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Participate in the Implementation of Individualised Care Plans

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Presentation on theme: "Participate in the Implementation of Individualised Care Plans"— Presentation transcript:

1 Participate in the Implementation of Individualised Care Plans

2 Aims and Objectives Plan work activities according to an individualised plan Establish and maintain appropriate relationships with clients and carers Provide and monitor support according to the individualised plan Contribute to ongoing relevance of the individualised plan Respond to situations of risk to the client within work role and responsibilities Complete documentation and reporting

3 Planning work activities

4 Organisational policies and procedures
Policies set out the general standards of service for that agency to achieve- must be accessible to all staff, clients and other interested parties. Procedures are specific written instructions that explain what a staff member is to do, step by step in a particular situation. It is YOUR responsibility to be familiar with the P & P within your work

5 Individualised Plans Also called Care Plans, Service plans, Client plans. A care plan is an individualised plan of care and gives directions for staff to follow in the provision of care. The plan details the care requirements that a person needs on a daily basis. This type of document is generally used in long term care because it replaces the need to detail all care given each day in the resident’s case notes.

6 Individualised Plans Provide an accurate, concise notation of the residents’ current condition. The care plan provide information about the resident’s goals and care needs. The care plan is a recipe about how the care needs to be provided. The notes provide baseline information on which to record any improvement or deterioration in the resident’s condition. A care plan is an individualised plan of care and gives directions for nursing staff to follow in the provision of care. Care plans are an essential document in the long term care of residents. The care plan details the care requirements that a person needs on a daily basis. This type of document is generally used in long term care because it replaces the need to detail all care given each day in the resident’s case notes. Instead a nurse/aid can document that all care has been conducted as per the nursing care plan and then just document changes. So, a care plan is basically a comprehensive document detailing all care considerations for example: In the health care setting the residents notes and care plan should: • Provide an accurate, concise notation of the residents’ current condition. • The care plan will provide information about the resident’s goals and care needs. • The care plan is a recipe about how the care needs to be provided. • The notes provide baseline information on which to record any improvement or deterioration in the resident’s condition. • The record provides evidence of care. The records will provide information about what care was provided, by whom, when and any comments from the resident, doctor, or significant other. • The notes provide a record about any emergencies which may have occurred and how these were handled.

7 Individualised plans The record provides evidence of care. The records will provide information about what care was provided, by whom, when and any comments from the resident, doctor, or significant other. The care plan is a dynamic document, meaning that it changes regularly dependent on the needs and changes in the resident. It should be used and reviewed on a regular basis. The care plan is a care tool to direct and guide staff in how the care needs to be provided to the resident. Care plans need to be individually tailored to the care needs of the individual, there is no magic formula to suit all residents, however there are some basic guidelines which you can follow in order to formulate the care plan.

