SECOND EDITION the LoNg-teRm CaRe Nursing Desk Reference the LoNg-teRm CaRehcmarketplace.com/media/browse/6650_browse.pdf · 2019-09-06 · the LoNg-teRm CaRe Nursing Desk Reference

Barbara Acello, MS, RN

NursingDesk

Reference

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200 Hoods Lane | Marblehead, MA 01945www.hcmarketplace.com

the LoNg-teRm CaRe

Nursing Desk ReferenceBarbara Acello, MS, RN

SECOND EDITION

Solutions and information for virtually every scenario that occurs in your nursing home

Long-term care nurses can rely on this authoritative reference daily. It is packed with practical, need-to-know resident care information, essential policies and procedures, and vital regulatory and safety requirements specific to long-term care.

author Barbara acello, mS, RN, has updated each section of this bestseller with particular attention to hot-button issues such as pain, pressure ulcers, medication administration, infection control, hydration, and nutrition.

this comprehensive reference provides: •Detailedinformationaboutcommonlong-termcareclinicalissues •Valuabletoolsandpracticalinformationabouthundredsofclinical

conditions •Timelyandrelevantupdatesthathelpyoustaycurrent •Onego-toresourceforallyourclinicalneeds

Bonus CD-ROM included!the companion CD-Rom contains vital tools and forms that help nurses save time and effort. these ready-made resources include depression and social adjustment scales, lawsuit prevention checklists, and pain assessment questionnaires.

Also of interest…The Long-Term Care Legal Desk ReferenceLong-Term Care Pocket Guide for Charge NursesClinical Documentation


SecoNd editioN

NursingDesk

Reference

the LoNg-teRm CaRe

The Long-Term Care Nursing Desk Reference, Second Edition is published by HCPro, Inc.

Copyright © 2009, 2005 HCPro, Inc.

All rights reserved. Printed in the United States of America. 5 4 3 2 1

ISBN: 978-1-60146-275-6

No part of this publication may be reproduced, in any form or by any means, without prior written consent

of HCPro, Inc., or the Copyright Clearance Center (978/750-8400). Please notify us immediately if you have

received an unauthorized copy.

HCPro, Inc., provides information resources for the healthcare industry.

HCPro, Inc., is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint

Commission trademarks.

Barbara Acello, MS, RN, Author

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Advice given is general. Readers should consult professional counsel for specific legal, ethical, or clinical

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iiiTh e Lo n g-Te r m Ca r e nu r s i n g De s k re f e r e n C e, se C o n D eD i T i o n © 2009 HCPro, Inc.

Dedication ..................................................................................................................ix

Disclaimers .................................................................................................................x

Introduction ...............................................................................................................xi

Chapter 1: Standards of Practice ..............................................................................1

Standards of Practice .....................................................................................................................1

The Nonnegotiable Nature of the ANA Code for Nurses with Interpretive Statements ..................3

Overview of Standards of Gerontological Nursing Practice ............................................................4

The Nursing Process .....................................................................................................................6

Chapter Resources ........................................................................................................................8

Chapter 2: Personal and Professional Practice Issues ............................................9

Identification Badges .....................................................................................................................9

Protecting Yourself Legally ..........................................................................................................12

Nursing Licensure Board Investigations: Protecting Your Nursing License ..................................20

Employee Injuries .......................................................................................................................23

Ergonomics .................................................................................................................................24

Back Injuries ...............................................................................................................................27

Chapter Resources ......................................................................................................................33

Chapter 3: Assessment ............................................................................................35

Resident Monitoring and Ongoing Care ......................................................................................35

Long-Term Care Facility Laws .....................................................................................................37

Understanding the Inspection Process ........................................................................................38

The Resident Assessment Instrument ..........................................................................................43

Aging Changes ............................................................................................................................48

Admission Nursing Assessment ..................................................................................................49

Physical Assessment of the Geriatric Resident .............................................................................52

Assessing Pain in the Elderly .......................................................................................................54

Contents

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Depression ..................................................................................................................................60

Social Adjustment Rating Scale ...................................................................................................60

The Cincinnati Pre-Hospital Stroke Scale ....................................................................................61

