaviours).

Not evaluated regularly (I suggested at least once every 7 days) by a Registered Nurse.

Not recorded as resolved or transferred to Long Term Care Plan.

Not developed to implement instructions included in General Pracitioner consultation plans recorded in notes.
Long Term

Care Plan (LTCP)

Not reflective of all presenting potential and actual medical / clinical problems.

Not documented within 3 weeks of the date of admission (ARRC requirement).

Not changed at the time of health status / functional change.

Interventions not reflective of each medical diagnosis.

Interventions not changed within LTCP to reflect changes recorded in care plan evaluations.

Frequency of clinical assessment for each actual clinical presentation eg; pain.

Do not clearly indicate the level of function, assistance required for each component of care / support.

Do not clearly evidence input and instruction from Medical or Nurse practitioner / Physiotherapist, Diversional Therapist, Dietitian,Psychiatric services             for the elderly etc.
Care Plan

Evaluations

Review of care plans not reflecting changes in residents health status as they occur.

Not reflective of how well the care plan goals/ objectives have been met since the previous evaluation.

Not completed within ARRC defined time-frames (at least six monthly).
Multi-Disciplinary

Input

Lack evidence of MDT input into care plan reviews and/or evaluations.

Lack evidence of resident, Next of Kin (NOK) / Family / Whanau / EPOA input into assessment and care planning.

Lack of evidence of timely referral in response to clinical presentation eg; unintentional weight loss not referred to Dietitian.

Failure to evidence implementing instructions ofMedical or Nurse Practitioner eg; B/P to be recorded daily for the next 7/7 may be noted in the medical           consultation notes however not evidenced as having been done.

Lack evidence of notification to NOK / EPOA relating to resident adverse events, change in health status, medical consults etc.
Policy and

procedures

Not consistent with service delivery as noted in clinical documentation.

 

Internal audits are available through the online HCSL quality system utilised by our clients which allows tracking of compliance status and corrective actions as part of on-site quality and risk management. This means when the auditors arrive, there will be no surprises and you’ll know you’ve achieved excellence in care in conjunction with providing a compliant service.

If you have any comments to make about this article, please contact us here.

 

in News
 by Gillian Robinson

Clinical online tools for Aged Residential Care

HCSL are pleased to announce that from January 2018, you will be able to access clinical online tools for:

  • Initial assessment and initial care plan.
  • Short term care plans (and evaluations)
  • Long term care planning (and evaluations)
  • Progress notes
  • Restraint/ Enabler restraint management (and evaluations)

All mobile device compatible so you can be with your residents rather than stuck in the office!

HCSL bringing cost effective, specifically designed tools for the New Zealand residential care sector.  The Corporates have their tools, why shouldn’t you have the same advantage?!

 

To find out more and get a no obligation free quote for use contact us here.

 

in Services
 by Gillian Robinson

Clinical Assessment Recognises Subtle Changes

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?

in News
Unwanted Weight Gain
 by Gillian Robinson

Unwanted Weight Gain in Aged Care Facilities

While most of the referrals for dietitian input in aged care facilities relates to unwanted weight loss, dietitians can be asked for input with residents who have unwanted weight gain.

What is overweight?

For many adults we use the Body Mass Index as a basis for identifying a ‘healthy weight range’.  The BMI is a ration of the person’s height to their weight.  (kg/m²)  The BMI is not without its limitations, but generally it is a useful tool in assessing if someone is within the recommended weight range (BMI 20 – 25kg/m²), below it (underweight and malnourished) or above it (overweight and obese).  For older adults, the ‘healthy weight range’ tends to shift upwards.  There is evidence older adults with a BMI between 22 – 27 kg/m², have a longer life expectancy.  There is evidence that older adults who have unwanted weight loss will reduce their life expectancy.

What is the aim?

