Management of acute care needs of RACF residents ......v Clinical pathway development process The...

This information does not replace clinical judgement i

Queensland Health

Management of acute care needs of RACF residentsA suite of collaborative pathways forGeneral Practitioners and Registered Nurses

Version 21

June 2019

Clinical Excellence Queensland

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Management of acute care needs of RACF residents: a suite of collaborative pathways for General Practitioners and Registered Nurses

Published by the State of Queensland (Queensland Health), June 2019

This document is licensed under a Creative Commons Attribution 3.0 Australia licence. To view a copy of this licence, visit creativecommons.org/licenses/by/3.0/au

© State of Queensland (Queensland Health) 2019

You are free to copy, communicate and adapt the work, as long as you attribute the State of Queensland (Queensland Health).

For more information contact:Healthcare Improvement Unit, Clinical Excellence Queensland, Department of Health, GPO Box 48, Brisbane QLD 4001, email [email protected] phone 3328 9148

Disclaimer:The content presented in this publication is distributed by the Queensland Government as an information source only. The State of Queensland makes no statements, representations or warranties about the accuracy, completeness or reliability of any information contained in this publication. The State of Queensland disclaims all responsibility and all liability (including without limitation for liability in negligence for all expenses, losses, damages and costs you might incur as a result of the information being inaccurate or incomplete in any way, and for any reason reliance was placed on such information.Prov

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iii

ContentsClinical pathway development process vHow to use these pathways 1Conditions of use 2Hospital and Health Service contact information 3Recognition of the deteriorating resident 4Management of residents with unstable vital signs 5Checklist for contact of GP or RaSS 6Behavioural emergencies 7 Behavioural emergencies practice points 8

Cellulitis 9 Cellulitis practice points 10

Chest pain 11 Chest pain practice points 12

Chronic obstructive pulmonary disease (COPD) 13 Chronic obstructive pulmonary disease (COPD) practice points 14

Congestive cardiac failure (CCF) 15 Congestive cardiac failure (CCF) practice points 16

Constipation 17 Constipation practice points 18

Deep venous thrombosis (DVT) 19 Deep venous thrombosis (DVT) practice points 20

End of life management 21 End of life management practice points 22

Falls 23 Falls practice points 24

Fever or suspected infection 25 Fever or suspected infection practice points 26

Gastroenteritis 27 Gastroenteritis practice points 28

High blood pressure (BP) 29 High blood pressure (BP) practice points 30

Hypoglycaemia 31 Hypoglycaemia practice points 32

Indwelling urinary catheter: preparation for insertion 33Indwelling urinary catheter: insertion 34 Indwelling urinary catheter: insertion practice points 35

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Contents

Indwelling urinary catheter - troubleshooting a blocked indwelling catheter (IDC) or suprapubic catheter (SPC) 37 Indwelling urinary catheter - troubleshooting a blocked IDC or SPC: practice points 38

Influenza-like illness (ILI) 39 Influenza-like illness (ILI) practice points 40

New or worsened confusion 41 New or worsened confusion practice points 42

Pain 43 Pain practice points 44

Percutaneous endoscopic gastrostomy (PEG) tube: trouble-shooting a blocked PEG 45 PEG tube: trouble-shooting a blocked PEG practice points 46

Percutaneous endoscopic gastrostomy (PEG) tube: trouble-shooting a leaking PEG 47 PEG tube: trouble-shooting a leaking PEG practice points 48

Pneumonia 49 Pneumonia practice points 50

Shortness of breath (SOB) 51 Shortness of breath (SOB) practice points 52

Subcutaneous fluids and dehydration 53 Subcutaneous fluids and dehydration practice points 54

Tracheostomy tubes 55 Tracheostomy tubes practice points 56

Urinary tract infections (UTI) 57 Urinary tract infections (UTI) practice points 58

Wound management 59 Wound management practice points 60

Appendix 1: RACF resident assessment tools 61 AVPU: Assessment tool for conscious state 61

Cognition appropriate pain assessment tool: PAINAD 62

Cognition appropriate pain assessment tool: ABBEY PAIN SCALE 63

Delirium screening tool: Confusion Assessment Method (CAM) 64

Neuropsychiatric inventory 65

Appendix 2: Residential Aged Care End of Life Care Pathway 67Appendix 3: Residential Care Facility Falls Assessment and Management Plan 79Appendix 4: Wound Assessment and Management resources 83References 88

