APPENDIX F

LONG-TERM CARE RESIDENT ASSESSMENT INSTRUMENT CASE STUDY AND CARE PLANS
Resident Assessment Instrument Case Study

A. Identification and Background Information
 Mrs. M is a 90-year-old Caucasian widowed female (birth date 1-1-12; social security number 100-10-1000) who is being admitted to the nursing home January 12, 2002. She has lived with her oldest daughter for the past 3 years. Recently Mrs. M has been having increased frequency of incontinent episodes. Her daughter can no longer work outside the home and meet Mrs. M's needs. Mrs. M has four children, 10 grandchildren, and has been widowed for 10 years. Her only child living in Missouri is the daughter with whom she has been living. Mrs. M is of German origin and immigrated to the United States when she was 16 years of age. She remains closely tied to the Lutheran church in the community. She was a homemaker and graduated from high school. Mrs. M can still speak German, and when she is upset or becoming ill, she will revert to that language. She usually goes to bed around 9:00 PM and is up at 5:00 AM. She denies sleeping during the day, but her daughter states that she "catnaps." Mrs. M is responsible for her own affairs. She has private funds that she will be using to pay for her nursing home stay. Her medical insurance is Medicare Part A and B. Her daughter is named as Durable Power of Attorney for Health Care and is also named Power of Attorney for Financial Affairs. Mrs. M has made her wishes known: in the event that she should die, she is not to be resuscitated. Her physician supports her position and has written a do not resuscitate (DNR) order and has written a progress note to document her conversation.

 B. Cognitive Patterns
 Mrs. M is alert and oriented. She was confused at night on one occasion since admission. She became restless and believed her deceased husband was present in the room. Once in the last 7 days she became highly agitated, and the staff sat her up in a chair using a lap buddy to keep her from getting up unassisted. Her daughter reports that this is new behavior and she had not been confused at home before admission. Both long- and short-term memory remain intact. She has not had problems with confusion during the day. She is able to find her own room. She recognizes staff voices but does not always recall names. She can respond appropriately to staff requests. She is currently able to identify the season.

C. Communication/Hearing Pattern
 Mrs. M is deaf in her right ear, and hearing aids are not useful. She can hear with difficulty if speech is directed toward her left ear. She is able to make her needs known by speaking. Her speech is clear. There is no speech deficit related to a previous stroke.

 D. Vision Patterns
 Mrs. M has macular degeneration and is now considered legally blind. She can differentiate between light and dark and can identify objects by shape. She wears glasses to maximize her remaining vision.

 E. Mood and Behavior Patterns
 Mrs. M has been occasionally tearful since admission. Her daughter states that she was not tearful at home. When asked what is wrong, she states that she misses her daughter and grandchildren. She is very concerned that she will not be able to go to her daughter's house anymore because she is having difficulty making it to the bathroom (BR). These moods are of short duration, and she can be redirected to another activity. She has been taking Prozac since 1997, when she was diagnosed with depression post-cerebrovascular accident (CVA).

 F. Psychosocial Well-Being
 Mrs. M enjoys activities and attending church services. She has expressed interest in leaving the facility for weekly trips to the mall or an outside activity. She does express concern about having incontinent episodes while on an outing. She enjoys books on tape and occasionally playing bingo with other residents. She has expressed interest in helping with the garden.

 G. Physical Functioning and Structural Problems
 Mrs. M has residual left-sided weakness. Her left arm is weaker than her right, but she is able to use the left arm to help support ambulation with a walker. Her left leg is also weaker than her right but is only problematic when she is tired or ill. She is able to balance herself using a walker. She became unsteady during the standing portion of the test for balance, but she was able to rebalance herself. Because of her congestive heart failure (CHF), she can only ambulate 20 to 30 feet before becoming fatigued and unsteady. She has limitation in range of motion (ROM). She is not able to use her left arm to touch the back of her head. She is only able to raise her lower left extremities to 70% of normal. She is able to get out of bed and ambulate to the BR unassisted on most days. Limited staff assist (defined as non-weight bearing) of one person is required an average of 3 times per week for transfers and assist to the BR. Limited assist is also required for transfers on and off the toilet 3 times per week. She ambulates with staff to all activities and meals for 20 to 30 feet, then staff will transport her in a wheelchair the remaining distance. She will self-propel in a wheelchair short distances in her room and in the hall on days when she is too fatigued to ambulate. She is able to turn herself in bed at night. She requires limited assistance of one person with dressing daily. She is unable to button her clothing. Occupational therapy (OT) has recommended the use of a large-handled buttonhook. She requires limited assist of one person with transfers in and out of the bathtub. She has fallen four times in the past 6 months. The last fall was 10 days ago and occurred when she was attempting to go to the BR during the night.
 Mrs. M is able to perform self-care activities and tasks of daily living. She is very slow but desires to do as much for herself as possible. Her daughter states that her mother was independent at home; however, her slowness in getting around was a problem, especially with incontinence. She will require assistance on outings. (See also physical therapy note.)