Using the Cincinnati Pre-Hospital Stroke Scale ...........................................................................64

Predicting Stroke ........................................................................................................................68

Chapter Resources ......................................................................................................................71

Chapter 4: Pressure Ulcers and Wound Care ........................................................73

Common Steps in All Procedures ................................................................................................73

Risk Factors for Pressure Ulcer Development ..............................................................................76

Pressure Ulcer Stages ..................................................................................................................77

Pressure Ulcer Assessment and Documentation ..........................................................................80

Pressure Ulcer Management ........................................................................................................81

Pressure Ulcer Colonization and Infection ..................................................................................84

Changing Wound Dressings ........................................................................................................88

Wound Pain ................................................................................................................................90

Skin Tears ...................................................................................................................................94

Graduated Compression Stockings ...........................................................................................100

Risk of Tetanus in Pressure Ulcers, Skin Tears, and Chronic Wounds ........................................106

Chapter Resources ....................................................................................................................108

Chapter 5: Planning ...............................................................................................111

The Care Plan ...........................................................................................................................111

Holistic Care .............................................................................................................................116

Maintaining and Improving the Residents .................................................................................117

Assessment ...............................................................................................................................117

Developing the Care Plan ..........................................................................................................119

Additional Assessments and Information ..................................................................................120

Risk Factors ..............................................................................................................................122

Resident Noncompliance and Refusals ......................................................................................123

Developing Realistic Goals ........................................................................................................124

Quarterly Care Plan Reviews .....................................................................................................125

Meeting Residents’ Needs..........................................................................................................125

Making the Plan User-Friendly .................................................................................................125


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Chapter 6: Clinical Values .....................................................................................127

Dehydration in the Elderly ........................................................................................................127

Preparing a Resident for an MRI ...............................................................................................128


Chapter 7: Medication Administration ................................................................133

Guidelines for Safe Medication Administration .........................................................................133

Medication Errors .....................................................................................................................137

Facts About Polypharmacy .......................................................................................................141

Medication and Treatment Orders .............................................................................................143

Drug-Induced Safety Problems .................................................................................................147

Resident Safety..........................................................................................................................149

Nursing Responsibilities for Managing Pain ..............................................................................150

Effective Pain Management .......................................................................................................154

Overview of Analgesic Therapy in Elderly Adults......................................................................159

Acetaminophen Toxicity ...........................................................................................................163

Antibiotic Administration .........................................................................................................165

Guidelines for Nursing Monitoring and Documentation ...........................................................168


Chapter 8: Intravenous Therapy ...........................................................................173

Intravenous Therapy Guidelines ...............................................................................................173

Complications of IV Therapy ....................................................................................................175

Calculating Intravenous Drip Rates ...........................................................................................178


Chapter 9: Transcultural Nursing .........................................................................181

Cultural Interpretation of Nonverbal Communication and Personal Space ................................181

The Effect of Culture on Family Relationships and Beliefs Regarding Institutionalizing the Elderly .....................................................................................................188


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Chapter 10: Infection Control ................................................................................193

Standard Precautions Overview ................................................................................................193

Additional Suggestions to Prevent Contamination.....................................................................200

Mode of Transmission of Pathogens ..........................................................................................202

Infection Control Considerations ..............................................................................................206

Cimex Lectularius (Bedbugs) ......................................................................................................208

Pseudomembranous Colitis ......................................................................................................212

Legionella .................................................................................................................................214

Necrotizing Fasciitis (Streptococcus A) .....................................................................................215


Chapter 11: Hydration and Urinary Elimination .................................................221

Dehydration..............................................................................................................................221

Understanding Hyponatremia and Hypernatremia in Dehydration ...........................................228

Prerenal Azotemia and Acute Renal Failure in Dehydration ......................................................231


Chapter 12: Nutrition .............................................................................................235

Dysphagia .................................................................................................................................235

Weight Loss and Malnutrition ...................................................................................................238

Liberalized Diets .......................................................................................................................242

Guidelines for Weighing Residents ............................................................................................244

Estimating Weight in Residents With Amputations ...................................................................246

Documenting Percentage of Meals Consumed ...........................................................................247

Calorie Counts and Food Intake Studies ...................................................................................251

