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

PRACTICEThe 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.

DocumentationClinical records are permanent, legal documentsDocumentation should reflect the care givenOnly IRT approved abbreviations should be used in residents fileBlack pen should be usedNo liquid paperRefer 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 ConferencesAre 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 observationsAlways 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