 H. Continence
 Mrs. M is continent of bowel. She easily becomes constipated, leading to fecal impaction, and has had megacolon in the past. Her bowel pattern is daily in the morning with recurrent constipation 3 times a week (constipation diagnosed by presence of fecal smearing, gas, and abdominal pain). She has occasional urinary incontinence (four times in the last 7 days) when she could not get to the BR on time (urgency). A urinalysis was done, showing greater than 30 (white blood cells) WBCs. Because of symptoms of urinary tract infection (UTI) and elevated WBCs, a culture and sensitivity (C&S) was ordered.

 I. Disease Diagnoses
 Mrs. M has the following diagnoses: CVA in 1997 requiring extensive rehabilitation; anterior wall myocardial infarction (MI) in 1988; CHF related to damage from her MI; arteriosclerotic heart disease (ASHD); osteoarthritis and rheumatoid arthritis (RA); gastrointestinal (GI) bleed and ulcer related to steroid and nonsteroidal antiinflammatory drug (NSAID) use; hypothyroidism for 10 years; pneumonia twice in the past 6 months; depression diagnosed post-CVA 1997.

 J. Health Conditions
 Mrs. M has difficulty with joint pain and stiffness in the early AM that resolves after her daily dose of Relafen and movement. She has difficulty moving her fingers in the AM. Her grip is weakened; therefore she uses a large-handled knife and buttonhook. She describes this pain as a 6 on a scale of 1 to 10. She had two episodes of pneumonia this past winter, which has concerned her daughter. Lung sounds on admission were diminished but clear. She sleeps at a 45-degree angle because of orthopnea. Mrs. M is afebrile. Her vital signs on admission were oral temperature 97.6°; apical pulse 68 and irregular; respiratory rate (RR) 18 even and unlabored at rest; and blood pressure (BP) 138/78. She has a grade III systolic murmur, no jugular venous distention, and 2+ pitting edema. She wears bilateral lower extremity Jobst stockings for edema. Her abdomen is soft with active bowel sounds in all four quadrants. She has no complaints of nausea or recent episodes of vomiting, and she has no history of drinking alcohol or smoking cigarettes.

 K. Oral/Nutrition Status
 The staff noted that Mrs. M was choking on fluids when drinking at meals. A speech therapy consult was ordered to rule out aspiration problems. A bedside swallow examination was performed and showed aspiration with thin liquids only. Speech therapy recommended that she drink only when sitting at 90 degrees with chin tucked and no straws. Her weight is 145 pounds, and she is 70 inches tall. In the past year she has lost 85 pounds. Her daughter reports that, although the weight loss has slowed, Mrs. M has had a 15-pound weight loss in the past 2 months. She is on a 2 g Na therapeutic diet. She does not always eat well, leaving 25% of the food in two out of three meals. She enjoys snacks throughout the day. At home, her daughter supplemented her diet with Carnation Instant Breakfast, increased protein intake to help with her skin, and increased fruit for fiber, and she gave her six small meals daily. Mrs. M feeds herself independently using large-handled utensils but requires staff assist at meals to cut meat and to orient for food location. OT has recommended a Dycem plate and rocker knife to use with meals (see also dietitian note).

 L. Oral/Dental Status
 Mrs. M has her own teeth and denies oral pain or discomfort. She last saw her dentist 6 months ago.

 M. Skin Condition
 Mrs. M's skin is intact. She has thin skin that tears easily related to steroid use and has healed skin tears. She has healing bruises associated with past falls. Her Braden scale indicates that she has no impairment with sensory perception; she is able to respond appropriately and can voice discomfort. She does have slight impaired sensory impairment resulting from CVA (score 3). She occasionally has incontinence (score 3). She is able to ambulate independently with her walker for short distances and does so frequently throughout the day (score 3). She is able to move in bed independently (score 3). Her nutritional intake is adequate, although she does have a history of significant weight loss (score 3). She occasionally slides down in her chair or does not completely raise herself up to move. This causes some skin shear (score 2). Mrs. M's total Braden score is 17 out of 23 total points possible. A score of 18 or less in people over 75 years of age indicates that the resident is at risk for skin breakdown.

 N. Activity Pursuit Patterns
 Mrs. M prefers to be awakened an hour before breakfast (0500) so that she can brush her teeth, comb her hair, and get dressed. She has difficulty moving in the morning because of arthritis; therefore she would prefer to bathe in the evening. A whirlpool bath is used. She has a very firm dislike of showers. Showering "messes up her hair."