The first question to ask is whether this weight gain is a cause for health concern, and if there are benefits gained from weight loss.  In some cases weight gain may lead to reduced mobility, worsening blood sugar control, exacerbation of shortness of breath and gastric reflux, problems in fitting clothes, problems with ill-fitting hoists, chairs, and increased difficulty with transfers.  If it agreed that weight loss would be beneficial, the first nutritional goal is to prevent further weight gain.  Aim to stabilise the current weight.  Weight loss may be the next goal once weight stabilisation is achieved.

How much weight to lose?

Stabilising the current weight is a good start.  If weight loss is desired, set a realistic weight goal with the resident.  Health benefits are noticeable with as little as 5% weight loss.  A 85kg woman losing around 4kg should notice some benefits.

The goal of weight loss it to be losing body fat, not body muscle.  If weight loss is too rapid, the risk is that significant muscle mass is lost.  This can lead to worse health outcomes.

Involving the resident who has unwanted weight gain

A discussion with the resident about whether they are noticing any effects from the weight gain, and whether they would like to try and prevent gaining more weight, is essential.  It may be useful to explain the expected health benefits possible with weight loss. Family may also like to be consulted, but the decision and the motivation really needs to come from the resident.

Just telling a resident they need to lose weight, or automatically changing their diet is not treating a resident with respect, nor providing care that is tailored to their needs.  You may feel that the ‘best’ option would be to lose weight. The resident may feel different. They have the right to choose what’s right for them.

What strategies may help unwanted weight gain?

Losing weight is hard.  There needs to be a reduction in the energy intake with an increase in energy output.  Changes to food and changes to levels of activity are needed for optimal results.  Activity and body movement are important in helping to maintain muscle mass.  The diet still needs to remain nutritionally adequate, especially in terms of protein to minimise the loss of body protein too.  Continue to offer quality protein foods, at main meals and tea meals.

An aged care facility menu is nutritionally balanced and tailored to ensure the nutritional needs of the residents are met.  Talk with the resident about what ideas they might be happy to try to help reduce their food intake.  Small changes eventually add up to significant calorie reduction.  Start with changing one or two things only in the diet.  If that is successful, add in other small changes.

Reducing Food Intake

  • Target between meal snacks such as morning tea, and/or afternoon tea. If the resident is not hungry at these times, he or she may be able to skip the food offered
  • Limit sweet drinks; offer water, ‘diet’ options and a sugar replacement in hot drinks
  • Reduce the frequency of desserts in the week, or offer lower calorie options such as fresh fruit, diet jelly, low fat yoghurt. Limit the use of cream on desserts.
  • Ensure the size of the main meal is a medium meal (not large), serve extra vegetables if the resident is wanting more food.
  • Look at the quantity of food eaten at meals. Reducing the amount slightly can help.
  • Target the amount eaten at ‘happy hours’ and other treat times
  • Try to encourage the resident to limit the amount of extra foods they may be buying and having in their room
  • Ask family and friends not to bring in food items. Suggest other options such as magazines, books, photo albums, flowers

Increasing activity levels

  • Encourage the resident to join in the home’s activities
  • Encourage the resident to walk more if possible, around the home, to the dining room, around the garden – short distances at first so they gain a sense of achievement
  • Family and friends may be able to help by joining the resident in walks or taking them on outings too

These are some ideas to try.  For more information and tailored nutritional advice contact your clinical dietitian.  If the resident is ready to make some changes, offer support and encouragement, to help enable their success.  Be positive.  As with all of us, sometimes we deviate from our own ‘diet’; we have a treat or a dessert or a second helping.  Don’t judge residents, or be so strict with restricting foods.  Avoid using phrases that suggest the resident is ‘being good’ or ‘being naughty’ in terms of whether they are following the agreed diet plan.  There are no ‘good’ foods and ‘bad’ foods.  And finally, weight loss takes time.  Simply stalling the weight increase is a significant achievement.  Long term encouragement and support is essential for successful and sustained weight loss.

Article contributed by: Liz Beaglehole (NZ Registered Dietitian), Canterbury Dietitians

liz@canterburydietitians.co.nz

in News
 by Gillian Robinson

Unintentional weight loss

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.

in News