Geri Unit 2: The Process of Caring for Elderly Individuals

The Nursing Process

-Problem-solving approach to nursing care

-Ongoing

-Patient-focused

-Provides a framework for nurses to plan and give individualized care

-Subject to change

(ADPIE)

ADPIE =

Assessment

Diagnosis

Plan

Implementation

Evaluation

Comprehensive assessment In LTCFs includes:

-Physical assessment

-Health history

-Interview of older adult (and possibly family)

-Functional assessment

-Interdisciplinary assessments

-Review of lab results

-Completion of RAI

RAI

Resident Assessment Instrument

LTCF =

Long term care facility

CMS:

Center for Medicare/Medicaid services

OBRA =

Omnibus Budget Reconciliation Act

Omnibus Budget Reconciliation Act (OBRA)

“The Federal Nursing Home Reform Act”

-Federal legislation which has set minimum standards for the assessment and care- planning processes in nursing facilities that are certified for Medicare and Medicaid reimbursement

-Defines requirements for the quality of care given to residents of nursing homes

-Addresses many aspects of nursing home life, including nutrition, infection control, patient’s rights, services provided, required qualifications for staff

-Current regulations of LTCs started with OBRA in 1987

___% of nursing homes are certified for Medicare and Medicaid reimbursement

99%

OBRA address many aspects of nursing home life including:

-Nutrition

-Infection control

-Patients rights

-Services provided

-Required qualifications for staff

RAI =

Resident Assessment Instrument

Resident Assessment Instrument (RAI) includes:

MDS, CATs, CAAs, RAI Utilization Guidelines

MDS =

Minimum Data Set

Minimum Data Set (MDS)

Assessment tool that was developed as a result of OBRA legislation

-An outline of minimally essential information that must be collected on every resident admitted to a nursing facility that receives Medicare or Medicaid reimbursement

-Done on admission and at regular intervals

-Directs care providers to problem areas that must be addressed in the plan of care

-Standardized for everyone

________ is a book that tells you how to bill for services provided to get paid (Used strictly for billing purposes)

RAI

CATs =

Care Area Triggers

Care Area Triggers (CATs)

-Embedded in the MDS responses

-Trigger (i.e., identify) problem areas that must be assessed or explored further

CATs – Care Area Triggers, See text, p. 54

Medicare:

federal government program of healthcare coverage for people age 65 and older, or who have a disability, regardless of income

Medicaid:

medical aid program for those unable to afford regular medical services, financed jointly by the state and federal government

__________ will pay for a pts short term rehab for 100 days a year and then pts will need to be discharged unless they have a secondary insurance that will take over

Medicare

_______ will pay for pts in long term care units for the rest of their life

Medicaid

Medicare Part A:

Covers hospital

No premium, but copay of $1632 per admission. Covers rehab limited time.

Medicare Part B:

Covers MD in the nursing home and outpatient care after that (will cover wheelchair/walker).

Premium $174.70/month, deductible $240

Medicare Part C:

Medicare Advantage Plans-Extra back up insurance for other healthcare issues; replace all of the above and insurance company manages Medicare.

Medicare Part D:

Covers meds.

Has premium, base $34.70, but plan dependant. Has “gap”. After $5030 in meds, have 25% copay until hit $8000. Gap ends 2024

Nursing Diagnoses

-Labels for the patient's strengths, deficits, and potential problems

-Must address the comprehensive assessment

-In LTC, may not be in NANDA language; may incorporate MDS language and format

In long term care instead of using NANDA for care plans they may use:

focus, goal, and interventions

(Ex: Focus: at risk for falls or hx of falls. Goal: resident will have no falls until next review/discharge. Interventions: move closer to nursing station, non-skid socks, green oxygen tubing to prevent trips)

Planning

-Identify the goals of the older adult/family

-Ideally, set goals and priorities mutually with older adult/family

-Plan interventions to allow the older adult to achieve the goals

-Goals must be realistic/relevant, measurable, attainable, specific, and must have time frame

-Interventions must be realistic, individualized, and must include continued assessment/monitoring of signs and symptoms, treatments

-In LTCs, plan of care is interdisciplinary, and planned interventions must complement the interventions of other therapies

_______ must be realistic/relevant, measurable, attainable, specific, and must have time frame

Goals

________ must be realistic, individualized, and must include continued assessment/monitoring of signs and symptoms, treatments

Interventions

The intervention must be updated before you ____________ and staff needs to be updated about what intervention you put in place

leave your shift

Implementation

Putting the interventions into action

-Must be documented that these interventions were done, as well as the older adult's response

In LTCs where are implementations documented?

In the care plan

Why is documentation of interventions necessary in LTC facilities?

