APPENDIX E: Significant assessment elements and nursing by 1Eg9MBX


									                                                                                           Lakeridge Health Corporation - Whitby
                                                                                        Complex Continuing Care & Geriatrics Program

                                                                                                               APPENDIX B

                                                                                             Restraint Reduction Program
                                                                  Alternatives to the Use of Restraints, Monitoring Devices & Other Considerations

            Isolated Risk Issue                                         Significant Assessment Elements                                                                Specific Interventions/Alternatives to Consider

                                             Ensure that minimum assessment criteria have been addressed:                                Ensure that patients’ photo is taken by security and individual is identified as a wandering risk on the Care
a) Wandering                                    Observe and describe the type of wandering, purposeful or random, and look for            Plan.
                                                    patterns and triggers of wandering behaviour (Why? Where? When?) and                  Patient should be monitored/located at frequent intervals by staff.
                                                    document.                                                                             Clearly identify patient’s room, lounge, bathroom, etc. with appropriate signage.
                                                Explore “agenda behaviors” such as rummaging. The patient may be hungry,                 Provide companions: develop a “buddy system” with family, volunteers.
                                                    lonely, bored, looking for a spouse, a bed, or need toileting, but be unable to       Provide as much supervised activity as possible (i.e. Provide them with an appropriate task in clear view of
                                                    express this.                                                                           the nursing station).
                                                Explore with family what works at home (i.e. distracting techniques)                     Offer food and drink and bathroom breaks every few hours.
                                                                                                                                          Ask the family to provide personal and familiar items (including music) at the bedside.
                                                                                                                                          For patients with irreversible cognitive impairment due to strokes or dementia, discharge them home or to a
                                                                                                                                            “safe wandering” environment as soon as possible.
                                                                                                                                          Apply Wanderguard bracelet, with family’s consent, as the least restraint of choice.

b) Aggression, Agitation, Physical/Verbal    Ensure that minimum assessment criteria have been addressed:                                Eliminate the cause (antecedent), if known, and if possible.
Abuse                                           Establish whether the behaviour is out of character for the patient (it is not           Always approach in a calm, non-threatening manner, establish eye contact, smile continuously, give simple
                                                    uncommon for patients with longstanding cognitive impairment to experience             clear requests using short, simple sentences. Slow down your movements and speech.
                                                    delirium during hospitalization.                                                      Do not use reality orientation or trying to reason; use validation and acknowledge the patient’s
                                                Describe the specific behaviours that place the patient or others at risk. Note any        misperceptions.
                                                    apparent triggers.                                                                    Smile and offer a handshake as your first physical contact; if the patient grasps and won’t let go, offer a
                                                Observe and describe the type of behaviour and look for patterns and triggers              soft substitute object such as a ball, newspaper, towel, etc. before you begin physical care.
                                                    (Why? Where? When?) and document.                                                     Back off if the patient becomes agitated; leave the room if necessary and return later - never force
                                                Watch for warning/early signs of agitation such as facial grimacing, flared nostrils,      personal care.
                                                    clenched fists, raised voice, escalating verbal abuse, any change from normal         Substitute a tub or bed bath for showers or only bathe when absolutely necessary.
                                                    behaviour.                                                                            Ask family to provide music tapes.
                                                A long-standing, well established response to stress or challenges does not usually      Offer food, activity and toileting at regular intervals.
                                                    change. Patients with memory loss may lose social inhibitions and be abusive          Use a buddy system (two are safer than one) for necessary procedures - unless the presence of two people
                                                    with anyone providing care.                                                             increases the agitation.
                                                Ask family members about techniques used to reduce agitation and aggression.             Enlist the help of family members for personal care.
                                                                                                                                          Handling violent situations requires that you protect yourself, others and the patient. Allow the patient
                                                                                                                                            lots of space. As a protective strategy, remove furniture which may cause injury, place the mattress on
                                                                                                                                            the floor.
                                                                                                                                          If the patient must be physically subdued, call for help (the patient may settle when several people arrive).
                                                                                                                                             Have a plan and team organized before you approach the pt, e.g. someone will distract while others
                                                                                                                                            approach from behind to secure the arms and legs and others will have the restraint equipment ready.