8 The Nursing Process and Care Planning
Assessment Planning Implementation Evaluation Conducting appropriate assessments on the individual will ensure accuracy in determining the care needs.   Let’s now review a sample care plan which is completed after an assessment on a particular issue has been identified. Sample Care Plan - Impaired Verbal Communication Problem: Impaired verbal communication related to: • Decreased oxygen to the brain. • Unable to speak English • Impaired articulation. • Disorientation. • Loose association of ideas, • Inability to speak sentences. • Slur or stutter. Goal: Resident will communicate and participate in activities of daily living using either verbal or non verbal modes. Interventions: • Assess contributing factors. Note whether the problem is expressive (loss of speech), Sensory (unable to understand words, Conduction (slow comprehension) or Global (loss of comprehension and speech). • Determine native language spoken and cultural background. • Assist patient to establish means of communication. • Listen carefully to patient on verbal expressions. • Validate meaning of non-verbal communication. • Maintain eye contact. • Keep communication simple. • Plan for alternative methods of communication (written instructions or picture boards). • Maintain a calm unhurried manner- allowing time for the resident to respond. In the sample care plan, you can see that there is a variety of reasons why a person will have impairments in verbal communication. However, the goal is simple… ensure that the resident can communicate their care needs to the staff. It is important that you have a plan for the interventions. If these interventions are written clearly and simply then it is more likely that they will be followed by all staff. If your interventions are difficult to read and understand, the risk is that they will not be followed by the staff which in turn will affect the care that the resident will receive. Activity: What do you document where? In small groups, review the sample care plan (in learner guides, reading section) and discuss examples of issues you write in progress notes, daily living charts, and other documentation you think may be relevant. Debrief: Ask each group to present an issue, and facilitate a discussion about where and how to document it. Go around the groups until all issues have been presented. Resident Classification Scale Funding for the care of residents varies based on their relative care needs. Through the Resident Classification Scale (RCS), all residents are categorised into a care category. The category determines a level of subsidy. The appraisal used for the RCS does not consider all of a resident’s care needs. It considers those factors that have been identified as contributing the most to differences in the total cost of care. As we have discussed previously, good documentation is necessary to indicate the care needs of your aged residents. The Resident Classification Scale (RCS) process is audited to ensure that the standard of documentation is maintained. This means that auditors will check that the resident is thoroughly assessed, before the plan of care is constructed. They will ensure that the assessment has been conducted in a fair way. It is usual that a person who has just moved into a new facility will feel scared and possibly exhibit more challenging behaviours and function less independently, than they will over a reasonable period of time. In the past the assessment period was completed too soon after the resident arrived in the facility and didn’t accurately assess the needs of the resident once they had settled down. The auditors will check that the assessment findings are reflected in the plan of care. In addition they will review the progress notes for any changes which have occurred in the resident condition since the formation of the care plan. Therefore good documentation is essential in ensuring that the audit goes well and that accurate funding will be received by the facility to provide for the care needs. The RCS assigns funding on the level of care that a person requires. The RCS has 22 questions related to determining the care needs of a resident. Each of these questions has four levels of care to choose from. • Level A refers to residents that need no assistance or have no difficulty in the question content. • Level B refers to the resident that needs occasional or some assistance with the care needs identified by the corresponding question. • Level C- refers to a person needing major assistance in the reference question • Level D refers to the person needing extensive support for care provided in the reference question. Trainer note: please try to provide real life examples as you discuss the following. Alternatively, ask participants to provide examples they think may illustrate different levels. This should be a lively, interactive session, not a straight lecture. Areas of care identified in the RCS. Communication: This question refers to the degree of assistance that a person has to communicate with staff, friends and family. This question measures the additional support that staff provide to encourage a resident to communicate their needs and socialize with others. Mobility- This question refers to the degree of assistance that a resident needs to change their location. This question includes the amount of assistance that the resident needs to mobilize, transfer and use mobility aids. Meals and drinks- this question refers to the amount of assistance that you need to give your resident to eat and drink. This question includes sitting up the person, the amount of prompting and encouragement you provide for them to finish eating their meal and any individual assistance you need to provide, such as feeding them. Personal Hygiene- this question asks about the amount of assistance that the resident needs to shower, dry, dress, and groom themselves. You need to ensure that you document everything that you need to do for the resident including nail care, makeup and applying skin cream. Toileting- how much assistance do you need to give your resident to take them to the toilet, attend personal hygiene after toileting and adjust their clothing (before and afterwards). You need to record emptying of a catheter within this question. Bladder Management- refers to the care and management of urinary incontinence. You need to document t how frequently the person is incontinent and ensure that you have a bladder management program in place to reduce the frequency of incontinence. Bowel Management- much the same as bladder management question except refers to the bowel management plan and need for fluids, high fibre diet, aperients and