MRS M PPS-SIGNIFICANT CHANGE CAA . - Nursing Home Help

Quality Improvement Program forMissouri’s Nursing HomesMRS. M PPS-SIGNIFICANT CHANGE CAA DOCUMENTATIONCAA Summary Note: #1 DeliriumDate: 12/30/10MDS items: #1 DeliriumTriggers: BIM score declined from 13-14 to 111.DELIRIUM: REVIEW of INDICATORS OF DELIRIUMMark ifAreaTriggeredxxChange in Vital SignsRectal temp above 1000F or below 950F(380C/ 350C)Pulse rate 60 or 100 beats/ minRespiratory rate 25 breaths/minute or 16 breaths/minuteHypotension or a significant decrease inblood pressureSystolic b/p 90mmHg ORDecline of 20 mmHg or greater insystolic b/p from person’s usualbaseline ORDecline of 10 mmHg or greater indiastolic b/p from person’s usualbaseline ORHypertension – systolic b/p above 160mmHg OR a diastolic b/p above 95mmHg.Supporting Documentation: (Basis/reason for checking the item,including the location, date, and source (if applicable) of thatinformation)Has been running a low grade temperature every afternoonIrregular Grade III systolic murmurAbnormal Laboratory ValuesElectrolytes, such as sodiumKidney functionLiver functionBlood sugarThyroid functionArterial blood gasesOtherAnemicPainxPain Care Area triggered (reviewfindings for relationship to deliriumPain frequency, intensity, andcharacteristics (time of onset, duration,quality) indicate possible relationship todeliriumAdverse effect of pain on function maybe related to deliriumYes was triggeredDefines pain as 7 out of 10. Has impacted ability to participate intherapy.Diseases and ConditionsCirculatory/Heart: anemia, cardiacHistory of CHF and a CVA. Irregular pulse and a systolic heartdysrhythmias, angina, MI, ASHD, CHF,murmur, MI, ASHDpulmonary edema, CVA, TIAPARTNERING WITH YOU TO PROMOTE QUALITYQIPMO University of Missouri S439 Sinclair School of Nursing Columbia, Missouri 65211(573) 882-0241 www.nursinghomehelp.org

Respiratory: asthma, emphysema, COPD,shortness of breath,Infectious: Infections, wound infectionother than foot or lower extremity,Isolation - activeMetabolic: diabetes, thyroid,hyponatremiaGastrointestinal bleedRenal disease, dialysisHospice CareCancerDehydrationSOB if lies flatRecent hospital stay with foley catheter that has now been removedOn thyroid replacementDX GI Bleed and UlcerSigns of Infection (fromobservation, clinical recordFeverCloudy or foul smelling urineCongested lungs or coughDyspneaDiarrheaAbdominal painPurulent wound drainageErythema around an incisionDaily afternoon elevated temperaturesSOB if lies flatIndicators of DehydrationDehydration care area triggered,indicating s/s of dehydration arepresentRecent decrease in urine volume ormore concentrated urine than usualRecent decrease in eating habits –skipping meals or leaving food uneaten,weight lossNausea, vomiting, diarrhea or blood lossReceiving IV medsReceiving diuretics or drugs that maycause electrolyte imbalanceNo S/S but did have IV fluids in hospital for hydration after surgeryDecrease appetite with recent weight lossHistory of GI Bleed. Recent blood transfusion post surgery.Bumex dailyFunctional StatusRecent decline in ADL statusIncreased risk for fallsRequires more assist since hip fxFell causing fx hipMedications (that may contribute todelirium)New med or dosage increaseDrugs w/anticholinergic properties(antipsychotics, antidepressants,antiparkinsonian, antihistamines)OpioidsBenzodiazepines, especially long actingAnalgesics, cardiac and GI meds, antiinflammatory drugsRecent abrupt discontinuation,omission, or decrease in dose of ashort/long acting benzodiazepineDrug interactionsResident taking more than one drugfrom a particular class of drugsPossible drug toxicity, esp. if the personProzac was just increased but symptoms were noted before increaseOn both cardiac, GI meds, and analgesicsMU MDS and Quality Research Team, Sinclair School of Nursing, University of Missouri (revised 03/11)2

is dehydrated or has renal insufficiency.Check serum drug levelsAssociated or Progressive Signsand SymptomsSleep disturbances (up & awake at noc,asleep during day)Agitation & inappropriate movements(unsafe climbing out of bed or chair,pulling out tubes)Hypoactivity (low or lack of motoractivity, lethargy or sluggish responses)Perceptual disturbances such ashallucinations and delusionsAltered levels of consciousnessSluggishOther ConsiderationsPsychosocial:- Recent change in mood: sad oranxious, crying, social withdrawal- Recent change in social situation(isolation, recent loss of family orfriendPhysical or environmental factors:- Hearing or vision impairment, mayhave an impact on ability to processinformation like directions,reminders, environmental clues- Lack of frequent reorientation,reassurance, reminders to help makesense of things- Recent change in environment (roomchange, new admission, return fromhosp)- Interference w/resident’s ability toget enough sleep (light, noise,frequent disruptions)- Noisy or chaotic environment (callingout, loud music, constant commotion,frequent caregiver changes)Fell less than a week ago resulting in a hip fracture which resulted inthe hospital stay. Returning now as more depressedDX Depression. Prozac recently increased.Return from hospital. Is having difficulty processing new informationat this time.Dx macular degeneration, Hard of HearingInput from resident and/or family orrepresentative regarding the care area.Family has noted a decline since returning from gestionsAnalysis of FindingsCare Plan ConsiderationsReview indicators and supporting documentation,CareDocument reason(s) care plan will or will not beand draw conclusions.Plan?developed.Document:YesNo Description of the problem Causes and contributing factors Risk factors related to the care areaProblem: Mrs. M’s BIM score has decreased fromYesCare plan to be developed to monitor currentprevious assessment.level of cognition for further decline. WillCauses: Low grade fever, multiple medical diagnosesincorporate interventions to minimize furtherincluding CHF, CVA, hypothyroid, and anemia.loss of cognitionRecent hospitalization with surgery.Risk factors: Increase confusion may interfere withMU MDS and Quality Research Team, Sinclair School of Nursing, University of Missouri (revised 03/11)3

