Download Elderly Care Standards: ADLs, Behavior, Depression, Falls, Nutrition, Oral Hygiene, Pain and more Lecture notes Nursing in PDF only on Docsity!
Samples* of Standards of Care
(SOC)
Developed by: Barbara Bates, MSN, LeadingAge NY ProCare Consultant
*To assist in developing your own facility’s SOC
Activities of Daily Living (ADL): p. 1-
Behavior Related to Dementia: p. 3-
Delirium: p. 6-
Depression: p. 8-
Falls: p.10-
Nutrition/Hydration in the Elderly: p.12-
Oral/Dental: p.15-
Pain: p.17-
Prevention of Skin Breakdown: p.20-
Urinary Incontinence: p.23-
Activities of Daily Living (ADL)
Definition: Task related to personal care such as personal hygiene, toileting, feeding,
ambulating, bed mobility, transfer, walking in room and in the corridor, locomotion on and off the unit, and dressing.
Background: Dependence on others for ADL assistance can lead to feelings of helplessness, isolation, diminished self-worth, and loss of control over one’s destiny. Many residents might require lower levels of assistance if provided with appropriate devices and aids, assisted with segmenting tasks, or are given adequate time to complete the task while being provided graduated promoting and assistance.
Standard of Care Activities of Daily Living
- Assess resident’s skills in performing ADLs on admission, quarterly and as needed. PT – OT will complete assessments as per policy. Compare current and previous ADL assessment, noting improvement and decline and modify care plan as appropriate. Rehabilitation/Restorative programs be developed and implemented to enhance ADL independence and address potential decline.
- Speech Therapy evaluation will be scheduled if deemed necessary by Medical Staff.
- Care plan will be developed to enhance independent completion of ADL’s as much as possible. Care plan will be developed based on resident goals/needs and will be communicated to the resident, family and care providers.
- The resident will be encouraged to perform self care with ADL’s at the level indicated on the care plan. (Ex. supervision, independent, limited assistance, etc.) If the resident shows change in level indicated on the care plan report to the nurse and rehabilitation staff.
- Assure resident is positioned correctly to perform eating – see that he/she is positioned upright, not leaning or tilting; position with the head & neck supported as needed to encourage slightly forward head position and to prevent tipping sideways or back.
- Always orient the resident to the location and types of items on their meal tray as appropriate
- Encourage the resident to make choices (i.e. clothing, time for bathing, method of bathing, time to get up, etc.)
- Resident will be up out of bed, dressed as per the resident’s choice.
- Assist the resident to keep clean, neat and well groomed including nail care and shaving.
- Monitor resident’s ability to maintain adequate nutrition related to ADL functionality. Document as per the facility’s policy
- Assure adequate intake each meal by providing assistance and adaptive utensils as needed.
- If a decline or improvement is noted in the ADL status of the resident, determine if a significant change of condition assessment (MDS/CAA/Careplan) review is required.
Behavior Related to Dementia
Dementia – characterized by a progressive impairment of cognitive function, personality, and
behavior. Person with dementia experiences loss of memory, orientation, language skills, concentration and judgment. Advanced stages a person experiences behavior and personality changes such as aggressiveness, mood swings, wandering and confusion.
Common Risk Factors: Impaired perception of reality Decreased self-esteem Impaired frustration tolerance Perceived threat to self Alteration in sleep/rest pattern Overstimulation Anxiety Impaired Coping Skills Physical Discomfort Drug reaction Impaired self expression Decreased sense of personal (verbal and nonverbal) boundaries.
Standard of Care Behavior
- Assess cognitive factors that may contribute to development of behaviors. Document and care plan appropriately as per care plan. Decreased ability to solve problems Alteration in sensory and perceptual capacities Impairment in judgment Psychotic or delusional thought patterns Impaired concentration or decreased response to redirection
- Assess physical factors that may foster behaviors – physical discomfort – being wet or cold, sensory overload such as noise.