If it is not documented it is not done

Evaluation

Ongoing

-Has the older adult achieved the goals?

-Did the interventions help to achieve the goals, need to be changed?

-In LTCs, care plan needs to be reviewed and updated on regular basis (every 3 months) and as older adult’s health status improves or worsens

In LTCs, care plan needs to be reviewed and updated on regular basis which is _____________ and as older adult’s health status improves or worsens

every 3 months

Leadership and Management

The manager administers; the leader innovates. The manager has a short-range view; the leader has a long-range perspective. The manager asks how and when; the leader asks what and why. The manager has his eye on the bottom line; the leader has his eye on the horizon. The manager accepts the status quo; the leader challenges it.

Leadership:

The act of influencing and motivating a group of people to act in the same direction towards achieving a common goal

-Do not have delegated authority but obtain their power through other means such as influence

-Focus on group process, information gathering, feedback and empowering others

-Have goals that may or may not reflect those of the organization

Management:

The process of leading and directing an organization to meet its goals through the use of appropriate resources

-Legitimate source of power due to the delegated authority,

-Emphasize control, decision making, decision analysis and results

-Greater formal responsibility and accountability for rationality and control than leaders

Nurse Leadership Definition

"Their role involves policy setting and overseeing quality measures; dealing with regulatory compliance, certainly taking on fiscal responsibilities and more. They have responsibility and accountability for the overall quality of patient care delivery, patient and staff satisfaction, and organizational outcomes."

Management Definition

"details related to patient care planning, quality improvement, goal setting and budgeting. The manager is responsible for ensuring the staff carries out all assignments and is held accountable if they're not."

Styles of Leadership: Autocratic/Authoritarian

-Autocrat makes all the decisions, gives the orders

-Primary concern is that the job gets done

-Task-oriented

-Generally not respected by their staff

Styles of Leadership: Autocratic

-Individual employee’s needs are not a priority

-Does not allow for creative, caring approaches

-Staff may miss out on opportunities to learn and grow

-Effective in crisis situations or emergencies

-Work gets done quickly and efficiently

Styles of Leadership: Laissez-Faire

-No direction or supervision

-Allows the employees to make the decisions, do the planning, set the goals, and manage the organization

-Staff may take own direction and not focus on patient/resident outcomes

-Lack of communication of expectations

-Works only if team members are motivated, have strong knowledge base, are self-directed, and have strong problem-solving skills

Styles of Leadership: Democratic

-Utilizes the team process to make decisions

-Focuses on individual characteristics and abilities of each employee

-Each individual’s needs will be met if they do not interfere with the greater needs of the team

-Takes time and energy

-Emergencies can be stressful, especially if a decision needs to be made quickly

-Encourages all team members to offer suggestions, problem-solve, make decisions

-Values all team members

Styles of Leadership: Multicratic

-Uses all styles or some styles combined

-Must be skilled in all styles...challenging

-Need ability to assess people and situations individually

Nurse Management Responsibilities May Include:

-Making patient care assignments

-Implementing facility policies

-Providing constructive feedback and evaluations

-Demonstrating strong clinical skills

-Delegating duties

-Resolving conflict

Prioritizing and Assignments

-Sickest patient gets seen first

-Safety is always a priority when making assignments

When prioritizing assignments take into consideration:

-Best care practices

-Employee satisfaction

-Skill level of employee

In LTC, assignment components should consider:

-Continuity of caregiver

-Rotate "difficult" patients

-Physicality of assignment

-Geography of unit

-Try to avoid pairing novice UAP with novice nurse

Novice =

new

Delegating

Transferring authority to a specific person to perform a specific task in a selected situation

-Each state’s Nurse Practice Act describes the roles and responsibilities of a licensed nurse, including who is allowed to delegate and what can be delegated

-When a licensed nurse delegates to UAP, the licensed nurse is still ultimately responsible for the quality of the patient care (i.e., “the person delegating retains accountability for the outcome of the activity”)

-LPN must know the Nurse Practice Act for the state, and policies and procedures of the facility and what tasks they can perform

-Must know the delegates job description

NPA =

Nurse Practice Act

5 Rights of Delegation

-Right task

-Right circumstances

-Right person

-Right direction/communication

-Right supervision

Right direction/communication:

If you delegate a task to somebody make sure that person knows to check in with you after to be sure it was completed & completed correctly

Right communication includes communicating with:

-Older adults

-Families

-Members of the IDT

-Healthcare providers by phone

Some Effective Communication Skills

-Active listening

-Paraphrasing

-Reflecting

-Empathizing

-Sharing perceptions

-Assertive communication

-Nonverbal communication

Assertive communication:

Communication style characterized by confidence and consideration for others

What is the most honest form of communication?

