HCPro.com - Long-Term Care - DO NOT USE Top Stories

Trainer's tip: Understand items and conditions problematic to MRI scanning

Thu, 09 Feb 2012 14:19:00 GMT

Other medical conditions, devices, and metallic items that are potentially problematic during MRI scanning are as follows:

Aneurysm clips.
Artificial eyes.
Cardiac pacing wires are sometimes left in place after heart bypass surgery.
Some eye shadow has a metallic base. Avoid eye makeup if a study is being done of the head.
Facial reconstruction surgery may involve implanted metal and wires.
Some heart valves may be scanned, but some cannot. Notify the scheduling secretary if the resident has had open-heart surgery.
Hernia mesh can usually be scanned safely, even if it contains metal. Notify the MRI center if mesh is present.
Metal in the eyes from accidental injury (an eye x -ray must be taken prior to the study as even a tiny fragment can damage the eye).
Prosthesis should be removed before the MRI study.
Shrapnel may cause a problem. Each case is reviewed by the radiologist individually.

Because there are so many variables related to safety of the MRI procedure, listing all contraindicated items here is impossible. Contact your local MRI diagnostic center with questions. A comprehensive listing of 1,300 items that have been safely tested with MRI can be found at www.mrisafety.com/.

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

Trainer’s tip: Good chair positioning begins with the feet!

Thu, 17 Nov 2011 18:44:00 GMT

Most nurses are surprised to learn that good chair positioning is determined by the placement of the feet. Sliding occurs when the feet:

Are dangling
Are not properly supported
Slip off the footrests

Sliding causes pressure on the spine, scapula, hips, and elbows. It is a primary cause of skin damage and shearing. After the resident has been transferred into the chair, the first step is to stabilize the feet. To accomplish this, you may have to adjust the leg rest length, seat the resident on a low profile cushion, or use a footrest extender/elevator cushion. The feet should be positioned so the knees are lower than the hips. If the knees are higher, the leg rests need to be lengthened, or the resident needs a wheelchair with a higher seat. If the feet dangle, shorten the leg rests or add a footrest elevator to the chair.

By beginning with the feet and using the 90-90-90 position, the body will be supported in good alignment, improving structural function and reducing discomfort. This will also reduce the need for restraints and redistribute pressure, reducing the risk of skin breakdown.

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

Chair and wheelchair positioning

Thu, 17 Nov 2011 18:33:00 GMT

The body works best when it is in good alignment. Pain is decreased and the risk of injury is reduced when the resident is properly positioned. When a resident is seated in a chair or wheelchair, pressure on the skin is affected by:

Postural alignment
Weight distribution and stability
Balance
Pressure redistribution (the ability to distribute a load over a surface, which causes a shift in pressure from one area to another) or pressure relief (the complete reduction of interface pressure below capillary closure pressure)

When the resident is properly positioned, he or she should end up in the 90-90-90 position. This means that the feet and ankles are at a 90 degree angle to the lower legs, the lower legs are at a 90 degree angle to the thighs, and the hips are at a 90 degree angle to the torso.

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

Trainer’s tip: Controlling and eliminating bed bugs

Thu, 03 Nov 2011 14:55:00 GMT

Maintain a high degree of suspicion for bed bugs (and/or scabies) if staff members or residents have rashes, or if the bed linen has tiny blood stains on it. When checking for bed bugs, shining a flashlight and aiming a hot hair dryer into the crevices will help force the insects out. As a temporary control measure, vacuum all carpeting, furnishings, and cracks and crevices in walls and floors thoroughly. When finished, discard the vacuum cleaner bag in a sealed plastic bag.

Determine whether your community requires reporting infestations to the local health authority. Bed bugs are all but impossible to eliminate without exterminator treatments. Even then, elimination is difficult, and eradicating the pests involves throwing out as many objects in the room as possible, then either freezing nonwashable items for 48 hours or exposing items to high temperatures. The most difficult part of the eradication effort is finding and eliminating the eggs. The exterminator must return seven to 10 days after the initial treatment and repeat the application to eliminate newly hatched bugs.

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

Maintaining a watchful eye for signs of bed bugs

Thu, 03 Nov 2011 14:50:00 GMT

The common bed bug, Cimex Lectularius, is a wingless, red-brown, blood-sucking insect that grows up to 7 mm in length (about the size of a pencil eraser) and has a lifespan of four months to a year. Although bed bugs do not fly or hop, they do run and multiply quickly. They travel easily from one place to another in luggage, through walls, and hidden in the seams of clothing. Bed bugs may spread to cracks and crevices in mattresses, to bed frames and box springs, behind headboards and baseboards, inside nightstands, within window and door casings, and behind pictures and moldings. They have also been found hiding in couches, chairs, and other furnishings; loosened wallpaper; and cracks in plaster and floors. Bed bugs can and do hide in clutter, such as piles of books, papers, boxes, and items near sleeping areas. They emerge at night to feed on their preferred host, humans.