- Assess emotional factors that can lead to behaviors; Document as per facility policy. Inability to cope with frustrating situations Expressions of low self esteem Non-compliance with care plan History of aggressive behaviors as means of coping with stress
- Evaluate impact of medication regimen on behaviors in relation to contribution to agitation. Document observations.
- Encourage resident involvement, allow time to process and respond.
- Observe for potential triggers that produce or could potentially produce behavior issues.
- Rule out delirium if new behaviors are observed (see standard for delirium)
- Keep resident, staff and other safe. Separate from other residents as needed.
- Educate resident related to appropriate social conduct with staff and peers as needed.
- Approach resident calmly, unhurriedly, allowing him or her the time to process question or direction.
- Reinforce positive statements.
- Encourage and assist resident in mutual problem solving.
- Monitor and document any concerns with resident’s behavior, interventions used and effectiveness as per facility policy.
- Review and assess past behavioral interventions, modify care plan utilizing interventions that have previously been successful.
- Refer to mental health as needed.
Nonaggressive behaviors – wandering, pacing, restlessness or increased motor activity, climbing out of bed, changing clothes or disrobing, wringing hands.
- Provide verbal feedback and initiate interpersonal approaches
- Initiate measures such as validation, reorientation, reduced stimuli, and consistent schedules. Document specific behaviors, approaches used and effect on behavior. Attempt to determine triggers that caused behavior.
- Complete documentation as per facility’s policy.
- Utilize slow, clear, soothing tones in speaking to the resident. Use brief comments, repeat if needed.
- Use distractions.
Verbally aggressive behaviors – may include cursing, yelling, screaming, unintelligible or repetitious speech, threats or accusations.
- Attempt verbal control; distraction, if possible allow for more personal space.
- Acknowledge fear of loss of control; evaluate use of touch and hand holding.
- If resident wanders or paces, consider need for visual supervision, especially if expressing desire to leave.
- Provide divisional activity – folding towels handling beads, walking with resident.
- Document behaviors, approaches used and effect on behavior. Attempt to determine triggers that caused behavior.
- Complete documentation as per facility’s policy.
Physically aggressive behavior – may include hitting, kicking, spitting or biting, throwing objects, pushing or pulling others or fighting.
- Permit verbalization of feelings associated with agitation.
- Offer acceptable alternatives to unacceptable behaviors – instead undressing in public – undress in own room; allow resident to select clothing
- Provide reassurance, redirect, diversion, separate resident from others, assist in problem solving. If possible leave the room briefly, reproach.
- Refer to appropriate mental health professionals as indicated
Delirium
Definition: An acute disturbance of consciousness and a change in cognition that develops
over a brief period. Common syndrome Can be reversible Is associated with increased mortality, increased hospital costs and long term cognitive and functional impairment Can be prevented with recognition of high risk residents and implementation of standard protocol Often under recognized
Risk Factors: Advanced Age Male Gender Dementia Poor functional status Medical illness Depression Multiple medications Pain Alcohol abuse Sensory Impairment Increased BUN/Creatinine ratio
Standard of Care
- Assess vital signs (TPR & B/P) – compare with baseline and document.
- Assess for change in baseline behavior and new onset of altered mental status. Utilize Brief Interview of Mental Status/CAM as assessment tool. Compare with previous scores.
- Notify Medical staff to rule out potential reversible causes of delirium versus extension of existing diagnosis/condition.
- Reversible causes may (not inclusive) include illness, infections, dehydration, medications, sensory loss, psychosocial issues, pain, and impaired mobility.
- Notify responsible party as per Facility’s policy related to communicating resident’s status change. Update family on presenting symptoms and interventions ordered by Medical and effects on resident.
- Modify care plan to address acute changes; if significant change in condition is identified as per RAI User manual, Interdisciplinary Team (IDT) will conduct a care plan meeting with family and/or responsible party.
- Eliminate and/or minimize risk factors.
