maretta vincart - the wesley private hospital - hip fracture patients with dementia and delirium:...
DESCRIPTION
Maretta Vincart, Clinical Nurse Educator (Orthopaedics/Rehabilitation), The Wesley Private Hospital delivered this presentation at the 2nd Annual Hip Fracture Management Conference 2013. This conference is the only regional event to discuss practical innovations and improvement processes for the management of Hip Fractures in the hospital setting. Find out more at http://www.healthcareconferences.com.au/hipfracture2013TRANSCRIPT
Hip Fracture Patients with Dementia and
Delirium: Development of Clinical Pathway &
Nursing Assessment Tool at The Wesley
Private Hospital
Maretta Vincart
Clinical Nurse Educator
Established in 1977
ORTHOPAEDICS
2 Orthopaedic Wards
69 dedicated Orthopaedic
beds TOTAL NUMBER OF
ORHOPAEDIC SURGERIES
2012 = 4,108
2013 (sept) = 2,981
Fracture - Neck of Femur
Time Frame
Jan to Dec 12 Jan to Sept 13
Specific Area # Patients # Patients
Fracture of neck of femur, part
unspecified 12 6
Fracture of intracapsular section of
femur 2 0
Fracture of upper epiphysis
(separation) of femur 0 0
Fracture of subcapital section of
femur 63 44
Fracture of midcervical section of
femur 0 4
Fracture of base of neck of femur 6 2
Fracture of other parts of neck of
femur 22 14
Total 105 70
• High risk patients
• Assessment limitations
• Documentation
• Staff knowledge /
experience
INVESTIGATE CURRENT PRACTICE
COMPARE IT TO EVIDENCE BASED PRACTICE
MODIFY PAIN ASSESSMENTS / CARE PATHWAYS
IMPROVE NURSING CARE AND ASSESSMENT
Complications associated with dementia
Source: Australian Institute of Health and Welfare, Dementia in Australia , 2012.
Dementia rates
Estimated number of people with dementia
People with dementia, selected years 2005–2050
Source: Australian Institute of Health and Welfare, Dementia in Australia , 2012.
These patients are at risk for
•Falls
•Pressure injuries
•HAI’s
•Medication errors
•Loss of fitness
•Prolonged LOS
•Increased risk of re-admission
DELIRIUM
Patient History
Family Name:_________________________ MR/UR: _____________
Given names: _____________________________________________
Address: _________________________________________________
Postcode: ___________________ DOB: ______________________
Doctor: __________________________________________________
(or please affix Patient Identification Label here)
SPECIAL / CULTURAL NEEDS STAFF ONLY
Primary Language Interpreter Required Arrange Interpreter
Other Specific Needs:
ALL CARE BUT NO RESPONSIBILITY TAKEN FOR VALUABLES / PERSONAL BELONGINGS KEPT WITH PATIENTS Kept at
own risk Taken home
by: (Sign)
Visual Aids Glasses Contact Lenses Eye Prosthesis Record on
Falls Assessment
Walking Aids Specify: __________________________________________________
Hearing Aids Left Right
Dentures Upper Partial Full
Lower Partial Full
DISCHARGE PLANNING Name & Suburb of GP
Do you live in a: House Unit/Flat Retirement Village Hostel Nursing Home Discuss possible post discharge needs with patient / carer
Refer to Discharge Planning Referral Guidelines
Notify Discharge Planner, if applicable
Date: ____ / ____ / ____
Discuss Discharge Time of 10am with patient / carer
Live alone?
If yes, who will care for you on discharge Name:
Is this person in good health and able to assist
Caring for someone else?
Have problems caring for yourself ? Specify:
Currently use any community services?
Which services? Nursing Home Help Meals
Discharge time is by 10am. Can someone collect you by this time?
Transport required – Documented in notes
If not, how do you plan to get home? _________________________________
ENDURING POWER OF ATTORNEY / ADVANCE HEALTH DIRECTIVE
Advance Health Directive Please provide us with a copy File copy in record
Enduring Power of Attorney (Name & Phone No if applicable)
PATIENT OR CARER SIGNATURE
I CERTIFY THAT THE INFORMATION GIVEN IS CORRECT TO THE BEST OF MY KNOWLEDGE.