exercise. Understanding and undertaking living activities- refers to the resident ability to remember, understand, follow, plan, initiate the activities of living and respond appropriately to direction you may give them to assist them maximising their independence. Problem wandering or intrusive behaviour- this question asks you to describe the behaviour if they wander around the facility with no clear direction, interfere with other residents, take other peoples belongings or abscond from the facility. Verbally disruptive or Noisy behaviour- means that you need to intervene for abusive language skills, and verbalised threats to staff and others. Noisy behaviour can be verbal and non vocal including banging on bed rails with cups or loud TVs. It only has to be enough noise to disrupt others. Physically aggressive behaviour- covers any physical contact that is threatening or the potential to cause harm in others. This is not limited to hitting, pushing, kicking or biting behaviour. Emotional dependence- this question refers to the amount of one to one assistance that your resident has to alleviate behaviours such as active and passive resistance, attention seeking, manipulative behaviour and withdrawal. Danger to self or others- this question refers to high risk behaviour which requires observation and management. This is behaviour such as unsafe smoking habits, walking without their walking aids, leaning out of windows etc. You need to document any triggers to the behaviour and how it is managed so it is important that you are specific in the description of the behaviour for any finding to be applied. Other behaviour - this question refers to any behaviour which hasn’t been claimed for in any of the above questions. This can include anything that requires staff to attend additional time to manage and prevent. Social and human needs refers to the amount of social and emotional support that the resident needs to continue with their socialisation and maintenance of relationship with family and friends. This question can include any board games you play, reading the newspaper, church activities, assisting the resident to attend any appointments. Social and Human needs (family and friends) the focus of this question is to determine how much time the family need for reassurance, emotional support and guidance to families for care planning, guardianship matters, and cultural/ religious matters. Medication- this question is generally answered by the registered nurse. The question asks about how much assistance a resident needs with their medication. Technical and complex nursing procedures- refers to the amount of care that a person needs to: • Maintain skin integrity • Eye care • Nebulisers • Oral hygiene • BP and BSL measurement • Wound dressings • Tube feeding • Catheter care • Stoma care • Oxygen therapy • Pain management programs Therapy- this includes the needs for therapy to maintain the current physical condition of the resident. Therapy can include physiotherapy, occupational therapy, walking exercises, speech therapy and diversional therapy. Other services required in the care of the resident, such as psychologist, dietician, podiatrist, social worker, music therapist and aromatherapist. The aim of RCS writing is to ensure that the facility receives the correct funding to ensure adequate care of the residents. Without this funding facilities would be unable to pay for the nurses and equipment for the care to be given. Hence it is essential that documentation adequately indicates the care needs of the resident. Let’s look at the types of things you should report on. Here are some examples of what you need to report/assess on. Communication - You need to indicate why the resident has difficulty communicating and write about what you need to do to overcome the problem. The resident may have the following difficulties related to communication: speech impairment due to a physical problem, language difficulty, slurred speech, use of wrong words, muddled speech poor concentration so he can’t remember what you said, unable to remember visitors, short term memory. Inability to understand directions hence has an inability to know what time to eat, sleep, shower etc therefore you may need to remind the person about completing their activities of daily living. Hearing problems which may need you to speak slowly and loudly, or insert hearing aids Visual problems so you may need to read books or the news to the person, you may need to speak closely to their face. For each of these possible problems, your report will need to indicate how frequently and what you need to do to encourage the resident to communicate. Mobility – you need to document the following for this question. Mobility- do you need to support the person under the elbow for them to walk. How far can the person walk and what level of supervision is needed? Does the person walk with a frame? Transfers- you need to comment how you transfer the resident. This can be using pelican belts, mechanical lifters or support from a nurse. Refer participants to their learning guides for the sample care plans. The sample care plans provide the participant with ideas about what types of interventions can be written on the care plans. An example of the documentation required to be completed under this category is: Impaired Physical Mobility. Issue: Impaired physical mobility related to: • Advanced disease processes. • Decreased muscle strength • Limb weakness related to the ageing process. • Chronic pain from arthritis. • Potential for falls related to senescent gait disorder. • To maintain optimum level of weight bearing ability. • To maintain optimum mobility and reduce the risk of falls. Interventions. • Walk with one nurse daily over short distances with the use of aid as able. • Push in wheelchair over longer distances. • Eliminate pain and discomfort associated with mobilisation. • Instruct resident in and assist with the correct use of mobility aids. • Teach resident that the primary goal of mobilisation is to maintain function in all joints. • Allow resident sufficient time to complete task. • Assist resident with transferring. • Assist resident to toilet/ dining areas/ bedroom as required. • Raise all effort made with self mobility to promote self confidence. Meals and Drinks- you need to document what type of assistance the person needs, this can include: • Soft diet/ minced or normal meal type • Do you cut up the food and prepare the fluids? • Do you supervise the person while they eat and encourage them to finish the meal? • Does the person need special utensils or plate guard to eat independently? • What type of appetite does the person have? By answering these questions fully you