- Assessments for falls, skin, elopement, pain, and mental status will be updated; Modify CNA care plans as needed.
- Ensure adequate nutrition
- Monitor intake and insure urinary and bowel output.
- Communicate change in intake to Dietician.
- Insure use of sensory aids as appropriate (glasses, hearing aids, etc.)
- Foster orientation, reassurance – carefully explain all activities, communicate slowly, clearly and provide explanation.
- Provide appropriate sensory stimulation – quiet room, utilize noise reduction techniques.
- Facilitate rest/sleep – back message, warm drinks (not caffeine) at bedtime, relaxation music or videos, avoid awakening.
- Foster familiarity – utilize familiar objects from home, care giver consistency.
- Maximize mobility – ambulation, active range of motion, etc.
- Consider psychotropic medications as a last resort.
- Reassure/educate family – encourage their involvement.
CNA Considerations
- Notify nurse of any change in mental status or change in resident’s usual behavior. Collect vital signs as directed – report and document.
- Check CNA care plan for any changes related to current status.
- Provide verbal reminders/reality orientation/validation during care.
- Report to nurse any significant changes in intake or output.
- Notify nurse of any observed behaviors and document as per Facility’s policy.
- Maintain a safe environment;
- Place resident in quiet, low stress environment with frequent
- Checks. Utilize relaxation music and or videos.
- Provide ROM, transfer, ambulation, exercise program as per the care plan. Record and document program as per facility’s policy.
- Insure sensory aids are in place.
- Break tasks into smaller tasks – do one step at a time.
- Keep environment quiet, well lit and place familiar objects in sight.
- Communicate clearly and slowly.
References
Lippincott Manual of Nursing Practice. (2010). Wolters Kluwer Health/ Lippincott, Williams & Wilkins. Ambler, PA.
Resident Assessment Instrument User Manual Version 3.0 (2012). Med-Pass Heaton Resources. Miamisburg, OH.
Geriatric Nursing Resources for Care of Older Adults. (2008). Hartford Institute for Geriatric Nursing. http://consultgerirn.org.
Waszynski, C. (2007). How to try this: detecting delirium. American Journal of Nursing. 107(12). Pp 50-59.
- Structure and encourage daily participation in relaxation and other therapies
- Provide emotional support – listening, expression of feelings, hope instillation, coping, encourage pleasant reminiscences, support adaptive coping.
- Educate resident/family regarding depression, treatment and the importance of adherence to prescribe treatment regimen.
- Observe and document for changes in mood; address and resolve if possible. Report any changes to nurse. Document as per facility policy. Modify care plans as needed.
- Encourage socialization. Encourage the resident to ask questions and allow time to discuss feelings.
- Instruct staff to maintain consistent approach when dealing with the resident.
- Utilize familiar items in resident room to assist with identification and comfort.
- Monitor and document any concerns with resident’s mood, interventions used, their effectiveness as per the facility policy.
- Encourage the resident to eat in the dining room to promote socialization.
CNA Considerations:
- Introduce self to the resident.
- Introduce resident to others and encourage relationship building.
- Encourage socialization; Encourage the resident to ask questions and allow time to discuss feelings.
- Utilize familiar items in resident room to assist with identification and comfort.
- Encourage resident to eat meals in dining room to promote socialization.
- Check activities calendar and daily program offerings. Allow resident the opportunity to attend activities of their choice.
- Provide 1:1 visits with recreation if resident prefers.
- Attempt to determine resident’s mood changes, report to nurse, resolve if possible.
- Observe for and document all mood changes as per policy; Notify nurse.
- Immediately notify nurse if resident is expressing thoughts that they would be better off dead or having self harming thoughts. Maintain observation of the resident; Document as per facility’s policy
References
Resident Assessment Instrument User Manual Version 3.0 (2012). Med-Pass Heaton Resources. Miamisburg, OH.