Bed bugs have an anticoagulant in their saliva to prevent blood from clotting during a meal. This substance causes sensitivity in some people, resulting in irritation, itching, and inflammation. Other people can live with bed bugs and not be aware of them. Some individuals develop welt-like bite marks, similar to flea or mosquito bites. They may appear in lines, similar to the pattern of scabies in which the insects are following the blood vessels. You may occasionally see bed bugs, but more commonly you will find these bite marks on residents, tiny blood stains on linens from crushed bugs, or dark spots from their droppings.

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

Trainer’s tip: Recognizing delirium and the common causes

Thu, 20 Oct 2011 16:50:00 GMT

If a resident's behavior or mental status is different than usual, suspect delirium. It is easily recognized in alert residents who suddenly develop confusion. In residents with cognitive impairment, the confusion seems to be worse than usual. The first approach in these residents is to increase fluid intake to see if the confusion clears. In the early stages, delirium may be identified by staff members who are familiar with how the resident functions in a variety of situation. Always perform a complete nursing assessment to identify the cause and rule out potentially serious problems. The most common causes of delirium are infectious circulatory, respiratory, and metabolic disorders. Others include:

Unfamiliar environment
Sensory deficits, deprivation, or overload
Exposure to chemicals of toxic substances
Dehydration
Inadequate oxygenation
Emotional stress
Chemotherapy
Trauma
Fatigue

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

The effect of delirium on the elderly

Thu, 20 Oct 2011 16:47:00 GMT

Delirium is often mistaken for dementia. Delirium is best described as an acute state of confusion. In contrast, mental confusion caused by dementia is "chronic" confusion. Residents who are alert suddenly or progressively become more confused with delirium. When delirium manifests itself in residents with dementia, personnel notice a worsening of confusion, and the resident may be more lethargic than usual. Residents with a history of dementia and impaired renal or cardiopulmonary function are at increased risk. Residents over age 75 are also considered at high risk.

Some residents develop a condition called chronic delirium. A common symptom is lack of awareness of the environment or the inability to correctly interpret environmental stimuli through the senses. In many cases, the resident's vision or hearing require correction. Inability to see or hear well causes the resident to be unable to interpret the environment correctly. Many residents become dependent on staff members for care because of unrecognized, uncorrected vision problems. They may respond inappropriately because of a hearing deficit. In severe cases, uncorrected sensory problems may cause delusions, hallucinations, and misinterpretation of noise and images. If sensory problems are suspected, keep the environment quiet, well-lit, and familiar. Keeping routines and personnel consistent also helps maintain the resident’s mental status. Strive to identify and correct the underlying cause. Work with the social worker to schedule the resident for hearing or vision examinations.

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

Trainer’s tip: Bariatric care equipment needs

Thu, 06 Oct 2011 20:05:00 GMT

Many long-term care facilities successfully care for residents with bariatric needs. Because specialized furnishing and equipment are needed, many facilities have designated rooms or wings equipped for bariatric care. Facilities cannot admit a resident needing bariatric care on the spur of the moment like they would with a normal geriatric resident. Planning is needed. At the very least, the facility must:

Obtain equipment and furnishings. This includes specialized beds, fans, chairs, mechanical lifts, gowns, scales, and toileting and bathing supplies.
Modify rooms.
Develop policies and procedures.
Plan staffing needs. Residents who are in the bariatric population need a lower resident-to-staff ratio. The residents are much more time-consuming to care for than other residents. Two or more staff members will be needed to assist with many routine tasks.
Inservice the staff.
Make a commitment to providing proper bariatric care.

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

Providing bariatric care

Thu, 06 Oct 2011 20:01:00 GMT

Residents who are obese have highly specialized needs. Care that is routine for persons of normal size cannot be done the same for the bariatric population. This includes many ADLs, such as bathing, transfers, mobility, and transportation. Routine activities may be difficult. Things we take for granted, such as standing up, sitting down, and walking to the bathroom, can be strenuous or painful for obese residents. Certain aspects of care can be frustrating or humiliating.