are assisting others to provide seamless care for the residents. The more in depth that you answer these questions, the better the care and funding that the person will receive. Personal hygiene- you need to document what care you give a person to assist with showering, drying, dressing and grooming. Things that you can document on include: • can the resident wash parts of themselves or do you need to do it for them? • Do you need to supervise throughout? • Do you apply makeup or shave the person? • Do you cut their fingernails? • How much help and what help do you need to give the person so they are clean and dressed? Toileting- this question asks about assisting the person on the toilet, adjusting clothing and post toilet hygiene so that they can go to the toilet. Things that you need to document on include: • what assistance do you need to give the resident to use the toilet? • Does the person ask for assistance to the toilet? • How much assistance do you give the person? Continence- is your resident incontinent? And if so you need to ensure that this has been assessed to make an effort to reduce the incontinence. Thing that you document on include: • Any toileting that you assist with? • Any continence aids that are used? • Amount of groin care that you provide to prevent excoriation. • How frequently the person is incontinent and if it is bowel and bladder incontinence. • Does the person need medication to help with their bowel (manage constipation). Comprehension - you need to document if the resident understands their activities of daily living. You need to record if your resident needs prompting to complete daily living skills such as personal hygiene, toileting etc or do you need to do these things for the resident. Is your resident orientated to time and place, in other words… does your resident know where they live or where they are and what day and month it is? Behaviour. Residents can exhibit a range of behaviours which you need to comment on. These behaviours include the following: • Wandering- this means that the person walks around the facility with no clear direction. Does the person walk into other people’s rooms? • Pilfering- taking items that don’t belong to them. Some people take a range of things from others and don’t know why. • Verbal aggression- includes screaming and swearing. • Physical aggression- includes punching, pinching, kicking, throwing things. • Attention seeking- includes calling out for staff attention, constantly ringing the call bell, banging on rails or chairs with cups or plates. • Manipulative behaviour - this can include favoritism of staff, telling staff about others so that fights between staff can occur. • High risk behaviour such as climbing over bed rails, unsteady walking when they could fall over and smoking (especially if you need to supervise the person otherwise they will burn themselves or other things. • Unsocial behaviours and bizarre behaviours such as spitting on the floor or wiping food on tables, including eating other people’s food. • Suspicious of others • Confused and disorientated • Impulsive • Sexual behaviours For all of these behaviours you need to assess the behaviour to determine how frequently it occurs and when it occurs most frequently. Then you need to document in the care plan ways that you manage the behaviour and prevent its occurrence, if you are unable to prevent it from occurring you need to write how you can reduce it. Refer participants to their workbooks for an example of a behaviour chart. 3 Organisational Correspondence 30 mins Every organisation sends and receives correspondence. Q. What form can correspondence take? Mail; Facsimiles; ; Memos; Messages; Internal reports; Organisational newsletters, etc. Activity: Incoming and Outgoing! Divide the group into 2 subgroups. Subgroup 1 will explain the process for incoming correspondence. Subgroup 2 will explain the process for outgoing correspondence. Rules: 1.     Pax are not allowed to do a straight presentation (i.e. it has to be creative) 2.     The presentation may only be 2 minutes long 3.     The presentation must cover the main ‘checkpoints’ in the process. 4.     Everybody in the group needs to be involved in the presentation Trainer note: participants may choose to draw the process on a flipchart, or to ‘act out’ the process, etc. Give 10 mins to prepare Each subgroup ‘presents’ Facilitate a discussion about the importance of correspondence to their organisation, and participants’ role in handling correspondence 15 mins Afternoon Tea Break 4 Providing Information There may be situations where you need to present information that has been collected previously and stored in some way. Q. What are examples of situations where you need to present information? Q. What are ways you can present information? Written (reports, s, letters, newsletters, memo’s, etc) or verbal (formal presentations, telephone conversations, meetings, etc) Q. How would you make sure that you present the information accurately and effectively? Know your audience; gather and analyse information carefully to meet audience needs; structure information logically (i.e. will be different for a written report than for a verbal report); review written report and ask someone to proofread; rehearse verbal report in front of someone. Activity: Privacy and Confidentiality Privacy and confidentiality are very important issues as they relate to individual rights. Divide into small groups and refer participants to their learner guides. Give 10 minutes to discuss the questions. Go through the questions and ask groups to present their answers. 5 Assessment Tasks Refer participants to their Learner Guides and explain the assessment tasks for this module. Make sure all participants understand what is required and are comfortable with what they need to do. 6 Summary Day 1 15 mins Activity: quiz show This activity aims to test participants’ knowledge. Divide into small groups (3 pax). Distribute the system cards (each group gets approx 10 cards). Tell participants to go through all the materials covered today and come up with 10 questions, with the answers, to be used in the Quiz Show. (approx 10 minutes) Collect all the cards and remove duplicate questions. While you do this, ask groups to choose a sound to make when they know the answer (i.e. the buzzer). Each group should have a separate sound. Shuffle the system cards and start the quiz show Keep score on flipchart At the end of the quiz, pronounce the winner and give them their prize. 7 Close 5 mins Facilitate a brief discussion about the most important learning points for the day. Make a link to the next module: Plan and Monitor a Service Delivery Plan Handout Evaluations.