Geriatric Nursing Resources for Care of Older Adults. (2008). Hartford Institute for Geriatric Nursing. http://consultgerirn.org
FALLS
Definition: Unintentional change in position coming to rest on the ground, floor, or onto the
next lower surface. May be witnessed, reported by the resident or observer or identified with a resident is found on the floor or ground. (includes an intercepted fall in which the resident would have fallen if they had not been caught by another person).
Risk Factors: History of Falls Wheelchair use
65 years of age or + Female (if older) Use of assistive device for mobility Presence of acute illness Orthostatic Hypotension Visual/hearing difficulties Incontinence Impaired mobility Diminished mental status Multiple medications Cluttered environment Poor lighting Difficulty with gait Impaired imbalance Neuropathy Sleeplessness Decreased lower extremity strength Uneven/slippery surfaces Inappropriate footwear
Standard of Care Safety/Prevention of Falls
- Assess the resident care environment routinely for potential hazards (spills, clutter, lights out, loose safety bars, etc.) Take appropriate corrective action.
- Assess resident for risk for falls utilizing standardized fall risk tool such as the Morse Fall Scale on admission and as indicated; communicate findings to staff, document results.
- Educate resident and family identified risk factors and prevention measures.
- Educate resident on how to summons help by using the call bell and assure the resident has the skill and understanding on how the bell works. Use specialty bells as needed.
- Keep call light within resident’s reach.
- Assure resident has foot wear that is well-fitting, sturdy with non-slip soles.
- Monitor for side effects of medications or potential interactions that may increase the risk of falls.
- Encourage routine mobility – walking, exercise, falls programs, range to promote and maintain resident’s current level of strength and balance.
- Encourage appropriate use of mobility assistive devices/aids issued for the resident.
- Referrals to PT – OT therapy as indicated for evaluation and recommendations for appropriation interventions and/or programs as per facility policy.
- Assess resident’s functional status on admission and as needed.
- Follow the recommendations for transfer and ambulation status as per PT – OT – Nursing recommendations.
- Monitor during activities/programs.
- Assure staff awareness of resident’s safety needs.
- Assure initiation of safety precautions such as low bed with fall mattress, alarms, nursing observations, scheduled toileting, etc.
- Identify residents at risk for falls and interventions – insure documentation on CAN care plan.
Nutrition/Hydration in the Elderly
Definitions:
Hydration Management – promotion of adequate fluid balance that prevents
complications resulting from abnormal or undesired fluid levels.
Malnutrition: Any disorder of nutritional status, including disorders resulting from a deficiency of nutrient intake, impaired nutrient metabolism or over nutrition.
Protein-energy under-nutrition : Presence of clinical (i.e. signs of wasting, low BMI) and biochemical (i.e. low albumin or other serum protein) evidence of insufficient intake.
Risk Factors: Dietary Intake – decreased appetite, problems eating/swallowing, eating inadequate servings of nutrients, eating fewer than two meals/day. Isolation – loss of spouse, loneliness Chronic illness – depression, poor oral health, dry mouth due to medication side effects, inability to ingest foods or independently eat, inability to focus. Physiological changes – change in taste due to medications, nutrient deficiencies or tastebud atrophy, decrease in lean body mass and redistribution of fat leads to decreased caloric requirements
Standard of Care Nutrition/Hydration
- Interview and assess resident/family for diet history, food preferences, food allergies, meal/hydration customary routines, alcohol use, past medical/surgical history and comorbidities. Review medications – identify any potential drug-nutrient interactions.
- Complete nutritional assessment and document upon admission, with quarterly review and as needed with condition change.
- Monitor intake via observation at meals and documentation in medical record. Encourage resident to complete meal including food and fluids. Adjust meal plans as needed. Record meal/fluid consumption as per facility’s policy.
- Obtain admission weight, and then weigh weekly the first 4 weeks following. Establish weight schedule as per the IDT.
- Obtain height on admission then annually.
- Monitor the resident for swallowing/chewing difficulties including mouth pain, ill fitting dentures, coughing, etc.