Determining Calories Needed to Maintain Weight ....................................................................253

Identifying Body Frame Size .....................................................................................................254

Low Serum Cholesterol in the Elderly .......................................................................................255


Chapter 13: Interventions for Common Medical Conditions and Problems ....257

Causes of Delirium in the Elderly .............................................................................................257

Major Forms of Dementia .........................................................................................................261

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Falls ..........................................................................................................................................266

Urinary Incontinence ................................................................................................................269

Incidence and Prevalence of Seizures ........................................................................................274

Shock .......................................................................................................................................275

Nursing Management of Postpolio Syndrome ...........................................................................275

Fire Ants and Other Pests .........................................................................................................284

Low Bed Safety .........................................................................................................................288

Facility Noise ............................................................................................................................292

The Yacker Tracker ...................................................................................................................306

Special Populations ...................................................................................................................307


Chapter 14: Behavior Management .....................................................................335

The ABC Plan of Behavior Management ....................................................................................335

Restraints ..................................................................................................................................338

Reducing the Risk for Restraint Complications .........................................................................345

Managing Wandering Behavior .................................................................................................350

Sample Missing Resident Policy and Procedure .........................................................................357


Chapter 15: Emergency Intervention ...................................................................361

Obligation of the Nurse to the Resident in Emergency Situations ..............................................361

Emergency Control of External Hemorrhage .............................................................................362

Maintaining the Resident’s Airway .............................................................................................365

Use of Oxygen in an Emergency ...............................................................................................366

Fires in Resident Rooms ............................................................................................................368

The Safe Medical Devices Act of 1990 .......................................................................................369

Violence Directed at Employees ................................................................................................373


Chapter 16: Restorative Nursing Care .................................................................381

Restorative Nursing Care and the OBRA 1987 Legislation ........................................................381

Immobility ................................................................................................................................393

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Caring for Residents After Hip Surgery .....................................................................................394

Normal Joint Range of Motion ..................................................................................................396

Restorative Meal Service ............................................................................................................398

Restorative Approaches to Activities of Daily Living ..................................................................406

Chair and Wheelchair Positioning ............................................................................................407

Wheelchair Mobility .................................................................................................................409

Independence ...........................................................................................................................414


Chapter 17: Nursing Issues in Death and Dying .................................................419

The Patient Self Determination Act ...........................................................................................419

Death Certificates and Cause of Death Statements ....................................................................423


Chapter 18: Documentation ..................................................................................425

Documentation Standards and Guidelines ................................................................................425

Transfer to Another Long-Term Care Facility or Discharge to the Resident’s Home ....................441

Nursing Assessment and Documentation Guidelines ................................................................443

Example Electronic Media Policy ..............................................................................................453


Chapter 19: Lifting and Transferring ....................................................................457

Lifting and Moving: The Mechanical Lift ...................................................................................457

Safety Considerations for Mechanical Lifts ................................................................................462

Mechanical Lift Preventive Maintenance Guidelines ..................................................................467

Recommendations for Infection Control in Sling Use ................................................................468

Back Belts—Do They Prevent Injury? .......................................................................................469


How to Use the Files on Your CD-ROM ...............................................................475

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This book is dedicated to the memory of Arnie Silverman, President of Skil-Care Corporation, and Donna L.

Wong, PhD, RN, PNP, CPN, FAAN. These individuals touched my life deeply and provided me with many

years of assistance in enhancing the quality of my numerous publications. Both of these individuals have made

many positive, unselfish, and lasting contributions to long-term care practice. Their untimely passing had a pro-

found impact on my life during manuscript development, and their many contributions are sincerely appreci-

ated and will be sorely missed.

Dedication

x Th e Lo n g-Te r m Ca r e nu r s i n g De s k re f e r e n C e, se C o n D eD i T i o n© 2009 HCPro, Inc.

In addition to the care provided by physicians, some facilities are also fortunate to have the services of advanced

practice nurses (including nurse practitioners and clinical nurse specialists) and physician assistants. These

well-educated and highly qualified individuals provide excellent care to residents in long-term care facilities.