9 Assessment Observation of their needs by sight, hearing, touch and smell • Communication with other members of the team to make accurate assessment of the care needs of the resident. Sometimes care workers need to provide different care activities to the same resident. Either because the resident favours a particular care worker of that the worker has expert knowledge. Assessment of the Resident Assessment of the care needs of a resident requires: • Observation of their needs by sight, hearing, touch and smell • Communication with other members of the team to make accurate assessment of the care needs of the resident. Sometimes care workers need to provide different care activities to the same resident. Either because the resident favours a particular care worker of that the worker has expert knowledge.

10 Assessment A thorough assessment must be compiled in a variety of areas to determine the long term care needs and goals of client care. Areas of assessment include the following: Physical care needs Psychological care requirements Socialisation needs of the individual Spiritual needs Assistance to maintain their personal affairs Relationships with family and others A thorough assessment must be compiled in a variety of areas to determine the long term care needs and goals of client care. Areas of assessment include the following: • Physical care needs • Psychological care requirements • Socialisation needs of the individual • Spiritual needs • Assistance to maintain their personal affairs • Relationships with family and others

11 Assessment forms currently used
Personal profile Communication Assessment Social and emotional needs assessment Nutrition and Hydration Assessment Mobility Assessment including falls risk and manual handling assessments Personal hygiene assessments, physical assessments oral hygiene assessments Toileting assessments Continence assessments Bladder and bowel Psychogeriatric Assessment scale (PAS) Behaviour Assessment – Verbal, Wandering, Physical agitation Cornell depression scale Medication Assessments Complex care needs Assessments – Pain scales, Waterlow scale for skin integrity, diabetes Assessment etc Discuss the Resident Profile forms that are used to carry out an initial assessment on the client. Current requirements for ACFI Forms include: Personal profile Communication Assessment Social and emotional needs assessment Nutrition and Hydration Assessment Mobility Assessment including falls risk and manual handling assessments Personal hygiene assessments, physical assessments oral hygiene assessments Toileting assessments Continence assessments Bladder and bowel Psychogeriatric Assessment scale (PAS) Behaviour Assessment – Verbal, Wandering, Physical agitation Cornell depression scale Medication Assessments Complex care needs Assessments – Pain scales, Waterlow scale for skin integrity, diabetes Assessment etc

12 Planning Once the assessment is completed goals of care need to be developed. The goals determine whether a client will be able to restore or maintain their current level of care. The goal of care may be to improve the person’s current ability or simply to preserve their current function and level of independence.