providing care, and put Mrs. M at risk for furtherinjury such as another fall, skin breakdown, weightloss, etc.Referral to another discipline is warranted - to whomand why?Speech to see for compensatory techniquesCAA Summary Note: #2 Cognitive Loss/DementiaDate: 12/30/10MDS items: BIM score less than 13 C0500 and inattention and altered level of consciousness C01300Analysis: Mrs. M does show signs of delirium, see Delirium CAA 12/30/10. She does have a history of aCVA with new onset of changes in behavior in inattention and altered levels of consciousness. Her PHQ-9also shows an increase in depression from her previous assessment. Medically she does have a thyroiddisorder, ASHD, Hx of MI and GI Bleed/Ulcer, CHF, SOB with activity and inability to lie flat, anddepression. Pain control has also been an issue since readmission but better participation noted intherapy over the last several days. Due to her recent surgery she does require more assistance with herADL’s. In the last week she has also had several environmental changes between the hospital and thenursing home which may also impact her cognition. Speech therapy to see. Will care plan to minimizefurther decline and to possibly improve her cognitive ability with continuity of care and painmanagement.Decision to proceed with care plan - YESCAA Summary Note: #3 Visual Function; #4 CommunicationDate: 12/30/10MDS items: Vision Impaired: B1000 Hearing, B0200 and Ability to understand others: B0800Mrs. M triggered for these CAA areas due to sensory deficits, resulting in highly impaired vision andhearing. There have been no changes in either area since the original admission. See Visual Function andCommunication CAA note dated 1/21/10.Decision to proceed with care plan - YESCAA Summary Note: #5 ADLs; #11 FallsDate: 12/30/10MDS items: #5 ADL’s - Requires assistance with ADLs G0110 and has a decline in cognition C0500; #11Falls - Has balance problems G0300See PT eval 12/21/10 and OT eval 12/21/10Vision/Communication CAA 12/30/10 and Urinary incontinence CAA dated 12/30/10Mrs. M triggered for the above CAAs due to her need for limited to extensive assistance with ADLs and arecent fall resulting in a fracture. PT and OT have addressed recommendations for Mrs. M’s ADL status.In addition to a recent history of falls, Mrs. M is at fall risk due to possible medication side effects, urinaryincontinence; weakness requiring limited to extensive staff assist at times because of fatigue, and sensoryMU MDS and Quality Research Team, Sinclair School of Nursing, University of Missouri (revised 03/11)4

deficits. Medications that contribute to fall risk include Prozac, Bumex, Calan, NTG (PRN) and Digoxin.Pharmacy review to be done per facility protocols to determine further recommendations at this time.Urinary incontinence is related to urgency secondary to diuretics and is likely to be exacerbated byrecent catheter insertion.Decision to proceed with care plan - YES, to alert staff to multiple risks for falls, and assistance with ADL’sCAA Summary Note: #6 Urinary IncontinenceDate: 12/30/10MDS items: Incontinence and requires assistance with toileting H0300Mrs. M triggered for this CAA due to urinary incontinence that has been a problem for her since prior toher admission at home and has continued since her original admission. A bladder diary was done withthe first admission and has been repeated during days 3-6 of this stay (See Nursing Note 12/26/10).During the hospitalization a catheter had been inserted but has since been removed on 12/21/10. Sincethe removal Mrs. M has been incontinent several times a week, which is similar to her voiding patternprior to hospitalization. This was confirmed by comparing the current dairy with the previous admissiondiary. Mrs. M is unable to ambulate to the BR w/ walker due to fatigue. She requires weight bearingassistance of one person to transfer on/off the commode. She is able to call for assistance, but due tourgency can only hold her urine for about 5 minutes. Urgency is greater in the morning after Bumexadministration. Delirium was also a possible incontinence factor as well as her increased need forassistance in toileting.Decision to proceed with care plan – YESCAA Summary Note: #10 ActivitiesDate: 12/30/10MDS Items: Little interest or pleasure in doing thingsD0200 AMrs. M triggered for Activities due to the observation of little interest or pleasure in doing things. She hasbeen a resident her for over a year. Prior to this most recent hospitalization she was an active participantin activities inside the home and occasionally went out with her daughter. She enjoyed small groupactivities but also enjoyed her time working on crossword puzzles. Currently due to pain, therapyattendance she has been too tired to participate in many activities. There are no other barriers such asenvironmental or staffing at this time. Review also the Cognitive loss, Delirium and Mood state CAAs12/30/10.Decision to proceed with care plan – YESCAA Summary Note: #12 Nutritional Status; #14 Dehydration/Fluid MaintenanceDate: 12/30/10MDS items: #12 Nutritional Status - Therapeutic diet K0500; #14 Dehydration/Fluid Maintenance Taking diuretic: N0400See current dietary note dated 12/22/10. No change essentially since original admission; see CAA notedated 1/19/10 for Nutritional Status and Dehydration/Fluid MaintenanceMU MDS and Quality Research Team, Sinclair School of Nursing, University of Missouri (revised 03/11)5