Clinical Care Policy: 2.4

Policy 2.4 All residents/clients will have the best possible clinical care delivered by the doctor or other health professionals of their choice

Policy 2.4 In consultation with the resident/client and/or their representative, individual care will be comprehensively documented, enabling ongoing assessment and evaluation

PRACTICE The definition of clinical care is care delivered by care staff, medical officers & allied health professionals On admission, staff conduct a baseline assessment; this data is used to formulate an individualised Care Plan

Care Plans Care plans are to be written and reviewed in consultation with the resident/client and/or their representative Care needs are monitored and evaluated regularly in consultation with the residents/clients and/or representatives

Care Plans Residents/clients are encouraged to make informed choices regarding their care needs

Medical Treatment In a emergency situation staff assess and call appropriate emergency personnel

Medical Treatment If a resident/client requires transfer to hospital a Discharge/Transfer (form 029) is completed and the person responsible contacted If an on call medical service is used or they are transferred to hospital, the residents/clients medical practitioner/healthcare professional is notified as soon as possible

Medical Practitioner/Healthcare professionals Document in the residents integrated notes to allow sufficient information for another medical practitioner to treat a resident in their absence or in a emergency.

Medical Practitioner/Healthcare professionals In community medical practitioners may choose to write in Community Services communication books or contact the client’s coordinator or family directly

Staff responsibility Staff ensure that orders are carried out, e.g. pathology, x-ray requests, treatments, etc Individual Care Plans are adjusted according to any new orders. All staff are required to record notes in the resident/client file in accordance with IRT policy & legislative requirements.

Documentation Clinical records are permanent, legal documents Documentation should reflect the care given Only IRT approved abbreviations should be used in residents file Black pen should be used No liquid paper Refer to policy 1.8 for additional guidelines

Care Plan Reviews Are to be reviewed at least:- 3 monthly (high care EACHP/EACHD) 6 monthly (low care CACP) AND on return from hospital when there has been a significant change in health or wellbeing

Care Plans High care residents/clients are required to have a RN review all aspects of their care plan Low care residents/clients require a RN to review plans of care relating to the specialized nursing procedures

Case Conferences Are to be held at least:- 6 monthly (high care) 12 monthly (low care) with the resident/client and their representative This is an opportunity to review of the care plan and ensure it is meeting the resident/client needs

CLINICAL SKILLS

Observations Temperature Pulse Respiration Blood Pressure Weight Urinalysis

Taking observations Always explain to the resident/client the procedure and gain their consent Preserve privacy & dignity After the procedure leave the resident/client comfortable and thank them for their cooperation Ensure all waste has been disposed of Ensure equipment is cleaned & stored safely Wash your hands

When are observations taken? On admission to a service or facility Whenever there is a considerable change When the resident/client complains of e.g. Dizziness When ordered by the Medical Practitioner After a fall or injury

Temperature The most appropriate methods of measuring temperature are:- Ear Auxilla (under arm) Dermal The result may indicate the presence of infection or the bodies inability to regulate their own temperature

Measuring a Temperature The resident/client should not be left unattended The thermometer should be left in place for the correct amount of time (varies between different types & brands of equipment) Ensure the thermometer is cleaned and stored safely

Pulse The heart rate or pulse is the number of times the heart beats per minute A normal range for an adult is between 60 to 100 beats The radial artery (near the wrist) is the most commonly used site Other points include the carotid (neck), brachial (elbow) & femoral (groin)

Measuring a Pulse When measuring a pulse the rate, strength & rhythm should be observed Count the pulse beat for one minute Avoid taking after exercise Thumbs should never be used as the thumb has a pulse of its own

Respirations A single respiration is one breath in and one breath out Count the respirations for one minute A normal range for an adult is 12-20 respirations per minute The rate, rhythm, depth, and sound should be observed

Blood Pressure The measurement of blood against the walls of the arteries when the heart contracts (systolic) & relaxes (diastolic) It is recorded using a sphygmomanometer as a set of numbers and values stated in millimetres e.g. 120/70 A normal range is 100-135 mmHg systolic & 60-80 mmHg diastolic

Measuring a Blood Pressure Take the blood pressure with the resident/client sitting or lying down The most common site for applying a cuff to measure the blood pressure is the upper arm Apply the deflated cuff evenly around the upper arm Palpate the brachial pulse

Measuring a Blood Pressure Position the stethoscope over the brachial pulse Pump up the cuff to a reasonable level Deflate slowly and listen for the commencement of the beat (take note of this reading) and the cessation of the beat (take note of this reading) Deflate the cuff all the way and remove

Weight Assist the resident/client to sit, stand, lie on the scale ( as appropriate for the type of scale) When the resident/client has settled on the scale and is still read the weight

Urinalysis Often the first measure in detecting abnormalities such as bleeding from the kidneys, infections in the bladder, glucose in the urine Observation includes colour, consistency, concentration, odour & volume

Urinalysis Reagent strip fully submerged in the urine tests levels of:- glucose, bilirubin, ketones, specific gravity, blood, protein, pH, urobilinongen, nitrite & leucocytes in the urine

Record & Report It is essential that all results of observations you attend are recorded contemporaneously Always report any abnormalities to your supervisor or doctor