NAME (PRINT) DATE: ____/____/____
SIGNATURE RELATIONSHIP TO PATIENT IF NOT COMPLETED BY PATIENT
STAFF ONLY: PREADMISSION ASSESSMENT ATTENDED BY: NAME (PRINT)
SIGN: DATE: ___/___/___
HISTORY REVIEWED AND/OR COMPLETED ON ARRIVAL IN WARD / UNIT:
CONDITION AT TIME OF REVIEW
POST OPERATIVE Yes No (If Yes, no further action. If No, complete assessment below)
PHYSICAL APPEARANCE: NAD Pale/Sweating Dyspnoeic Cyanotic Other: ______________
MENTAL STATUS: Orientated Vague Confused Other: ______________
EMOTIONAL STATUS: Calm Somewhat Distressed Very Distressed Other: ______________
NAME (PRINT) SIGNATURE
DESIGNATION WARD / UNIT DATE: ____/____/____
Patient History & Nursing Assessment
NEUROLOGY Specialist/s
Stroke / TIA When:
Any Residual weakness? Where:
Epilepsy Last Fit:
Parkinson’s Disease
Fits / faints / “funny turns” When:
Speech / swallowing problems Specify:
Cough or choke when eating or drinking
A fall or falls within the last 6 months How often:
Difficulty walking / unsteady on feet
Short term memory loss / dementia Specify:
GENERAL HEALTH & WELLBEING
How much do you weigh _________ kg
How tall are you ________cm ________ feet / ins
Had previous blood clots
Smoke ________ per day
If no, have you smoked in the past When Ceased:
Drink alcohol _________ standard drinks / day
Have pain Where:
Disturbed sleep patterns / Sleep apnoea Sedation CPAP
Have a mental health condition Specify:
Diagnosed with anxiety and/or depression Specify:
Would you like to speak to a Chaplain
Family Name: ________________________ MR/UR No: _______________
Given names: ___________________________________________________
Address: _______________________________________________________
Postcode: ___________________________ DOB: ____________________
Doctor: _________________________________________________________
(or please affix Patient Identification Label here)
FALLS RISK SCREEN
INSTRUCTIONS
Complete on admission.
Complete Falls Risk Monitoring Form (Page 4) 3rd
Daily or with any change in patients condition
CATEGORY CRITERIA YES NO
1. AGE Age 65 years or over
2. HISTORY History of, or admission diagnosis related to, falls or seizures
3. DIAGNOSIS For or post surgery or post Epidural anaesthetic.
IV Therapy, Drains, Catheters. Hb < 90, Stroke, TIA, CCF, Oncology, Orthopaedic;
4. MENTAL
STATUS
Disorientation, confusion; agitation
History of dementia: impaired memory; vague; unable to follow instructions
5. SENSORY Significantly impaired sight or sensation (pain)
6. MOBILITY IV/s, drain/s, telemetry, catheter/s in situ (or for insertion within next 24/24)
Impaired co-ordination / unsteady gait; limb weakness; prolonged bed rest; uses aid;
7. MEDICATIONS 4 or more medications OR
One or more of the following medications
O sedatives (including benzodiazepines)
O narcotic O analgesia O diuretics O anti-parkinsons
8. CONTINENCE Incontinence; change in continence status eg. removal of catheter, urgency / frequency / nocturia / recent aperients
A “YES” response to any of the above criteria indicates that the patient is “AT RISK” of falling
Initiate Appropriate Falls Prevention Strategies as identified on Nursing Risk Monitoring Form( Page 4)
Identify on Clinical Pathway or Nursing Care Record
REFER TO: ‘Falls Risk Assessment & Management’ Policy (Nursing Policy 3.03) & Falls Assessment & Guidelines.
VENOUS THROMBOEMBOLISM (VTE) RISK ASSESSMENT INSTRUCTIONS: THIS IS A GUIDE ONLY. IF UNSURE PLEASE CONSULT TREATING VMO.
More than one (1) criteria may be selected A positive response indicates the patient is at ‘High Risk’ of VTE
Refer: Standing Orders - mechanical prophylaxis Document in Patient Record using VTE Sticker
GENERAL CRITERIA
Ischaemic stroke Impaired mobility History of VTE or PE
Actively treated Cancer SOB at rest or little exertion Respiratory Failure
Exacerbation of respiratory disease Rheumatoid arthritis Systemic Lupus
Age > 60 years Obesity Thrombophilia
Oestrogen therapy Pregnancy Puerperium
ADDITIONAL CRITERIA FOR SURGICAL PATIENTS
Hip or knee arthroplasty Major trauma Hip fracture surgery
Major abdominal surgery age > 40 yrs Any surgery > 45 mins duration
VTE STICKER COMPLETED AND PLACED IN PROGRESS NOTES MALNUTRITION SCREENING ASSESSMENT © - Tick appropriate boxes and add for the total score