13 Providing Information
Sample Care Plan Impaired Verbal Communication Identified need/Problem: Impaired verbal communication related to: Decreased oxygen to the brain. Unable to speak English Impaired articulation. Disorientation. Loose association of ideas, Inability to speak sentences. Slur or stutter. Let’s now review a sample care plan which is completed after an assessment on a particular issue has been identified. Sample Care Plan - Impaired Verbal Communication Problem: Impaired verbal communication related to: • Decreased oxygen to the brain. • Unable to speak English • Impaired articulation. • Disorientation. • Loose association of ideas, • Inability to speak sentences. • Slur or stutter. In the sample care plan, you can see that there is a variety of reasons why a person will have impairments in verbal communication. However, the goal is simple… ensure that the resident can communicate their care needs to the staff. It is important that you have a plan for the interventions. If these interventions are written clearly and simply then it is more likely that they will be followed by all staff. If your interventions are difficult to read and understand, the risk is that they will not be followed by the staff which in turn will affect the care that the resident will receive. Activity: What do you document where? In small groups, review the sample care plan (in learner guides, reading section) and discuss examples of issues you write in progress notes, daily living charts, and other documentation you think may be relevant. Debrief: Ask each group to present an issue, and facilitate a discussion about where and how to document it. Go around the groups until all issues have been presented.    30 mins Every organisation sends and receives correspondence. Q. What form can correspondence take? Mail; Facsimiles; ; Memos; Messages; Internal reports; Organisational newsletters, etc. Activity: Incoming and Outgoing! Divide the group into 2 subgroups. Subgroup 1 will explain the process for incoming correspondence. Subgroup 2 will explain the process for outgoing correspondence. Rules: 1.     Pax are not allowed to do a straight presentation (i.e. it has to be creative) 2.     The presentation may only be 2 minutes long 3.     The presentation must cover the main ‘checkpoints’ in the process. 4.     Everybody in the group needs to be involved in the presentation Trainer note: participants may choose to draw the process on a flipchart, or to ‘act out’ the process, etc. Give 10 mins to prepare Each subgroup ‘presents’ Facilitate a discussion about the importance of correspondence to their organisation, and participants’ role in handling correspondence 15 mins Afternoon Tea Break 4 Providing Information There may be situations where you need to present information that has been collected previously and stored in some way. Q. What are examples of situations where you need to present information? Q. What are ways you can present information? Written (reports, s, letters, newsletters, memo’s, etc) or verbal (formal presentations, telephone conversations, meetings, etc) Q. How would you make sure that you present the information accurately and effectively? Know your audience; gather and analyse information carefully to meet audience needs; structure information logically (i.e. will be different for a written report than for a verbal report); review written report and ask someone to proofread; rehearse verbal report in front of someone.

14 Sample care plan Goal: Resident will communicate and participate in activities of daily living using either verbal or non verbal modes. Assess contributing factors. Note whether the problem is expressive (loss of speech), Sensory (unable to understand words, Conduction (slow comprehension) or Global (loss of comprehension and speech). Assess contributing factors. Note whether the problem is expressive (loss of speech), Sensory (unable to understand words, Conduction (slow comprehension) or Global (loss of comprehension and speech).

15 Implementation The nurses actions
Like a written handover, how everyone should be carrying out the care. Ensures that everyone is doing the same level of care

16 Sample care plan Interventions:
• Determine native language spoken and cultural background. Assist patient to establish means of communication. Listen carefully to patient on verbal expressions. Validate meaning of non-verbal communication. Maintain eye contact. Keep communication simple. Plan for alternative methods of communication (written instructions or picture boards). Maintain a calm unhurried manner- allowing time for the resident to respond. Interventions: • Assess contributing factors. Note whether the problem is expressive (loss of speech), Sensory (unable to understand words, Conduction (slow comprehension) or Global (loss of comprehension and speech). • Determine native language spoken and cultural background. • Assist patient to establish means of communication. • Listen carefully to patient on verbal expressions. • Validate meaning of non-verbal communication. • Maintain eye contact. • Keep communication simple. • Plan for alternative methods of communication (written instructions or picture boards). • Maintain a calm unhurried manner- allowing time for the resident to respond.

17 Evaluation This includes your monthly, two monthly evaluation of how the person r the care is meeting their goals and preferences It assists to determine if the staff are meeting the needs of the client.

18 Evaluation See ACFI Checklists

19 What are the Care Worker responsibilities
READ the individualised care plans Evaluate them regularly Input into the care plans from your individual knowledge of the client Contribute to case conferences and feed back the effective actions you use

20 Appropriate relationships with clients

21 Communication Introducing yourself With client With staff
With management With relatives and friends Documentation

22 Introducing yourself Be polite. Use open communication skills.
Be genuine in your motivation. Provide name, position and the task you want to carry out. Wait until you have consent. Respect the person’s right to refuse. Check your own emotions, feelings, frustrations before you enter the room.

23 Communication with clients
Respect basic human rights Be approachable Sometimes need to make the first move to communicate Develop a trusting relationship Clear, calm, open language and body language. Be culturally sensitive. Allow clients to make as many decisions as they can.

24 Communication with staff
Be understanding of the mood/stress of other staff Be willing to work with them Use the “power with” not the “power over” principle Be willing to learn from others, instead of right every time. Work cooperately, plan and talk all shift.