In many situations in this book, we note that physician notification is necessary. We are using the term “phy-

sician” for brevity only. This is not intended to minimize the important work of advance practice nurses and

physician assistants. When the reader is advised to notify the physician, facilities may also notify the advanced

practice nurse or physician assistant, if available, and as required by state law and facility policies. The proce-

dures listed in this book are for example purposes only. Always follow your facility policies and procedures and

physician orders.

The book is meant to be a source of useful reference information on a wide variety of subjects, not a compre-

hensive textbook. It addresses many issues and problems seen in long-term care facilities today. Each section of

the following chapters is meant to be a stand-alone topic, enabling you to quickly reference critical information.

The book is formatted and designed to make the material easy to find. However, because each subject is self-

contained, if the chapters are read sequentially, the sections may seem redundant. Please keep this in mind as

you review the material presented here.

Disclaimers

xiTh e Lo n g-Te r m Ca r e nu r s i n g De s k re f e r e n C e, se C o n D eD i T i o n © 2009 HCPro, Inc.

This book was developed to be a reference guide of up-to-date information that will help you survive and thrive

in the ever-changing long-term care facility environment. It is not meant to be an exhaustive or comprehensive

source of long-term care information, such as a textbook. The book was written using current clinical informa-

tion that is useful to nurses and nursing students and will complement more exhaustive sources of long-term

care nursing reference material.

As an experienced nurse, consultant, and author, I am considered an expert in some areas, including long-

term care. I have been called upon to assist in many long-term care–related lawsuits as an expert witness. An

expert witness assists the attorneys, judge, and jury by explaining technical nursing information and opera-

tional aspects of long-term care. Much of the information in this book is based on my experience with the legal

system, both in chart reviews and as a testifying expert at deposition and trial. With today’s litigious society,

I believe that nurses must stay informed regarding legal issues affecting nursing practice. Sadly, resident acu-

ity has increased, some areas of the United States have a nursing shortage, and caring for residents has become

much more difficult than it was in the previous decade. The number of lawsuits against long-term care facilities

has increased. Some law firms virtually survive because of lawsuits against long-term care facilities and their

employees. I write about some of the issues here in hopes that you will benefit from the information in your

personal practice and stay out of the courtroom, which is usually not a fun place to be.

There is so much important information to share. All of the information here is relevant to nurses in long-term

care practice, but the data may not be committed to memory. The book is designed to make the material easy to

find. The format consists of many short, concise narratives, charts, lists, and tables so that you can readily access

and apply or implement the information. Because each subject is self-contained, if the chapter is read sequen-

tially, the sections may seem redundant. However, everything is important. Determining which subject is the

most important in this book would be impossible. Some of the information is difficult to find in other nursing

sources. Information is grouped together in a logical format that will enable you to quickly locate the informa-

tion about subjects for which the long-term care nurse is accountable. Section headings will assist you in finding

the information quickly. Each chapter contains a listing of Web references for additional, related information.

In addition to the care provided by physicians, some facilities are also fortunate to have the services of advanced

practice nurses (including nurse practitioners and clinical nurse specialists) and physician assistants. These well-

educated and highly qualified individuals provide excellent care to residents in long-term care facilities. In many

situations in this book, we note that physician notification is necessary. We are using the term “physician” for

brevity only. This is not intended to minimize the important work of advance practice nurses and physician

Introduction

xii Th e Lo n g-Te r m Ca r e nu r s i n g De s k re f e r e n C e, se C o n D eD i T i o n© 2009 HCPro, Inc.

in T r o D u C T i o n

assistants. When the reader is advised to notify the physician, facilities may also notify the advanced practice

nurse or physician assistant if available and as required by state law and facility policies.

Regulatory demands and resident acuity are increasing. The second edition of this book includes updated regu-

latory and quality assurance information to assist facilities in their mission of providing high-quality care. Safety

and infection control information has also been expanded. I deeply admire the many professionals who are

committed to our long-term care elderly, and sincerely hope the information is useful to facilities in providing

quality care and making a difference in the lives of the residents.

Acknowledgments

The Long-Term Care Nursing Desk Reference, Second Edition was written with a great deal of professional

collaboration.

As always, I am grateful for the unfailing support of my family, particularly my husband, Francis, whose able

assistance allows me to continue my writing endeavors. I could not spend many long hours at the computer

without the complete cooperation and support of my children and grandchildren.

