Maretta Vincart - The Wesley Private Hospital - Hip Fracture Patients With Dementia And Delirium: Development Of Clinical Pathway & Nursing Assessment Tool at The Wesley Private Hospital
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Maretta Vincart - The Wesley Private Hospital - Hip Fracture Patients With Dementia And Delirium: Development Of Clinical Pathway & Nursing Assessment Tool at The Wesley Private Hospital

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Maretta Vincart, Clinical Nurse Educator (Orthopaedics/Rehabilitation), The Wesley Private Hospital delivered this presentation at the 2nd Annual Hip Fracture Management Conference 2013. This ...

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/hipfracture2013

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    Maretta Vincart - The Wesley Private Hospital - Hip Fracture Patients With Dementia And Delirium: Development Of Clinical Pathway & Nursing Assessment Tool at The Wesley Private Hospital Maretta Vincart - The Wesley Private Hospital - Hip Fracture Patients With Dementia And Delirium: Development Of Clinical Pathway & Nursing Assessment Tool at The Wesley Private Hospital Presentation Transcript

    • 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 # Patients # Patients Specific Area 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 Fracture of base of neck of femur 0 6 4 2 22 105 14 70 Fracture of other parts of neck of femur Total
    • • • • • 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
    • Dementia rates Estimated number of people with dementia People with dementia, selected years 2005–2050 These patients are at risk for •Falls •Pressure injuries •HAI’s •Medication errors •Loss of fitness •Prolonged LOS •Increased risk of re-admission Source: Australian Institute of Health and Welfare, Dementia in Australia, 2012. Complications associated with dementia Source: Australian Institute of Health and Welfare, Dementia in Australia, 2012.
    • DELIRIUM
    • Patient History Family Name:_________________________ MR/UR: _____________ Given names: _____________________________________________ Address: _________________________________________________ Patient History & Nursing Assessment Postcode: ___________________ DOB: ______________________ Doctor: __________________________________________________ (or please affix Patient Identification Label here) SPECIAL / CULTURAL NEEDS STAFF ONLY Other Specific Needs: ALL CARE BUT NO RESPONSIBILITY TAKEN FOR VALUABLES / PERSONAL BELONGINGS KEPT WITH PATIENTS  Visual Aids  Glasses  Walking Aids  Left  Upper  Lower  Dentures DISCHARGE PLANNING  Eye Prosthesis  Right  Partial  Partial Record on Falls Assessment  Any Residual weakness?  Epilepsy Where: Last Fit: When:  Speech / swallowing problems Specify:  Cough or choke when eating or drinking  Full  Full  A fall or falls within the last 6 months Name & Suburb of GP Do you live in a:  House  Unit/Flat  Retirement Village  Hostel  Nursing Home Name: Is this person in good health and able to assist  Caring for someone else? Discuss possible post discharge needs with patient / carer  Short term memory loss / dementia How often:  Difficulty walking / unsteady on feet Refer to Discharge Planning Referral Guidelines  Live alone? If yes, who will care for you on discharge When:  Fits / faints / “funny turns” Kept at Taken home own risk by: (Sign) Specify: __________________________________________________  Hearing Aids  Contact Lenses Specialist/s  Stroke / TIA  Parkinson’s Disease Arrange Interpreter  Interpreter Required Primary Language NEUROLOGY Specify: Notify Discharge Planner, if applicable  Have problems caring for yourself ? Specify: Date: ____ / ____ / ____  Currently use any community services?  Nursing Which services?  Home Help  Meals Discuss Discharge Time of 10am with patient / carer Transport required – Documented in notes _________________________________ ENDURING POWER OF ATTORNEY / ADVANCE HEALTH DIRECTIVE  Advance Health Directive How much do you weigh _________ kg How tall are you Discharge time is by 10am. Can someone collect you by this time? If not, how do you plan to get home? GENERAL HEALTH & W ELLBEING ________cm  Enduring Power of Attorney (Name & Phone No if applicable) PATIENT OR CARER SIGNATURE  Smoke ________ feet / ins  Had previous blood clots Please provide us with a copy File copy in record I CERTIFY THAT THE INFORMATION GIVEN IS CORRECT TO THE BEST OF MY KNOWLEDGE. NAME (PRINT) DATE: ____/____/____ RELATIONSHIP TO PATIENT SIGNATURE DATE: ___/___/___  Yes PHYSICAL APPEARANCE:  NAD  No (If Yes, no further action. If No, complete assessment below)  Pale/Sweating  Dyspnoeic MENTAL STATUS:  Orientated  Vague  Confused EMOTIONAL STATUS:  Calm  Somewhat Distressed  Cyanotic  Very Distressed NAME (PRINT) W ARD / UNIT  Other: ______________  Other: ______________ SIGNATURE DESIGNATION  Other: ______________ DATE: ____/____/____ _________ standard drinks / day Where:  Disturbed sleep patterns / Sleep apnoea  Sedation  Have a mental health condition BY: NAME (PRINT) HISTORY REVIEWED AND/OR COMPLETED ON ARRIVAL IN WARD / UNIT: CONDITION AT TIME OF REVIEW POST OPERATIVE When Ceased:  Have pain STAFF ONLY: SIGN: ________ per day  Drink alcohol IF NOT COMPLETED BY PATIENT  PREADMISSION ASSESSMENT ATTENDED If no, have you smoked in the past Specify:  Diagnosed with anxiety and/or depression Specify:  Would you like to speak to a Chaplain  CPAP
    • Address: _______________________________________________________ Admission Risk Assessments 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 NO  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 8. CONTINENCE O anti-parkinsons  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.  More than one (1) criteria may be selected  Refer: Standing Orders - mechanical prophylaxis  Ischaemic stroke  Actively treated Cancer  Exacerbation of respiratory disease  Age > 60 years  Oestrogen therapy  A positive response indicates the patient is at ‘High Risk’ of VTE  Document in Patient Record using VTE Sticker GENERAL CRITERIA  Impaired mobility  SOB at rest or little exertion  Rheumatoid arthritis  Obesity  Pregnancy  History of VTE or PE  Respiratory Failure  Systemic Lupus  Thrombophilia  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 W 181.00 VENOUS THROMBOEMBOLISM (VTE) RISK ASSESSMENT INSTRUCTIONS: THIS IS A GUIDE ONLY. IF UNSURE PLEASE CONSULT TREATING VMO. Admission Risk Assessments YES 1. AGE
    • • Initial assessment • Cognitive assessment and documentation • Pain assessment tool not suited to cognitively impaired patients.
    • Family Name: _____________________ MR/UR: ______________ Given names: ___________________________________________ Address: _______________________________________________ Carer Communication 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.
    • 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