A. Have the patient lost weight recently without trying?
B. How much weight has the patient lost?
C. Has the patient been eating poorly due to decreased appetite?
Total Score
Yes go to question B. 0.5 – 5.0kg Score 1 No Score 0
No go to question C. 5.1 – 10.0kg Score 2
If Score is 2, refer to
Nutrition Dept Ext. 7435
Unsure Score 2 go to question C
10.1 – 15kg Score 3 Yes Score 1
Over 15kg Score 4
Unsure Score 2
NAME (PRINT) SIGN DATE ___/___/___
Admission Risk Assessments
Ad
mis
sio
n R
isk A
ssessm
en
ts
W 1
81
.00
• Initial assessment
• Cognitive assessment and
documentation
• Pain assessment tool not
suited to cognitively impaired
patients.
Family Name: _____________________ MR/UR: ______________
Given names: ___________________________________________
Address: _______________________________________________
Postcode: ______________ DOB: _________________________
Doctor: ________________________________________________
(or place Patient ID Label here)
Patients RELATIVE or CARER to complete
We value your input and involvement in your friend/relatives care. Can you please take a few minutes to answer the following questions to ensure we have all the
information necessary to provide the best care possible.
1. Does your relative/friend have any communication difficulties? (e.g cannot say what they want or have
trouble understanding information)
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
2. Does your relative/friend display any particular behaviours when they are experiencing discomfort or
pain?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
3. Does your relative/friend have any special food requirements, likes or dislikes?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
4. What are your relative/friend usual sleeping habits? (e.g. bed time, waking time, special blankets,
position, routines etc)
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
5. What are their usual hygiene habits? (e.g. showering, bathing, shaving, toileting, continence, denture
management etc)
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
If possible, could you please bring in some personal items of comfort (e.g. toiletries,
photos, books etc) so that we can reassure and create a familiar environment for
your relative or friend.
Carer Communication
Does your relative/friend have any specific cultural or religious practices?
_________________________________________________________________________
Please list any past hobbies/interests or employment:
_________________________________________________________________________
_________________________________________________________________________
Please provide names of significant others in the table provided below. These could
be individuals that have a significant role or meaning in your friend/relatives life.
These may include family members, special people or pets etc.
NAME RELATIONSHIP FREQUENCY OF CONTACT
ADDITIONAL COMMENTS:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Name & Relationship of person completing form:
Form reviewed by: Name:___________________ Designation_________________ Ward: ______________
GUIDELINES FOR PAIN
ASSESSMENT FOR PERSONS
WITH COGNITIVE IMPAIRMENT
• Self report
• Painful conditions or treatments
• Observe behaviours
• Surrogate reporting
• Analgesic trial Reference : PAH Behavioural observation chart
• Importance of documentation
implementation to be user friendly
and effective for management of
hip fracture patients.
• Assessment tools to better patient
experience and outcomes.
• Implementation of initial cognitive
assessment (CAM/MINI MENTAL).
• Pathway modification to include
cognitive assessment.
• Implementation of pain assessment
tools suitable for the
confused/delirious/demented hip
fracture patients.
References/Works Cited
Delirium Care Pathways – Risk Factors 2011. Adapted from : Clinical Epidemiology and
Health Services Evaluation Unit 2006, Clinical Practice Guidelines for the Management of
Delirium in Older People, Victorian Government Department of Human Services, Melbourne,
Victoria : http://www.health.gov.au
Merkel S, Voepel-Lewis T, Shayevitz JR, et al:The GLACC: A behavioural scale for scoring
postoperative pain in young children. Pediatric nursing 1997; 23:293-797.
The ACI Orthogeriatric Model of Care 2010, ACI Aged Health Care Network:
http://www.health.nsw.gov.au/gmct
Australian Commission on Safety and Quality in Health Care – Vital Signs 2013: The State of
Safety and Quality in Australian Health Care Commonwealth of Australia 2013.
http://www.safetyandquality.gov.au
BioRICS NV: http://assessmentscales.com/scales/painad
WongBaker Faces Foundation: http://www.wongbakerfaces.org/
Dementia Care Australia Pty Ltd. Website: http://wwww.dementiacareaustralia.com.au
Australian Institute of Health and Welfare. Dementia in Australia 2012
Prince Charles Hospital – Behavioural Observation Chart & Fractured NOF Pathway