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Clinical pathway development processThe “Management of acute care needs of RACF residents” pathways were initiated by the Healthcare Improvement Unit, Clinical Excellence Queensland and have been collaboratively developed via a steering committee including the following representatives:

• General Practitioners (GPs)• Residential Aged Care Facility (RACF) clinicians and manager representatives of both private and

Queensland Health (QH) RACFs• Consumer representation via COTA for older Australians• Leading Age Services Australia• Emergency physician• Geriatricians• Gerontic nursing representatives• Palliative care physician representative• RACF support services’ clinical leads and clinicians• Primary Health Network representative• Statewide General Medicine Network chair• Statewide Older Persons Health Clinical Network representative• Social worker representative

Additionally, subspecialist input was sought for relevant pathways including:• Endocrinology• Gastrostomy services• Infectious diseases physicians• Neurosurgery• Pharmacist• Public Health physicians• Respiratory medicine• Urology• Vascular surgery

The guideline development process involved:1. Initial draft of each pathway was prepared by one Steering Committee member following review of: a. Existing pathways (including those of Comprehensive Aged Residential Emergency and Partners in Assessment Care and Treatment (CARE-PACT) and other national and international RACF support services) b. Available published evidence on the topic c. State, National and International evidence-based guidelines2. Draft guideline reviewed by Steering Committee and feedback provided3. Consultation with subspecialists where relevant4. Revision of guideline on basis of feedback from Steering Committee and subspecialist input5. Endorsement by Steering Committee6. Consultation with (and amendment in response to feedback from): a. Statewide Older Persons Health Clinical Network b. Statewide Dementia Clinical Network c. Statewide General Medicine Clinical Network d. Queensland Emergency Department Strategic Advisory Panel e. Statewide Surgical Advisory Committee f. General Practice Liaison Network g. Statewide RACF Support Services Community of Practice7. User acceptability testing

These pathways will be reviewed in 2022 by a Healthcare Improvement Unit Steering Committee.Any feedback on the pathways should be emailed to: [email protected]

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1

How to use these pathways

These pathways are intended as clinical support tools for management of the acutely unwell patient living in RACFs.

The pathways are designed for use by RACF clinical staff at Registered Nurse (RN), Clinical Nurse (CN), Clinical Nurse Consultant (CNC) or Nurse Practitioner (NP) level, in collaboration with GPs.

The recommendations within these pathways do not indicate an exclusive course of action. They do not replace the need for application of clinical judgement to each individual resident nor variations based on local policies and procedures. The pathways should not replace the clinical judgement of users. If concern exists regarding a resident’s well-being these concerns should be appropriately escalated.

Users should always stay within their scope of clinical practice.

It is recommended that RACFs ensure that they have clinical competency processes for common clinical procedures such as (but not limited to) indwelling catheter insertion, wound assessment and management, subcutaneous fluid administration and tracheostomy care. These pathways do not replace need for such clinical competency processes.

Potential uses of the pathways include:

A. As a clinical support tool for management of residents of aged care facilities who are acutely unwell:

1. Start with assessment of residents’ current vital signs

2. Consult #Recognition of the deteriorating resident to assist in determination of whether vital signs are:

a. Unstable = vital signs are in the red or danger area - refer to #Management of Resident with unstable vital signs pathway

b. Stable = vital signs in the green or caution area - refer to the pathway most relevant to the residents’ symptoms

3. Take a directed history - if cognitively impaired, review additional history from other staff or family

4. Undertake a focused physical examination

5. Select appropriate pathway in consultation with GP

*** Where these pathways suggest medications, these MUST be prescribed by the GP (or NP) for the individual patient and do not constitute standing orders.

B. As an educational resource for clinical staff across the continuum of care.

These pathways are not designed for use by residents or their families and should not be relied on by residents or families as professional medical advice.

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Conditions of use

These pathways are intended as clinical support tools for management of the acutely unwell patients living in RACFs. They are designed for use by RACF clinical staff (at RN, CN, CNC or NP level) in collaboration with GPs.

We provide no guarantee that the information provided is up-to-date or complete and in no circumstance does the information contained within constitute professional advice for management of individual patients.

You are responsible for ensuring use of clinical judgement, and if concern exists on the basis of clinical judgement, additional clinical input should be sought.