Adrienne Trivers, HCPro Managing Editor, has nurtured this project through manuscript development to the

completed book you hold in your hand. Her foresight, acumen, and close contact with the industry identified a

need for this manual. I sincerely appreciate her vision of excellence in nursing publishing. Many unnamed indi-

viduals at HCPro handle the manuscript as it makes its way through the production process. Each individual

makes a contribution that ultimately enhances the value of the book, and I am eternally grateful for their efforts.

My sincere thanks to Ken Reynolds, LNHA, for his unfailing assistance and support as a reviewer, first reader,

and technical advisor. The following individuals and organizations have directly contributed to the development

of this book, and I sincerely appreciate their cooperation:

Nancy Bergstrom, PhD, RN

Phil DuBois, LNHA, and the staff of Market Square Health Care Center

Beverly Futrell, CNA

Genevieve Gipson, RN, MEd, RNC

Charlene Harrington, RN, PhD, FAAN

Steve Warren, Skil-Care Corporation

Please feel free to contact me through HCPro Publishers or by e-mail if you have questions or comments.


[email protected]

1Th e Lo n g-Te r m Ca r e nu r s i n g De s k re f e r e n C e, se C o n D eD i T i o n © 2009 HCPro, Inc.

Standards of Practice

A profession is an occupation or career, such as law, medicine, or engineering, that requires considerable edu-

cational preparation and specialized study. A professional is an individual who is engaged in certain activities or

careers, such as lawyers, doctors, nurses, and other professional people. Professionals are educated, qualified,

and often must be licensed to perform these duties. Professional behavior involves conforming to the standards

of the profession. A professional may be considered a skilled practitioner or expert.

All professions have standards and practices for their members. The standard of care is the degree of care or

competence that one is expected to exercise in a particular circumstance or role.1 In the nursing profession, the

American Nurses Association (ANA) and state licensure boards identify standards for registered nurses to fol-

low. Failure to provide care that meets or exceeds these standards may cause patient/resident harm and is cause

for disciplinary action against the licensee.

The standard of care is what a reasonable, prudent professional would do based on his or her education, expe-

rience, institutional policies and procedures, standards set by the relevant professional organization(s), text-

books, research, and professional literature. The standard of care is not what the best professional would do

but rather what any reasonable professional would do in the same or similar circumstances.

Technology and practices change rapidly. Facilities must strive to keep their policies and procedures up to

date. If facility policies and procedures are outdated, research and evidence-based practices supersede facility

policies and procedures. If a professional holds certifications and advanced education, he or she is held to the

same standard as other professional individuals with like qualifications. For example, if a registered nurse

holds a certification in gerontologic nursing care, he or she is held to a higher standard than nurses without

this certification.

Standards of PracticeChapTer one

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Negligence is failure to exercise the degree of care considered reasonable under the circumstances, resulting in

an unintended injury to another party2—in other words, failing to meet the professional standard. Malpractice

constitutes mistakes or negligent conduct by a professional that result in damage or harm to others.3 The care

of each patient or resident involves many standards of care. No single standard encompasses all professionals

caring for the individual. Many standards apply to each profession and each situation.

Adhering to professional standards of practice or standards of care protects the residents from injury. It also

protects both the professional and healthcare facility from liability. This is an area in which your knowledge

must constantly be updated. Today’s healthcare system is weighed down by excess paper, including documents

generated by mail and those created by photocopying and faxing. Electronic technology is beginning to re-

place paper systems, improving communication and enhancing its effectiveness, as well as making it more

cost-effective.

ANA standards require that documentation be based on the nursing process. It must be ongoing and accessible

to all members of the healthcare team. An experienced reader can readily identify the various components of the

nursing process when reading the medical record. Years ago, nurses often neglected documentation, focusing

instead on resident care. If they were busy with resident care, documentation suffered. “Put the patient ahead

of the paper” was a common expression. Today, management must support nurses in finding a way to do both.

Documentation is part of the resident’s care, and nurses no longer have the luxury of choosing between provid-

ing care and keeping records.