- Ensure resident has sensory devices in place at meals; dentures are in place and secure.
- Refer to Speech Pathologist, Dentist or other consultants as indicated. PT-OT provide adaptive equipment/utensils; develop programs to enhance mobility and independent functioning to promote appetite increase and functional independence.
- Complete ordered laboratory tests to monitor nutritional status – modify care as needed.
- Provide required diet as recommended by Dietician; ordered by Medical.
- Nurses and CNAs will monitor and accurately document food and fluid intake as per facility’s policy. Encourage family involvement at meal time, bringing favorite foods from home.
- Nurse Manager/RN supervisors will monitor resident’s 24 hour fluid intake report and modify care as needed; communicate decreased intake to Nutrition/Medical.
- Report and document resident refusal to eat, decline in intake and hydration. Modify care plan, Communicate to Nutrition/Medical.
- Monitor for signs and symptoms of dehydration, foods causing G-I distress.
- Monitor for signs and symptoms of Hyper or Hypoglycemia when indicated.
- Encourage intake. Alert Nutrition staff when pattern of intake changes.
- Honor food/fluid preferences. Offer alternative choices if meals refused.
- Provide nutritional supplements and snacks as needed.
- Monitor for tolerance to diet – adjust as needed.
- Modify resident’s diet consistency following order form medical staff.
- Provide adequate nutrition to meet estimated needs.
- Provide a conducive environment for meals – encourage residents sitting in dining chairs, utilizing napkins, colorful table settings, proper positioning, etc.
- Assist residents with eating as per their plan of care – if feeding sit with the resident at eye level and make eye contact during feeding.
- Do not interrupt resident for non-urgent procedures or clinical rounds during meals.
- Utilize nutritional supplements/snacks between meals but not within an hour preceding a meal and at bedtime.
CNA Considerations:
- Encourage adequate intake each meal. Record all fluid and meal intake as per facility’s policy.
- Assist residents as needed. Report changes in ability to eat/swallow to nurse.
- Report any hoarding, stealing from other residents, throwing foods, or eating of non food items.
- Offer alternatives if meal is refused.
- Call nurse to evaluate any pocketing (holding food in mouth for an extended period of time) or swallowing difficulties.
- Check care plan, if resident wears sensory devices and dentures – ensure they are in place.
Oral/Dental
Oral Hygiene Background :
Directly linked with systemic infection, CVA, cardiac disease, acute MI, glucose control in diabetes, nutritional intake, comfort, ability to speak, and a resident’s self esteem and overall well being.
Definitions: Oral – refers to mouth (natural teeth, gingival and supporting tissue, hard and soft palate, mucosal lining of the mouth and throat, tongue, salivary glands, chewing muscles, upper and lower jaw, lips). Oral Cavity – includes cheeks, hard and soft palate. Oral hygiene – prevention of plaque related disease; destruction of plaque through mechanical action of tooth brushing and flossing or use of other oral hygiene aides.
Standard of Care Oral/Dental Care
- Conduct an assessment/evaluation of oral cavity on admission, quarterly and as indicated.
- Assess condition of: Oral cavity – lips, oral mucosa and tongue; should be pink, moist and intact. Absence or presence of natural teeth and/or dentures; Natural teeth should be intact; dentures should fit comfortably, should not move while person speaks. Ability to function with or without teeth or dentures. Resident’s ability to speak, chew and swallow. Look for abnormal findings such as dryness, swelling, sores, ulcers, bleeding, white patches, broken or decayed teeth, halitosis, difficulty swallowing, signs of aspiration and pain.
- Document assessment and develop a care plan to address abnormal findings. Document as per facility’s policy.
- Refer to Medical, Dental, Speech Therapist and other specialists as indicated.
- Develop an oral hygiene plan of care. Document the plan and communicate to resident, family and care givers.
- Encourage resident self care with oral hygiene if possible.
- Provide oral care at least twice per day and when additionally needed.
