1. Clinical Care
Policy: 2.4

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

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

4. 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

5. 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

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

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

8. 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

9. 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.

10. 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

11. 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.

12. 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

13. 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

14. 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

15. 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

16. CLINICAL SKILLS

17. Observations Temperature Pulse Respiration Blood Pressure Weight
Urinalysis

18. 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

19. 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

20. 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

21. 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

22. 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)

23. 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

24. 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 respirations per minute
The rate, rhythm, depth, and sound should be observed

25. 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 mmHg systolic & mmHg diastolic

26. 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

27. 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

28. 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

29. 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

30. 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

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