The health professional should always remain within their scope of practice.

This manual is only endorsed for use for management of residents of aged care facilities where these are defined as facilities that:

a. Provide residential care to older persons and are funded under the Aged Care Act and are subject to Commonwealth reporting to the System for Payment of Aged Residential Care (SPARC); or b. Are operated under the National Aboriginal and Torres Strait Islander Aged Care Program.

The pathways are only endorsed for use in QH Hospital and Health Services (HHSs) with an operational RACF acute care support service (RaSS) that meets the RaSS guideline requirements including appropriate clinical governance.

The use of a paper-based copy of the pathways should only be undertaken if this is known to have been endorsed by the HHS RaSS and is known to be the latest version.

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Hospital and Health Service contact information

Service Relevant pathways Contact details Hours of operation

[Insert name of local RaSS service] telephone triage (RACF registered nurses and clinical managers, GPs)

All

[Insert name of local RaSS service] Consultant (for contact directly by GPs and QAS paramedics only – all other clinicians please see above telephone triage contact number)

All

[Insert name of local HHS] dementia RACF support services

Behavioural emergencies

Dementia Australia including referrals for Severe Behaviour Response Team


Gastrostomy support service Percutaneous gastrostomy tubes

Interventional radiology service Gastrostomy tubes that have been radiologically inserted (RIGs)

[Insert name of local HHS] outpatient services

Cardiology Chest pain Referrals via [insert details of local central OPD referral process]Chronic pain Pain

Ear, Nose and Throat

Tracheostomy

Endocrinology Hypoglycaemia Falls assessment FallsGastroenterology Percutaneous

gastrostomy tubesGeneral medicine COPD, high blood

pressureInfectious diseases Fever, advice on

management of infections due to multi-resistant organisms

Plastic surgery Wounds (Pressure injuries)

Respiratory COPD Urology Indwelling catheter:

blocked Vascular surgery Wounds (Arterial and

venous lower limb ulcers)

(Older Persons) Mental Health Service

Behavioural emergencies Pain

Palliative care services End of lifePainManagement of residents with unstable vital signs

Public Health Unit Influenza-like illnessGastroenteritis

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This information does not replace clinical judgement 4

Recognition of the deteriorating resident

Any rapid deterioration in condition should be treated with suspicion: the parameters below should not replace clinical judgement; change in residents’ behaviours may also be an indication of deterioration and

should prompt review of vital signs as belowIF YOU ARE CONCERNED ABOUT A RESIDENT CALL THE GP AND DISCUSS

VITAL SIGN RED (DANGER) = Potential life-threat, urgent medical review indicated: review #Management of residents with unstable vital signs

YELLOW (CAUTION) =Medical review indicated

NORMAL =Medical review as indicated by presenting complaint

YELLOW (CAUTION) =Medical review indicated

RED (DANGER) = Potential life-threat, urgent medical review indicated: review #Management of residents with unstable vital signs

Response and cognition

Responsive to pain only or newly unresponsive or sudden change in mental state

Not alert but responsive to voice (unless this resident is normally only responsive to voice)

Alert (or cognition that is normal for this resident)

Respiratory rate (breaths per minute)

Less than 6 6 to 9 10 to 24 25 to 30 More than 30

Respiratory effort

Obvious distress and / or cyanosis (despite oxygen)

Unusually laboured or noisy breathing

Typical for this resident

Pulse oximetry (oxygen saturations)

Less than 88 per cent despite oxygen

88 to 91 per cent despite oxygen

92 to 100 per cent with or without oxygen and usual for this resident

Heart rate (beats per minute)

Less than 40 40 to 49 50 to 100 (persistently)

101 to 130 More than 130

Systolic blood pressure (systolic = top; mmHg)

Less than 90 90 to 109 110 to 180 (or in range specified by GP for this patient)

181 to 200 (or higher in an otherwise well resident)

More than 200 with symptoms

Blood glucose (mmol/L)

Less than 4 and unresponsive to treatment

Persistently 4.0 to 5.9 or less than 4 and responsive to treatment

6 - 15 or in range specified by GP for this patient

Persistently more than 15 and resident well

Persistently more than 15 and resident unwell

Temperature Less than 35 degrees Celsius

35 to 35.5 degrees Celsius

35.6 to 37.7 degrees Celsius

37.8 to 39 degrees Celsius

More than 39 degrees Celsius

Pain Clearly distressed (despite recent pain-relieving medication)