Documentation validates that care was given. Sometimes, it proves that the facility was providing care it was

paid to provide. It is an essential element of communication. Accurate and complete documentation is essential

so others can determine what has been done. All healthcare practitioners rely on the data in the medical record

when they are planning future clinical approaches to resident care.

As healthcare professionals, we all have a broad knowledge of many subjects. We have specific, specialized

knowledge in our selected areas of expertise and practice. Nevertheless, knowing all we need to know about

every subject is impossible. For the most part, our generalized knowledge sustains us, but sometimes we must

learn more about applicable, current standards in subjects outside our specialty area. At the very least, profes-

sionals must familiarize themselves with new drugs. Aside from that, you may be faced with situations in which

you will need to research standards, even if you think you know them cold. Some of the simplest standards

may be the most difficult to find, and you may need to be resourceful to find what you need. Sources of infor-

mation about current standards can be obtained from the following:

sT a n D a r D s o f pr a C T i C e


Licensure boards and certifying bodies •

Nurse practice acts •

Professional organizations and associations •

Educational institutions•

Professional journals•

Current textbooks•

Policy and procedure manuals •

State and federal regulatory agencies for your facility •

ConclusionKnowing and following the standards of practice for your profession and employment setting will ensure that

residents receive quality care. Applying professional practice standards does the following:

Protects resident (and employee) safety•

Achieves desirable resident (care) outcomes•

Facilitates access to appropriate services and levels of healthcare•

Identifies the scope of accountability for nursing care•

Reduces nurse and facility liability •

References to ANA standards of practice are listed throughout this book and are relevant in all states. See http://

nursingworld.org or call 1-800-274-4ANA to order ANA standards and other publications.

The Nonnegotiable Nature of the ANA Code for Nurses with Interpretive Statements

SummaryThe ANA Code for Nurses with Interpretive Statements (Code for Nurses) lists and describes the goals, values, and

ethical precepts that direct the profession of nursing. The ANA believes the Code for Nurses is nonnegotiable

and that each nurse has an obligation to uphold and adhere to the code of ethics.

BackgroundHealthcare ethics are concerned with the rights, responsibilities, and obligations of healthcare professionals,

institutions of care, and clients. Upon entering the profession of nursing, nurses accept the responsibilities

and trust that have accrued to nursing over the years and also the obligation to adhere to the profession’s

code of ethics. The Code for Nurses, published by the ANA, is the standard by which ethical conduct is

guided and evaluated by the profession. It provides a framework within which nurses can make ethical

Ch a p T e r o n e


decisions and discharge their professional responsibilities to the public, to other members of the health team,

and to the profession.

The Code for Nurses is not open to negotiation in employment settings, nor is it permissible for individuals,

groups of nurses, or interested parties to adapt or change the language of this code. The Code for Nurses

encompasses all nursing activities and may supersede specific policies of institutions, employers, or practices.

Therefore, the content of the Code for Nurses is nonnegotiable.

Overview of Standards of Gerontological Nursing Practice

Caring for elderly residentsGerontological nursing focuses on identifying the resident’s strengths and assisting the resident in using these

strengths to maximize his or her independence. The aging adult is involved in decision-making to the fullest

extent possible.

Factors the gerontological nurse must consider when caring for aging residents include the following:

Consequences and complications of the aging process•

Individual effects of the aging process on each client; the different rates at which people age•

The effect of losses on the client•

Social, economic, psychological, and biological factors•

The response of the client to the illness and treatment•

The cumulative effect of multiple chronic illnesses and degenerative processes•

The client’s cultural values•

Societal attitudes and cultural values associated with aging•

Basic gerontological nursing practiceBasic gerontological nursing practice is performed in a number of settings. Responsibilities of the gerontological

nurse include the delivery of direct care, the management and development of nonprofessional caregivers, and

the evaluation of care and services for the client. All professional nurses caring for geriatric clients must have the

basic knowledge and skills to do the following:

Develop the care plan by using the nursing process•

Establish a therapeutic relationship with the client and family•

Recognize age-related changes •

Collect data to determine health status and functional ability•

Function as a member of the interdisciplinary team•



Participate with clients, families, and other healthcare providers in making ethical decisions•