Avoid assuming that bariatric residents are just larger versions of the normal adult. They experience many problems not seen in adults of normal weight, including internal fluid shifts and a change in the body’s center of gravity. Their risk of blood clots and other complications is greater due to immobility. Most have fragile skin and numerous skin-related problems. The weight of the chest makes breathing difficult, and the resident may need to use oxygen, a CPAP mask, or a BiPAP mask. Many need a fan blowing on their face and neck at all times in order to feel comfortable. Breathing is even more difficult when the person is lying down. The extra skin causes the person to feel very hot, so the resident may prefer to remain undressed and covered with a sheet or wear only lightweight clothing.

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

Trainer's tip: Learn to differentiate types of mental illness

Thu, 22 Sep 2011 17:54:00 GMT

Many different things can cause mental health problems. Sometimes mental disorders are genetic, meaning they run in families. Mental illnesses can be caused by reactions to stressful events, by imbalances in the body’s chemistry, or by a combination of several factors. It is important to remember that mentally ill people usually cannot control the way they think, feel, or behave. Mental illness is not the person’s fault; they cannot help themselves. The seven main types of mental disorders are cognitive, dissociative, anxiety, eating, mood, personality, and psychotic disorders:

Cognitive impairment is a loss of mental abilities and awareness that occurs in varying degrees with a variety of underlying causes. Examples include dementia and Alzheimer’s disease.
Dissociative disorders come in many forms, all thought to stem from traumatic events. Examples include dissociative identity disorder (formerly known as multiple personality disorder) and dissociative amnesia.
Anxiety disorders cause physical symptoms such as rapid shallow breathing, increased heart rate, sweating, and trembling; it can also cause emotional symptoms. Examples include post-traumatic stress disorder and phobias.
Eating disorders affect physical health. Examples include anorexia and bulimia.
Mood disorders usually involve chemical imbalances in the brain. Examples include depression and bipolar disorder.
Personality disorders are chronic conditions with biological and psychological causes. Examples include obsessive-compulsive personality and passive-aggressive personality.
Psychotic disorders cause people to lose touch with reality, making it difficult to meet the ordinary demands of life. Examples include schizophrenia.

This is an excerpt from the HCPro book, The CNA Training Solution, Second Edition.

Abnormal thinking and mental health problems

Thu, 22 Sep 2011 17:50:00 GMT

Mental health problems are common among the elderly, the chronically ill, and the disabled. Since people with mental illness can demonstrate many different symptoms, we often do not recognize the signs. As a result, many people do not receive the medications or treatments that might help. Caregivers should learn how to recognize mental illness and how to care for the mentally ill. Mental illness is a brain disorder that causes abnormal ways of thinking, feeling, or acting. Symptoms of abnormal thinking include:

Delusions. This means believing things that are not true. A person might think someone wants to kill or hurt him or her.
Hallucinations. This means seeing or hearing things that are not really there. A person who is hallucinating might hear people talking to him or her when no one actually is.
Confused thinking. This person might be illogical or not understand things happening around him or her.
Suicidal thoughts. Someone with a mental illness might have frequent or constant thoughts of killing him or herself.

This is an excerpt from the HCPro book, The CNA Training Solution, Second Edition.

Coding M1200D, Nutrition or Hydration Intervention to Manage Skin Problems

Mon, 19 Sep 2011 16:38:00 GMT

Version 1.07 of the RAI User’s Manual contains many changes that will go into effect October 1. Keeping track of all the changes is enough to make your head spin. So let’s take it one step at a time and look at the new coding tips for item M1200D, Nutrition or Hydration Intervention to Manage Skin Problems:

The determination as to whether or not one should receive nutritional or hydration interventions for skin problems should be based on an individualized nutritional assessment. The interdisciplinary team should review the resident’s diet and determine if the resident is taking in sufficient amounts of nutrients and fluids or are already taking supplements that are fortified with the US Recommended Daily Intake (US RDI) of nutrients.
Additional supplementation above the US RDI has not been proven to provide any further benefits for management of skin problems including pressure ulcers. Vitamin and mineral supplementation should only be employed as an intervention for managing skin problems, including pressure ulcers, when nutritional deficiencies are confirmed or suspected through a thorough nutritional assessment (AMDA PU Guideline, page 6). If it is determined that nutritional supplementation, i.e. adding additional protein, calories, or nutrients is warranted, the facility should document the nutrition or hydration factors that are influencing skin problems and/or wound healing and “tailor nutritional supplementation to the individual’s intake, degree of under-nutrition, and relative impact of nutrition as a factor overall; and obtain dietary consultation as needed,” (AMDA PU Therapy Companion, page 4).
It is important to remember that additional supplementation is not automatically required for pressure ulcer management. Any interventions should be specifically tailored to the resident’s needs, condition, and prognosis (AMDA PU Therapy Companion, page 11).