25 Communication with Management
Understand that reporting on is part of your job role. Find convenient times to report. How urgent is the incident/ problem? Give your opinion in an appropriate setting. Be respectful of the position your manager holds. Provide clear communication or written documentation.

26 Appropriate relationships with carers

27 Communication with Relatives and Friends
Find out the policy on what you can communicate and who can communicate the information. Develop a rapport with relatives but do not breach confidentiality. Communicate what your job role allows but do not communication information outside of your scope of practice.

28 Confidentiality and Privacy
Personal information, which is obtained while caring for a client, is confidential. The client has the right to decide who to share this information with. Confidentiality applies to information that a client or other care worker tells you verbally or gives you in writing. It also applies to things that you learn through observation. All information in a person’s health care record is confidential and may not be disclosed without permission from the client or their guardian. Information may be shared with other relevant health and aged care workers when they need the information in order to provide appropriate care.

29 Maintaining Confidentiality
A carer has a moral duty and often legal obligation to protect the privacy of an individual by restricting information obtained in a professional capacity to appropriate personnel and settings, and to professional purposes. A nurse must, where relevant, inform an individual that in order to provide competent care, it is necessary for a carer to disclose information that may be important to the clinical decision making by other members of a health care team. A carer must, where practicable, seek consent from the individual or a person entitled to act on behalf of the individual before disclosing information. In the absence of consent, the nurse uses professional judgement regarding the necessity to disclose particular details, giving due consideration to the interests, well–being, health and safety of the individual and recognising that the carer is required by law to disclose certain information. A nurse has a moral duty and a legal obligation to protect the privacy of an individual by restricting information obtained in a professional capacity to appropriate personnel and settings, and to professional purposes. • A nurse must, where relevant, inform an individual that in order to provide competent care, it is necessary for a nurse to disclose information that may be important to the clinical decision making by other members of a health care team. • A nurse must, where practicable, seek consent from the individual or a person entitled to act on behalf of the individual before disclosing information. In the absence of consent, the nurse uses professional judgement regarding the necessity to disclose particular details, giving due consideration to the interests, well–being, health and safety of the individual and recognising that the nurse is required by law to disclose certain information.

30 Privacy In the context of Aged care and Health care privacy means discretion and secrecy A nurse has a moral duty and a legal obligation to protect the privacy of an individual by restricting information obtained in a professional capacity to appropriate personnel and settings, and to professional purposes. • A nurse must, where relevant, inform an individual that in order to provide competent care, it is necessary for a nurse to disclose information that may be important to the clinical decision making by other members of a health care team. • A nurse must, where practicable, seek consent from the individual or a person entitled to act on behalf of the individual before disclosing information. In the absence of consent, the nurse uses professional judgement regarding the necessity to disclose particular details, giving due consideration to the interests, well–being, health and safety of the individual and recognising that the nurse is required by law to disclose certain information.

31 Appropriate conversation
Need to socially appropriate at all time. Need to direct your conversation at the clients needs or carers needs- NOT YOUR OWN. Do not swear, complain, or give out personal or sensitive information. Be friendly with your work mates but remember they are not your best friend. Do not reveal personal information to colleagues.

32 Supporting Independence

33

34 Contributing to the individualised plan

35 Problem solving skills
1. Define the problem 2.Generate Ideas 3. Investigate solutions 4. Choose an option 5.Plan to act 6. Evaluation

36 Use the problem solving technique to solve the following problem
The co-worker that you are teamed with likes to spend time talking to the clients, and leaves you the bulk of work. It also means that you have trouble getting to know the clients you work with. What could you, and your work team, do to resolve this situation?

37

38 Identifying risks to the client

39 Providing care Assessment Observation Questioning Consultation
Medical History Physical ability Lifestyle choices Family history and dynamics Past experiences Social contacts

40

41 Risk Assessment

42 Scope of Practice

43 Role of an Aged Care Worker
Multi skilled Flexible in work practices in care delivery Work as part of the multi-disciplinary team Participate in planning & delivery of care Abide by the mission statement & job description Responsibilities include- OHS, documentation, provision of care.

44 Role & Responsibility To observe (collect physical data) the patient;
Report to supervisor/ RN any change in a pts condition; Other areas the AIN is responsible for reporting include: equipment faults, safety hazards, need for supplies, incidents/ accidents, breaches in confidentiality, absences from duty/ breaches in duty of care- abuse.