- Remove dentures morning and night, clean with toothpaste. Brush the residents tongue; Rinse off and reinsert dentures as per the resident.
- Monitor for any difficulty with chewing related to poor dentition and modify diet consistency as needed.
- Ensure annual dental examination and as needed.
CNA Considerations:
- Check CNA care plan follow the oral hygiene care plan, to determine if resident has dentures, or any mouth/swallowing problems.
- Provide mouth care as per the CNA care plan – encourage resident assisting with process.
- Store resident dentures in appropriately labeled containers in water.
- Check meal trays before discarding to assure dentures are not on tray.
- Brush teeth minimally two times per day, assist resident with flossing as needed.
- Report any dental concerns, complaint of pain, etc. to nurse and document as per facility’s policy.
References
Resident Assessment Instrument User Manual Version 3.0 (2012). Med-Pass Heaton Resources. Miamisburg, OH.
Geriatric Nursing Resources for Care of Older Adults. (2008). Hartford Institute for Geriatric Nursing. http://consultgerirn.org
regarding verbal and nonverbal/behavior pain expressions, particularly in those with dementia.
- Anticipate and aggressively treat for pain before, during and after painful diagnostic or therapeutic treatments (wound care, therapy session, restorative programs, etc). Educate resident and family.
- Educate resident and family on medications, benefits, adverse effects. Educate on the need to take medications regularly and to avoid allowing pain to escalate.
- Monitor medication closely – avoid under or over medicating;
- Administer pain medications on a regular basis to maintain therapeutic levels, avoid PRN medications.
- Clearly document the pain care plan to maintain consistency across shifts and with all care providers.
- Provide nonpharmacoligic pain treatment strategies such as relaxation therapy, guided imagery, breathing exercises, distraction, heat, cold, message, position change, therapeutic activities, etc. Combination of both pharmacological and nonpharmacological pain treatment are generally most effective. Document effects of all treatment for pain management.
- Provide rest periods to facilitate comfort, sleep and relaxation.
- Monitor resident during activities and or programs for signs of pain and discomfort. Report pain to nurse.
- Coordinate pain medication schedules prior to PT-OT, Restorative nursing programs, Therapeutic recreations, etc. to enhance resident’s involvement and comfort.
- Monitor, report and document side effects of pain medications such as sedation, confusion, constipation, loss of appetite, nausea, etc.
- Ensure pain management care plan is communicated to the resident, family and care providers.
CNA Considerations:
- Observe, report to nurse, and document resident’s complaint’s of pain as soon as possible.
- Observe and report to nurse non-verbal signs of pain such as facial grimacing, rubbing, guarding, etc. as soon as possible. Changes in behavior such as aggression, irritability, crying, vocalizations, sleep disturbances, restlessness, decreased appetite, etc. all could be pain related – if observed – report.
- Allow the resident to move at his or her own speed or pace.
- Follow recommendations for position as per the CNA care plan to enhance comfort.
- Maintain a quiet, calm, relaxing environment for resident’s experiencing pain.
- Encourage rest periods to facilitate comfort – provide relaxation music, diversion, breathing exercises etc. to aid in comfort as per the resident’s care plan.
REFERENCES
Resident Assessment Instrument User Manual Version 3.0 (2012). Med-Pass Heaton Resources. Miamisburg, OH.
Geriatric Nursing Resources for Care of Older Adults. (2008). Hartford Institute for Geriatric Nursing. http://consultgerirn.org
Lippincott Manual of Nursing Practice. (2010). Wolters Kluwer Health/ Lippincott, Williams & Wilkins. Ambler, PA.
Gulanick, M & Myers, J. (2011). Nursing Care Plans – Diagnoses, Interventions and Outcomes. 7 th^ Edition. Elsevier Mosby, St. Louis, Missouri
Ackley, B.J. & Ladwig, G. B. (2008). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care. 8th^ Edition. Elsevier Mosby, St. Louis, Missouri