Obvious discomfort (despite pain-relieving medication)

Nil or tolerable(with or without pain-relieving medication)

** modified from Hewitt, J. Aged Care Emergency Manual, 2013. Sourced from: https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0019/274132/aged-care-emergency-manual-24032014.pdf

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5 This information does not replace clinical judgement

NO

YES

Management of residents with unstable vital signs

Resident has unstable vital signs:review #Recognition of the

deteriorating resident

1. Ensure a staff member remains with resident: apply oxygen to maintain oxygen saturations at 92 to 96 per cent (or if a history of chronic lung disease, 88 to 92 per cent) and support in position of comfort

2. Consult resident’s medical chart for Advance Care Plan or Advance Health Directive

3. If not immediately life-threatening review #Checklist for contact and ring GP

Does resident have a documented wish to NOT BE transferred to hospital?

Consult palliative care provider**

Refer to HHS RaSS

at GP discretion

GP / after-hours doctor reviews and determines appropriate

management in consultation with the resident (or their substitute

health decision maker)

Is residenton a palliative

pathway?

YES

YES

NEED FOR FURTHERSUPPORT

NO

1. Call QAS on 0002. Ring GP if not yet aware3. Prepare transfer documentation -

review #Checklist for contact4. Notify substitute health decision

maker5. Notify HHS RaSS

** Palliative care provider is the nominated clinician over-seeing the resident’s palliative care - this may be, for example, the resident’s GP or a nominated palliative care service

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Checklist for contact of GP or RaSS

STEP ACTION DONE?

1 Collect resident’s medical record and medication chart including: • Results of recent tests • Recent changes to medications• Substitute health decision maker contact details (e.g. enduring power of

attorney (EPOA)• Contact details for treating GP

2 Have a copy of the relevant RACF decision support tool in front of you 3 Check the resident’s Advance Care Plan (ACP) / Advance Health Directive

(AHD) for documented wishes

4 Undertake a full set of vital signs including:

• Response and cognition• Airway and breathing assesment (respiratory rate and effort; oxygen

saturations)• Circulation assesment (pulse and blood pressure)• Disability assesment (including blood glucose)• Temperature and pain assessment (use cognition appropriate tool)

5 Pen and paper available to document any instructions 6 Prepare to discuss with GP or a RaSS in the ISBAR format

Identify yourself, your role and where you are calling from Situation or the reason for your call and the current problem e.g. Chest pain Background including past medical history of resident and usual level of functionAssessment including

• Vital signs• Other relevant clinical findings including any recent behavioural changes• Advance Care Plan wishes • Recent medication changes• Recent investigation results

Recommendations arrived at in collaboration with GP or a RaSS

7 If resident is to be reviewed in facility by GP or a RaSS or to be transferred to hospital – prepare documentation including copies of:

• Facility name and 24 hour contact details for RN or clinical manager• Summary of reason for transfer and recent vital signs• Past medical history and baseline level of function • Recent medical notes, results of investigations • Recent changes to medications• Current (regular, prn and short-course) medication AND sign-off charts• Advance Care Plan or Advance Health Directive • Contact details for next of kin and substitute health decision makers

8 Notify next of kin / substitute health decision maker of resident condition and ensure they agree with the recommendations of GP / RaSS – if not, notify GP or RaSS

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YES

NO

YES


Resident displaying physically threatening

behaviour to self or others

Refer to #Management of

residents with unstable vital signs

1. Employ immediate management strategies: (review practice point 1)

2. Check vital signs (review #Recognition of the deteriorating resident)

3. If not immediately life-threatening (review #Checklist for contact and ring GP)

4. Initiate supportive care (review practice point 2)

Undertake cognition-appropriate pain assessment (review appendix 1)

Undertake Neuropsychiatric Inventory(review appendix 1)

Review and address identifiable triggers for challenging behaviour

(review practice point 3)

Call QAS on 000 and implement immediate management strategies (review practice point 1) and notify substitute health decision maker and

HHS RaSS

Refer to#New or worsened confusion pathway

Administer analgesia and refer to #Pain management pathway and

monitor behaviour

Refer to HHS dementia outreach service

or Dementia Support Australia

Refer to HHS older persons mental

health services

Refer toHHS RaSS

at GP discretion

Is therean immediate risk tostaff or to resident/s safety from violent

behaviour?