45 What is expected of you as an AIN
Fulfils the duties of the job description Technical skills (i.e.. BP) communication skills (interaction with staff & clients) Time management Team work Documentation skills

46 Personal attributes Conscientious Trustworthy Patient Thorough
cooperative Respectful Caring Honest Accurate Empathetic Reliable Flexible Organised Adaptable Passionate

47 Duty of Care

48 Rights of workers Safe work environment
Free from harassment and discrimination Work conditions and wages in accordance with IR laws EEO

49 Accountability & Responsibility
Duties as per job description Completion of specific tasks at the required standard in a reasonable time frame. Accountable means you are answerable for the things you do. Who are you accountable and responsible to?

50 Activity Think of an organisation you know and develop an Organisational chart which indicates who you report to.

51 Reporting to your Supervisor
Be professional – Provide accurate Data eg: results from tests: UA Provide objective not subjective reporting Be proactive and seek a time to talk to your Supervisor that is convenient. Allow that the Supervisor, while knowing your role, may not be aware of every part of the job. When reporting provide some solutions that will work. Document your concerns so the Supervisor has something to work from. Carry out the instructions you are given and report back their results.

52 Reporting inappropriate behaviour
Clients Use data collected over time, Relate specific incidents or behaviours of concern Report the time frame of the behaviour Report any triggers of the behaviour Use a non judgmental approach Always maintain confidentiality Colleagues Provide accurate information Be non judgmental when reporting Provide time and location incidents take place Always report privately Have an incident report written out so the the Supervisor has all the facts

53 Incident reporting

54 Completing Documentation

55 Care Records Also known as: Commenced on admission The purpose is:
Case notes Client file Residents notes Commenced on admission The purpose is: Centralised record for all to document About care Information about the client

56 Information contained in the care record
Progress notes Observation charts Care Plans Admission, discharge and transfer notes Medical history and doctors notes

57 Progress notes Ongoing record of the older persons day to day care and progress Must document only facts, not interpretations of events

58 Progress notes: Ensure quality Assist when making assessment
Ensures the worker works within the care plan Continuity of care Accountability Evaluating care The process of reflecting, monitoring and improving care delivery

59 Guidelines for report writing
Must be written on all clients at least once a day Plus exception report writing The report must contain the time and date, must be signed and designation recorded

60 Report writing Permanent records Factual Accurate
Legible using black or blue ink Use professional language Be brief, simple and to the point

61 Principles of report writing
Record promptly or ASAP after event has occurred Use the 24 hour clock Only use approved abbreviations Correct spelling and grammar Do not leave any spaces Check previous entries Make corrections properly Rule a line through the error Write the correction and initial your entry Do not erase or use whiteout Ensure the original entry can be read

62 Case scenario You have just finished caring for Mrs. Jones
You have showered her and she dressed herself She was happy and chatty You noticed a red spot on her lower R leg She ambulated into the bathroom with a PUF She ate a small amount of breakfast and is now sitting in the lounge room Document in the progress notes

63 Confidentiality and access to records
Client notes are confidential and access is restricted to: The storage of records must be locked to maintain confidentiality Designated staff The clients ensuring someone is with them e.g.. RN when they read their notes Refer to Policy and Procedure of facility

64 Reasons for documentation
Legal requirement Funding Management systems, staffing and development Resident lifestyle Physical environment and safe systems

65 Types of documentation
Observation chart Bowel chart FBC Accident forms Care Plans Admission data Restraint charts Complaints form

66 Accident/Incident forms
Legal requirement Identifying risks Hazard control Monitoring behavioural trends Monitoring work practices

67 Case Scenario You discover Mrs. Campbell lying on the bathroom floor at 1650 hours You left her sitting by her bed 5 minutes previously She has sustained a skin tear 3cm to her L forearm and has a bruise on her R knee You stay with the client and buzz for assistance The RN arrives and asks you to record a set of obs, dress the skin tear and complete an incident form The RN contacts the DR and Mrs. Campbell's daughter Complete the form

68 Verbal reports Given at the start of each shift – handover or changeover Staff finishing should also report any tasks or care not completed

69 Group Work Break into 5 groups
List 4 changes you might observe when caring for a client Each group to pick 1 system and report back to the group Integumentary system Circulatory system Urinary system Digestive system Musculoskeletal system

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