For more in-depth guidance on MDS 3.0 coding and processes, attend our all-new MDS 3.0 Boot Camp: Beyond the Basics Boot Camp. This course will help you harness the potential of the MDS 3.0 to deliver outcomes that will grow your business. Your interdisciplinary team will learn to improve processes, enhance communication, and execute clinical pathways to achieve premium person-centered care, quality outcomes, and accurate payment.

This advanced Boot Camp goes beyond filling out the MDS 3.0 form-it will instill the culture change your facility needs to thrive in a time of heightened compliance scrutiny, sicker residents, and shrinking revenue. Attend the only MDS 3.0 program that instructs on the most up-to-date MDS 3.0 and SNF PPS information.

Attend a class and get CPRA certified!
The CPRA credential conferred by HCPro is the new standard for MDS certification in long-term care. The CPRA exam-available in Fall 2011-is the most accurate measure of interdisciplinary competence in resident assessment with a special focus on converting clinical theory into practice.

How do I get my CPRA certification?
You will take an online certification exam at your convenience. The exam is not administered at the live Boot Camp location. While you do not need to attend the Boot Camp to qualify for certification, the Boot Camp teaches all of the material covered on the exam and is an excellent way to ensure that you're fully prepared for both the exam and your work. For complete details, visit www.cpraonline.com.

For more information about our MDS 3.0 Boot Camp: Beyond the Basics Boot Camp, call our customer service team at 800/780-0584.

Trainer’s tip: Recognize the symptoms of hyponatremia and hypernatremia

Thu, 08 Sep 2011 14:56:00 GMT

Residents with hyponatremia may be asymptomatic until the sodium level is well below normal. An astute CNA may report an increase in the resident’s normal urinary output. Symptoms of moderate to severe hyponatremia, which develop as a result of water moving into brain cells causing swelling and disrupting normal function, include:

Apathy
Feeling tired
Weakness
Confusion
Disorientation
Headache
Muscle cramps
Nausea

The signs and symptoms of hypernatremia can be very subtle. Reduced urinary output is common. Urine may appear dark and concentrated. Residents who are hypernatremic commonly have a reduced level of consciousness. The signs and symptoms are usually neurologic, including delirium, irritability, restlessness, lethargy, muscular twitching, spasticity, seizures, and hyperreflexia. These are caused by decreased water content in the brain cells, which leads to shrinkage. If the condition persists over time, it can cause cerebral hemorrhage. Hypernatremic residents are often found to have an infection.

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

Understanding hyponatremia and hypernatremia in dehydration

Thu, 08 Sep 2011 14:51:00 GMT

Many elderly long-term care facility residents are found to be dehydrated with hypovolemia, or low circulating blood volume. Some are diagnosed with hyponatremia, and others are diagnosed with hypernatremia. Long-term care nurses must be able to identify these conditions on laboratory reports and know how to prevent them from developing.

Hyponatremia occurs when the sodium level in the blood is low or the resident is in fluid overload. Although there are other causes, hyponatremia commonly develops in elderly residents as a result of excessive intake or excretion of dietary sodium or water, certain diseases, consuming a low-salt diet for prolonged periods, excessive sweating, severe or prolonged diarrhea, or taking diuretics, which increase the excretion of sodium into urine.

Hypernatremia is almost always an indication of excessive fluid depletion. It usually occurs with inadequate fluid intake and increased water loss. It commonly develops in elderly residents as a result of:

Certain diseases and medical conditions
Physical or mental inability to consume sufficient fluids
Lack of thirst
Conditions that override the body’s volume control mechanisms, usually excessive diuresis or diabetes insipidus
Fever
Vomiting
Diarrhea
Loss of excessive water through the kidneys
Receiving tube feedings with inadequate free water

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

Is it okay if the care plan goal dates and interventions dates are different but within a few days of each other?

Mon, 05 Sep 2011 15:43:00 GMT

Q: When any comprehensive MDS is done, do the care plan goals and intervention dates all have to be the same for each problem? When our team works on the care plan it is usually individually, although we do discuss the resident with each other. The care plan meetings have always been scheduled after the date for the completion of the care plan. Also, when the quarterly is done, we each review and update the goals prior to the care plan meeting and go over it there. Is it okay if the care plan goal dates and interventions dates are different but within a few days of each other?