Act as an advocate for the aging client and family members•

Teach clients and families about measures that promote independence, maintain and restore health, and •

promote comfort

Act as a source of referrals to other professionals or agencies, as appropriate•

Apply existing knowledge in geriatrics to nursing practice and interventions•

Protect the client’s rights and autonomy•

Participate in continuing education, state and national professional organizations, and certification•

Apply the standards of gerontological nursing practice to improve clients’ quality of care and quality of life•

Standards of gerontological nursing careMeasuring nursing care also evaluates accountability. The ANA Standards of Gerontological Nursing Practice

provides a tool to measure accountability. Measurement criteria are listed for each standard so that nurses may

assess their own performance and managers can assess staff members’ performance.

Types of standardsThe first standards were published in 1981. In 1994, the standards were revised to reflect the current scope of

practice and address health promotion, health maintenance, disease prevention, and self-care. The standards

now address the full scope of gerontological nursing practice in two parts: Standards of Clinical Gerontological

Nursing Care (Standards of Care) and Standards of Gerontological Nursing Performance.

Standards of CareThe Standards of Care include:

Assessment: Collection of resident health data•

Diagnosis: Analysis of assessment data to determine diagnosis•

Outcome identification: Identification of outcomes individualized to the client•

Planning: Development of a care plan that prescribes interventions necessary to attain expected outcomes•

Implementation: Implementation of the interventions listed in the care plan•

Evaluation: Evaluation of the client’s progress toward attainment of expected outcomes•

Standards of Gerontological Nursing PerformanceThe standards for professional performance describe a competent level of behavior, including activities related

to quality of care, performance appraisal, education, collegiality, ethics, collaboration, research, and resource

utilization. Gerontological nurses are expected to engage in appropriate activities for their level of education,

position, and practice setting. Gerontological nurses should seek activities such as membership in professional

organizations, specialty certification, further education, or advanced practice education.

Ch a p T e r o n e


The Nursing Process

The nursing process consists of four steps:

1. Assessment of the resident’s health data

a. Analysis of data and formulation of a nursing diagnosis

2. Planning priorities for resident care

3. Implementation of the plan according to priorities and planned outcome criteria

4. Evaluation of the resident’s response and revision of the plan as necessary

Although a review of the nursing process may seem elementary, use of the nursing process is a critical element

in the delivery of effective long-term care. Managerial personnel will find that units run more efficiently and

effectively if the nursing department promotes and adheres to this model of care. A breakdown of the nursing

process commonly leads to negative outcomes and litigation. The process begins with assessment—a key ele-

ment that is often missing in residents with negative outcomes. Since assessment provides the foundation for

the nursing process, the remainder of the process is ineffective without it. When making clinical judgments,

nurses must base their decisions on the consideration of consequences, which prescribe and justify nursing

actions.4 Nurses often have a mental block when it comes to using care plans. This undoubtedly comes from

nursing school. Working to actively overcome this mental block is critical. When the care plan is implemented

in accordance with the standards of good clinical practice, it becomes a powerful tool in providing quality care

to residents. The care plan should be used to guide staff in implementing interventions that enhance and pro-

mote each resident’s path toward achieving or maintaining his or her highest practicable level of well-being.

Assessment consists of an initial and ongoing examination of the resident’s status. Upon completion of the

assessment, the nurse makes a complete diagnostic statement to guide the care plan. Nursing diagnoses are

statements describing the resident’s response to illness, injury, or diagnosis. Nursing diagnoses are listed

according to priority and are based on a mutual resident-nurse decision. Realistic care plan priorities are devel-

oped to meet the resident’s individual needs. The plan is implemented, with the nurse constantly assessing

the effectiveness and ineffectiveness of the approaches. The resident’s progress is evaluated based on designated

outcome criteria. The plan is continually reassessed, modified, and updated to assist the resident in achieving

the established goals. Using the nursing process is an excellent means of ensuring high-quality nursing care.

Documentation and quality of the residents’ care plans are greatly enhanced if they reflect the use of the

nursing process.