 O. Medications
 Lanoxin 0.25 mg daily, Prilosec 20 mg daily, Relafen 1000 mg daily, Calan 80 mg tid, Prednisone 5 mg daily, Synthroid 0.1 mg daily, Bumex 1 mg daily, Prozac 20 mg daily, Nitroglycerin (NTG) 0.4 mg sublingual (SL) as needed for chest pain (she has difficulty with hypotension after NTG (last used 6/12/01), Peri Colace 100 mg bid, and Metamucil 1 tbsp every AM before breakfast. All medications except NTG are oral (PO).

 P. Special Treatments and Procedures
 Restorative aide for therapeutic exercise plan 5 times per week.

 Q. Discharge Potential and Overall Status
 At this time it is not anticipated that Mrs. M will be discharged to return home with her daughter. Her overall status has deteriorated in the last 90 days. A new onset of incontinence and falls has been the most significant change.
 NOTE: There are separate physician's orders for laboratory, DNR, speech therapy evaluation, physical therapy evaluation, and therapeutic exercise program.

Care Plans

Problem #1: Acute Confusion Goal

1. Will show improvement in delirium symptoms indicated by no confusion at night during next 7 days.
Interventions

 Discipline
1. Follow up with physician regarding potential factors causing delirium
  1. R/O pneumonia, exacerbation of CHF
  2. UTI
N (nurse)
2. Check hourly between 9 PM and 5 AM; if restlessness noted, check the following and follow up appropriately:
  1. Vital signs and O2 saturation; if abnormal, notify the physician
  2. Need to toilet
  3. Need to eat or drink
  4. Pain
N, certified nursing assistant (CNA)
3. Offer reassurance if scared or lonely

 All
4. Assist up in chair and position at nurse's station

 N, CNA
5. Elevate head of bed (HOB) to 45 degrees

 CNA

Problem #2: Impaired Mobility/Activities of Daily Living (ADLs) Goals
  1. Improved ambulation-increase distance to total of 40 feet with walker and stand-by assist (SBA) to minimum assist of 1 by 3/1/02.
  2. Maintain ability to dress self with minimal assist to setup during next 90 days.
Interventions

 Discipline
1. Therapeutic exercise plan 5 ×weekly
  1. Ambulate to dining room (DR) × 3 per day with walker and SBA to minimum assist
  2. If resident becomes tired, wheelchair (w/c) transport remaining distance to DR
  3. Alternating leg lifts, 5 repetitions each leg: 3 sets daily (see RA manual)
  4. Passive and active ROM to left upper extremity (LUE) and left lower extremity (LLE) q day
RA, CNA
2. Promote use of adaptive ADLs equipment
  1. Large-handled buttonhook for upper extremity (UE)dressing
  2. Dycem for plate stabilization
  3. Large-handled rocker knife for cutting
  4. Adaptive foam handles for utensils
  5. Keep adaptive equipment in tote bag at bedside
RA, CNA
3. Assess q AM and prn for arthritis pain
  1. Offer prn medication in addition to routine medication
  2. Offer pain medication before AM care and exercises
  3. Provide extra assistance prn related to pain and stiffness
N
4. Promote independence
  1. Provide encouragement and reassurance during ambulation and ADLs
  2. Allow time as needed to complete self-care
  3. Break tasks into shorter segments to conserve strength
RA, N, CNA

Problem #3: Potential for Injury Goals
Interventions

Discipline
1. Monitor gait, balance and fatigue with ADLs
  1. Encourage resident to call for assist when unsure of strength/balance
  2. Provide SBA to minimum assist prn for ambulation and ADLs
  3. Consider nonskid socks on feet at night
All
2. Keep light on in room when awake, night light on at night

 All
3. Keep light on in BR

 All
4. Answer call light immediately because of urge incontinence and sensory loss

 All
5. Encourage use of well-fitting, nonskid shoes

 All
6. Keep bed in low position with side rails down at all times

 All
7. Use bed alarm, chair alarm with periods of confusion

 N, CNA
8. Encourage to wear glasses when awake
  1. Be sure glasses are clean at all times
  2. Approach with caution and identify self–do not startle
  3. Use wide gestures with directions to compensate for loss of central vision
All
9. Speak directly into left ear

 All
10. Collaborate with pharmacist/physician re any medications that may contribute to falls–review
current medications and any new medications

 N
11. Monitor and record orthostatic BP on 1/14/02, 1/15/02, and 1/16/02
  1. Report to physician if >20-point drop in SBP, >10-point drop in DBP
  2. Report to physician if resident complains of dizziness/lightheadedness with position change
CNA

N
N
12. Evaluate all falls per facility policy; communicate as appropriate to physician and family