To read our Regulatory Specialist’s response, visit MDSCentral.

CMS releases updated RAI User's Manual

Mon, 05 Sep 2011 15:38:00 GMT

CMS released version 1.07 of the RAI User’s Manual August 31. The updates included in this version of the manual will become effective as of October 1. Sections that have been updated include the following:

Title page
Table of contents
Chapter 1
Chapter 2
Chapter 3 sections as follows:
- Introduction
- Section C
- Section H
- Section I
- Section K
- Section M
- Section N
- Section O
Chapter 4
Chapter 6
Appendix A
Appendix B
Appendix C
Appendix E

To access version 1.07 of the RAI User’s Manual, visit the CMS MDS 3.0 Training Materials webpage.

Stay tuned to MDSCentral for more information and analysis of these updates.

Trainer’s tip: Residents who may require intake & output monitoring

Thu, 25 Aug 2011 20:22:00 GMT

Intake and output (I&O) monitoring is a simple procedure that does not require a physician’s order. Sadly, nurses sometimes do not take this important intervention seriously. Write the need for I&O monitoring, as well as any special approaches or resident preferences, on the care plan. If the resident is known to be at high risk of dehydration upon admission, begin a temporary care plan to address this risk.

Facility personnel should routinely monitor fluid balance (I&O) for the following:

All residents receiving tube feedings
Residents with catheters
Residents with urinary tract infections
Residents with physician orders for fluid restrictions or orders to force (encourage) fluids
Residents with specific physician orders for additional liquid (fluid)
Residents who are known to be dehydrated or who are at risk for dehydration
Residents with certain heart and kidney conditions that are at high risk for fluid imbalance
Residents receiving intravenous fluids or parenteral nutrition therapy
Any resident who develops a fever, vomiting, diarrhea or a nonfebrile infection, unexplained weight loss or gain, pedal edema, neck vein distension, or shortness of breath

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

Intake and output monitoring

Thu, 25 Aug 2011 20:19:00 GMT

You should monitor residents who have fluid imbalances or are at high risk of dehydration by calculating intake and output (I&O) each shift. Take I&O monitoring seriously. Set a realistic intake goal for each shift. Most fluid is consumed on the day shift, with the least consumed on nights. Thus, set a specific goal for each shift. Setting a goal will tell the nurse at a glance whether the resident has consumed enough fluid on his or her shift. If not, the CNA should encourage fluids before leaving for the day. When establishing goals for fluid intake, fluid is usually divided as follows:

Day shift: 1/2 of total 24-hour fluid goal
Second shift: 1/3 of total 24-hour fluid goal
Third shift: 1/6 of total 24-hour fluid goal

For residents with a fluid restriction, total fluid allowance for each shift can be distributed in the same quantity listed above. Modify the amounts listed as necessary to personalize fluid intake to the resident’s individual needs.

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

National Version 5010 Testing Week

Mon, 22 Aug 2011 20:06:00 GMT

Today marks the beginning of a National 5010 Testing Week, which runs through Friday, August 26. According to a CMS press release, “National 5010 Testing Week is an opportunity for trading partners to come together and test compliance efforts that are already underway with the added benefit of real-time help desk support and direct and immediate access to MACs.”

CMS encourages all trading partners to participate in this testing week, including providers, clearinghouses, and vendors.

The Version 5010 compliance date – Sunday, January 1, 2012 – will be here before we know it. So trading partners should really use this opportunity to test it out.

More information about the on HIPPA Version 5010 can be found here: http://www.cms.gov/Versions5010andD0/.

Trainer’s tip: Observe residents for signs that may lead to malnutrition

Thu, 11 Aug 2011 18:46:00 GMT

The body will begin to break down if it does not get the type and amount of fuel it needs. Malnutrition means, “badly nourished,” another way of saying that the person isn’t getting enough of the right nutrients the body needs to stay healthy. It can be caused by not getting enough nutritious foods or by not adequately digesting and absorbing nutrients from food. Getting too much food can also be harmful. Someone who experiences one or more of the following might be headed for malnutrition:

Doesn’t eat from the major food groups most of the time
Eats less than half of two or more meals a day
Eats less than one hot meal a day
Changes from solid foods to pureed foods, or makes other dietary changes
Is socially isolated or depressed and subsequently does not eat
Uses laxatives excessively, which hinders the digestion of nutrients by causing food to pass through the intestines too quickly

This is an excerpt from the HCPro book, The CNA Training Solution, Second Edition.