              Isolated Risk Issue                                         Significant Assessment Elements                                                                    Specific Interventions/Alternatives to Consider

c) Delirium                                   Obtain baseline or premorbid cognitive functioning                                              If fluid & electrolyte balance and lab values are abnormal, treat AS REQUIRED UNDER THE
                                              Assess underlying physiology: neurological, vital signs, fluid and electrolyte balance,            DIRECTION OF PHYSICIAN
                                               lab values.                                                                                     If psychoactive side effects are related to medications, consult with physician and pharmacist to consider
                                              Review medications for potential psychoactive side effects, consult with pharmacist and            alternatives.

d) Interferes with Life Support Treatments    Ensure that minimum assessment criteria have been addressed:                                    Discuss with team and family the meaning behind removal of life support and any expressed wishes of the
                                               o Assess for depression and for pain.                                                            patient (i.e. Advance Directive).
                                               o Assess whether removal of life support is an expressed wish of the patient.                   Enlist family, friends and volunteers to sit with the patient.
                                               o Assess availability of family and other support networks.                                     Alter medication routes (antibiotics given IM or orally to eliminate the IV).
                                                                                                                                               Use robe or gauze to hide tubing insertion site
                                                                                                                                               Move IV /feeding pole and pump out of visual field
                                                                                                                                               Consider removing urinary catheters and treating incontinence with toileting/ diapers.
                                                                                                                                               Restore an appropriate sleep/wake routine.
                                                                                                                                               Keep patient pain-free and comfortable.

                                                Assess whether patient is sliding/falling out of their chair due to positioning problems.     Occupational Therapist to provide a comprehensive seating assessment.
a) Sliders & Forward Leaners                                                                                                                   non-slip mat under the seated patient.
                                                                                                                                               Customized chairs or seats designed following a seating assessment by OT.
                                                                                                                                               Footstools or foot supports, wedge-shaped foam seat cushions.
                                                                                                                                               Partially reclining chairs for forward leaners.

b) Risk of Falls                                Assess for patterns and triggers, assess for location and time of day of falls e.g.) falls      Physiotherapist to provide a comprehensive mobility assessment.
                                                 occur during the most active period of the person’s day and mainly in bedrooms and              Physician, in consultation with pharmacist, to decrease medications to the lowest number at the smallest
                                                 bathrooms. Document findings.                                                                    dosage and avoid long acting benzodiazipines.
                                                Assess for additional factors which contribute to falls (ensure that minimum assessment         Treat postural hypotension e.g. pressure stockings, keeping HOB elevated
                                                 criteria have been addressed):                                                                  Start mobility strengthening exercises, keep active and walking, encourage weight bearing while
                                                 o Normal aging results in changes in sensory perception and impaired vision. Be                   transferring; set up a schedule for assisted walks.
                                                     aware that glare from floors, poorly discriminated handrails, and poorly lit rooms          Begin scheduled toileting routine.
                                                     can result in falls.                                                                        Ask family to provide comfortable, well-fitting shoes with non-slip soles or non-skid slipper socks.
                                                 o The elderly can become deconditioned quickly when inactive (e.g. Musculo-                     Ensure adequate lighting and a night-light, removing safety hazards or obstacles.
                                                     skeletal problems develop including loss of strength and endurance, joint stiffness,        Do not leave unattended while toileting if strength and balance are a concern.
                                                     pain, etc.).                                                                                Encourage use of glasses and/or hearing aids.
                                                 o Foot problems, improper or poorly fitted shoes.                                               Talk to family about one-to-one companion visits
                                                                                                                                                 Nursing to increase frequency of observation checks.
                                                                                                                                                 Consider use of a Caroll Bed as a least restraint of choice, which lowers to the floor. A mat or mattress can
                                                                                                                                                   be placed at the side of the bed on the floor. This would eliminate the need for bedrails and lower the risk
                                                                                                                                                   of fall should the resident/patient want to climb out.
                                                                                                                                                 Consider use of a short bed rail as a least restraint alternative, to decrease risk of falls.

                                                                                      * Remember to note all alternatives in use in the Care Plan*

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