 N

Problem #4: Alteration in Mood, Risk for Social Isolation Goals

1. Feelings of loneliness for family will resolve by 3/1/02 as evidenced by the following:
  1. No further episodes of tearfulness
  2. Statements of satisfaction with placement
2. Will demonstrate active participation in facility life ongoing as evidenced by the following:
  1. Socialization with others
  2. Activity attendance of choice, both in and out of facility
  3. Weekly outings out of facility
Interventions

 Discipline
1. Meet with resident 2 × per week to enhance adjustment and coping skills
  1. Develop trusting relationship with resident and family
  2. Discuss perceived loss of relationship with family
  3. Allow expression of feelings/concerns
  4. Assist resident to identify choices
  5. Communicate to team members ways to enhance adjustment
Social Service
2.Encourage involvement in activities. Resident preferences include the following:
  1. Church activities
  2. Books on tape
  3. Bingo
  4. Gardening
  5. Outings out of facility (check with nursing retoileting)
    • To shopping mall monthly–facilitated by nursing home transportation
    • To own church weekly–facilitated by daughter
    • As requested and facilitated by family/nursing home staff
ACT
3. Encourage family involvement in facility activities All
4. Monitor for change in mood status
  1. Tearfulness, statements of sadness
  2. Withdrawal from activities
  3. Change in appetite, sleep pattern
All
5. Administer antidepressant medication per medication administration record (MAR)

 N
6. See incontinence care plan

 All
7. See Potential for Injury care plan for vision and hearing needs

 All

Problem #5: Urinary Incontinence Goals
  1. Will achieve urinary continence through routine toileting with staff assist—immediately.
  2. Will toilet independently by 3/1/02.
Interventions

 Discipline
Offer assistance/cue to BR use as follows:
  • Within 30 minutes of receiving AM diuretic
  • Immediately after breakfast for bowel movement (BM)
  • Per facility routine (before and after meals, and at bedtime)
  • Before activities and outings
 N, RA, CNA
2. Keep call light within reach when in room; leave on bed when resident is out of room

 All
3. Answer call light immediately

 All
4. If incontinence continues once UTI resolved, follow up for additional causes

 N

Problem #6: Altered Nutritional Status and Risk for Dehydration Goals
  1. Maintain current body weight of 145 to 160 lbs.
  2. Maintain adequate hydration without compromising cardiac stability (CHF) ongoing.
  3. Improve albumin level to 3.5 g/dl next 90 days.
Interventions

 Discipline
1. Collaborate with physician regarding dietary recommendations
  • Change 2 g Na to 4 g Na diet
  • 5 small meals daily
  • Carnation Instant Breakfast at 2 PM and bedtime
  • Albumin level checks monthly ×2 months
 D
2. Include food preferences of fresh fruit: seedless grapes, oranges, peaches

 D
3. Encourage high fiber foods to prevent constipation

 D
4. May substitute cold cereal at night

 D, CNA
5. Encourage 100% meal consumption

 CNA
6. Set up food on plate and orient to clock face

 CNA
7. Use adaptive equipment (see ADLs care plan)

CNA
8. Weigh weekly: Tuesdays in the AM before breakfast
  • a. If weight is up 3 lbs in 1week, assess for signs/symptoms (s/s) of CHF exacerbation (shortness of breath, rales/crackles, increased fatigue, edema)
  • b. If weight is down 3 lbs, assess for dehydration (change in level of consciousness [LOC]; drop in BP, orthostasis, drop in urine output)
 CNA

N
9. Encourage 1500 to 2000 ml of decaffeinated fluids daily 10. Follow safety precautions for swallowing
  • a. Maintain upright position with chin tuck for fluid intake
  • b. Do NOT use straws
 D, N, CNA
10. Follow safety precautions for swallowing
  • Maintain upright position with chin tuck for fluid intake
  • Do NOT use straws
 CNA
11. Obtain chemistry profile per physician order
  • Review values and report abnormal results to physician
 N, MD
12. Auscultate lung sounds daily and prn if choking noted with liquids

 N

Problem #7: Risk for Skin Breakdown; Risk for Skin Tears Goals
  1. Will maintain skin integrity ongoing as indicated by the following:
            a. No pressure ulcer development
            b. No skin tears
  2. Will have Braden score of 20 by 3/1/02
Interventions

 Discipline
1. Complete Braden scale weekly on Wednesday until score reaches 20, then complete quarterly

N
2. Report any changes in skin integrity or signs of breakdown to nurse

All
3. Inspect bed and wheelchair daily for areas that could cause skin tears

CNA
4. Encourage to wear long sleeves

CNA
5. Maintain proper positioning in wheelchair to prevent sliding down (skin shear)

 CNA