In long-term care, the resident is completely assessed at the time of admission. The resident is at high risk for

negative outcomes at this time because he or she is not familiar with the facility, staff are not familiar with the

resident, and medical problems may be unstable. A nursing care plan is initiated immediately, describing care



for obvious medical problems and high-risk conditions. (This is a temporary plan that will be replaced with a

comprehensive interdisciplinary care plan when the Minimum Data Set [MDS] is completed.) The plan should

describe the immediate care of the resident after admission or a significant change in status.

All direct care staff should be involved in the care planning process. They have the most frequent contact with

residents and are often knowledgeable about a resident’s daily life, needs, problems, and strengths. Staff who

have not participated in care plan decisions should be informed about how the care and services they provide is

intended to improve, maintain, or minimize decline in the resident’s condition and well-being. This information

is essential to their understanding of the care they provide and the expected outcomes for the resident. Without

knowing the reasons they are performing particular tasks, direct care staff may not understand the relationship

between the care and services they provide for a resident and the expected outcomes for that resident.

The care plan should be:

Created promptly on admission, listing high-risk conditions and obvious/evident problems•

Reflective of a review of the medical record, identifying medications that require monitoring and other •

potential problems that may not be triggered by the MDS, such as use of warfarin (Coumadin)

Further refined after various admission assessments•

Updated as often as necessary to ensure the plan is current•

Promptly updated and modified for illness or change in condition•

Readily and freely accessible to direct caregiving staff•

Used as the basis of making assignments and giving reports to direct care staff•

Reviewed each shift with appropriate direct care personnel (problems, goals, approaches)•

Reviewed as often as necessary by caregiving staff•

Implemented (problems, goals, approaches)•

Evaluated (effectiveness of problems, goals, approaches)•

Revised if approaches are ineffective, inappropriate, or no longer relevant•

Gerontological nursing practice involves assessing the health and functional status of aging adults, planning

and providing appropriate nursing and other healthcare services, and evaluating the effectiveness of such

care. Emphasis is placed on maximizing functional ability in activities of daily living; promoting, maintain-

ing, and restoring health; preventing and minimizing disabilities of acute and chronic illness; and maintaining

life in dignity and comfort until death. Gerontological nursing focuses on the resident and his or her family.5

Documentation should reflect the nursing process, including observations, assessments, care given and resident

response, and revision of the plan of care as appropriate.

Ch a p T e r o n e


Chapter Resources

References1. Merriam-Webster’s Dictionary of Law (Merriam-Webster’s, Incorporated, 1996).

2. The American Heritage® Dictionary of the English Language, Fourth Edition (Houghton Mifflin

Company, 2000).

3. Ibid.

4. American Nurses’ Association, Code for Nurses. (Washington, DC: American Nurses Publishing, 2001)

5. American Nurses’ Association, Scope and Standards of Gerontological Nursing Practice. (Washington, DC:

American Nurses’ Publishing, 1997).

Web resources•AgencyforHealthCarePolicyandResearch:www.ahrq.gov•AmericanNursesAssociation:www.nursingworld.org•EthicalConductforHealthcareInstitutions:www.hospitalconnect.com•CenterforHealthCareEthics:http://chce.slu.edu•CentreforAppliedEthics:www.ethics.ubc.ca•CenterforClinicalEthics:http://wings.buffalo.edu/faculty/research/bioethics•HealthOntheNetFoundation:www.hon.ch•InstituteforHealthcareImprovement:www.ihi.org/IHI•KennedyInstituteofEthics:www.georgetown.edu•NationalCouncilofStateBoardsofNursing,Inc.:www.ncsbn.org•NationalGuidelineClearinghouse:www.guideline.gov•NursingHomeProjectDescription:www.qualitynet.org/dcs/ContentServer?pagename=Medqic/MQPage/Homepage •InstituteforHealthcareImprovement:www.ihi.org/ihi•QualityTools:www.ahrq.gov•SharingInnovationsinQualityProfessionalStandardsandGuidelines:http://siq.air.org•StandardofCare:www.standardofcare.com•TexasMedicalFoundation:TheQualityImprovementOrganization(QIO)forTexas(contentapplicableinallstates):

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SECOND EDITION the LoNg-teRm CaRe Nursing Desk Reference the LoNg-teRm CaRehcmarketplace.com/media/browse/6650_browse.pdf · 2019-09-06 · the LoNg-teRm CaRe Nursing Desk Reference