Nonverbal communication

Assertive vs aggressive communication

Assertive communication is that assertiveness includes respect for yourself and the other party

Aggressive communication quickly disrespects and often insults the other party, leaving yourself feeling guilty or angry

Nonverbal Communication

Most honest form of communication

-Body language

-Facial expressions

-Clothing

-Appearance

Conflict

-Present in all aspects of life and in all organizations

-Brings an awareness of needs and the stimulus to make change

________ is neutral; management of it, how it is handled and results can make it positive or negative

Conflict

Causes of Conflict May Include:

-Unclear roles

-Desire for scarce resources (Ex: supplies, staff)

-Unresolved conflict from a prior conflict

-Perceived or felt conflict (people perceive & feel things differently)

5 Conflict Resolution Strategies

-Avoidance

-Competition

-Accommodation

-Compromise

-Collaboration

Conflict Resolution Strategies: Avoidance

Avoiding the situation that is causing conflict

Conflict Resolution Strategies: Competition

Making it about yourself or constantly trying to trump the other person

Conflict Resolution Strategies: Accommodation

Meet with them 1 on 1 or meeting with both together

Conflict Resolution Strategies: Compromise

Meet in the middle or completely separate the 2 that are having a conflict

Conflict Resolution Strategies: Collaboration

A meeting where they collaborate to try and make everyone on the unit happy

Conflict Resolution Skills May Include:

-Managing anger

-Not taking what is said personally

-Discussing/negotiating in a private setting

-Identifying the need being expressed

-Assertive communication but don't be aggressive

-Respecting oneself and the person(s) with opposing views

QM =

Quality Management

Quality Management (QM) Characteristics:

-Patient focused

-Total organizational involvement

-Use of quality tools for statistical measurement

-Identification of process for improvement

gather data

-determine solutions

-choose solution

-implement plan

-evaluate outcome

Some areas for QM

-Patient satisfaction

-Falls

-Wounds

-Infections (HCAIs)

-Readmissions

QAPI =

Quality Assessment & Performance Improvement

Affordable Care Act requires _______ done in LTC

QAPI

Requirements of programs are dictated by ______

Centers for Medicare and Medicaid Services (CMS)

CMS =

Centers for Medicare and Medicaid Services

The nursing process is:

A framework for providing nursing care

3 multiple choice options

The steps of the nursing process are:

Assessment, Nursing diagnosis, Planning, Intervention & Evaluation

3 multiple choice options

Nursing diagnoses differ from medical diagnoses because they:

Are standardized for any person who is receiving nursing care

3 multiple choice options

When setting priories during the planning stage of the nursing process, it is important to consider:

The needs of the patient/resident

3 multiple choice options

Evaluation of the nursing care plan is documented by means of:

The nurse's notes

3 multiple choice options

Ethics is the study of the moral actions and values. One of the dilemmas within ethical thinking is concern over:

Who decides what is right and what is wrong

3 multiple choice options

Because of Mrs.E's failing health and inability to live on her own, she has been admitted to a long-term care facility. Which method of financing cannot be used to cover her care in the facility?

Medicare

3 multiple choice options

The legal concept of omission in care applies when:

You have intentionally or unintentionally missed an antibiotic dose

3 multiple choice options

A restraint-free environment consists of an environment in which

The least-restrictive device is used on each resident

3 multiple choice options

Elder abuse is growing concern in modern society. Which of the following statements is correct?

It is against the law to threaten abuse as well as to perform abusive acts

3 multiple choice options

As an LPN. you must practice within the definition of your states nurse practice act. The best way for you to determine wether the current job description is within the nurse practice act is to:

Read the current job description and compare to the nurse practice act for your state

3 multiple choice options

The authoritarian style of management is not usually effective in the gerontological setting because:

Most employees need much more guidance to perform tasks correctly

3 multiple choice options

Generally, the best and safest patient care given to older people in all settings is based on:

The interdisciplinary team approach

3 multiple choice options

You were hired 6 months ago as an LPN charge nurse for a skilled nursing facility. You are preparing for your first evaluation. You know that this performance review is not intended to:

Criticize your overall performance

3 multiple choice options

As a nurse manager you should be cognizant of your interactions with all employees. If you want to be everyone's buddy or make sure everyone is your best friend, you would be demonstrating the:

Leniency error

3 multiple choice options

The following behaviors are examples of incivility:

All of the above

3 multiple choice options

Transformational leadership is defined as:

Motivating others to exceed expectations based on trust and respect for the leader and his or her vision

3 multiple choice options

Aggressive communication

Being overly forceful, pushy, or hostile

Assertive communication

Takes a listener's feelings and rights into account