Is thereevidence of delirium

or is there an identifiable physical cause?(review practice

point 3)

NO

UNSTABLEVITALS

ESTABLISHED DEMENTIADIAGNOSIS / COGNITIVE

DECLINE

SUSPECTEDMENTAL ILLNESS

UNCLEAR

STABLE VITALS

ONGOING BEHAVIOURAL CHALLENGES

NO PAIN

PAINPRESENT

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Behavioural emergencies practice points [1-4](1) Immediate management strategies (3) PIECES framework for assessment

1. Reduce risk:• Remove other residents from danger• Remove potentially harmful objects if safe to do so• Remove distractions• Stand back from the resident

2. Verbal de-escalation:• Use a calm voice with a respectful tone and a

slow, even speed• Use eye contact consistent with the person's

cultural needs• Use the residents name• Use simple sentences without patronising• Encourage resident to talk about what they are

feeling• Communicate empathy• Enter the person’s reality, do not argue

3. Distraction and redirection:• Options include redirecting to an object or past

activity of interest; changing the subject

P - PHYSICAL:1. Pain - use cognition appropriate pain tool2. Urinary retention / constipation3. New injury - recent falls?4. Wound / skin tear5. Polypharmacy: community pharmacist review6. Infections7. Delirium: perform Confusion Assessment Method (CAM)I - INTELLECTUAL:1. Memory, visual perception and cognition

assessmentE - EMOTIONAL:1. Are there neurovegetative signs of depression?2. Undertake a Neuropsychiatric Inventory3. Grief or Loss?C - CAPABILITY:1. Undertake a capability assessment2. Support maximising of capabilities and3. Provide meaningful activitiesE - ENVIRONMENTAL:1. Orientation prompts2. Assess for and remove environmental / situational

triggers: startle response to noise of door shutting; meal-times; showering

3. Change to environment or routineS - SOCIAL SELF:1. Review persons life history - are there any contributors

from their life-experience?2. Cultural contributors to behaviours? e.g. language

barrier with secondary frustration3. Identify and remedy unaddressed social needs e.g.

boredom; lack of physical exercise

(2) Supportive care

1. Orientation prompts2. Family / volunteer involvement where appropriate;

where indicated, utilise a nursing special3. Adequate nutrition and hydration4. Regular mobilisation as tolerated5. Support of a normal sleep-wake cycle6. Ensure availability of hearing aids / glasses as

indicated7. Provide explanation and reassurance to resident

to counteract fear8. Provision of meaningful activity

(4) Pharmacologic approaches

1. Review prior history and determine whether there have been previously effective management strategies utilised

2. Review EXISTING MEDICATIONS for contributors to behavioural disturbance:• Anticholinergics e.g. oxybutynin, ranitidine, promethazine / anti-epileptics / Levo-dopa and dopamine

agonists / Opioids / psychotropics / corticosteroids / antibiotics / antivirals3. NON-PHARMACOLOGICAL METHODS should be tried unless immediate threat of harm4. EFFECTIVENESS OF MEDICATIONS IN BEHAVIOURAL DISTURBANCE IN DEMENTIA IS LOW and there is increased risk of mortality in those treated pharmacologicallyIf non-pharmacological methods exhausted, consider in consultation with GP and subsitute healthdecision maker for resident:

• Risperidone commence at 0.25mg - 0.5mg / day, gradually increasing if needed to maximum 2mg / day (divided doses) OR

• Olanzapine 2.5mg daily OR• Can trial oxazepam e.g. 7.5mg orally once to three times daily (CAUTION: HIGH FALLS RISK)

(5) Behavioural emergency resources

• HHS relevant services: HHS older persons mental health services or dementia outreach services• Dementia support Australia (Dementia Behaviour Management Advisory Service and Severe Behavioural• Response Teams) - 1800 699 799• Educational resources available at: https://www.dementia.com.au/resources/library• Dementia Training Australia resources including Dementia Training Australia Quick Reference Cards available

at: https://www.dementiatrainingaustralia.com.au• Behaviour Management: a guide to good practice 2012. Dementia Collaborative Research Centre

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https://www.dementia.com.au/getattachment/947c82e7-841f-49cd-bdb8-43486b446b01/Behaviour-Management-A-Guide-to-Good-Practice-5.aspx


NO

YES

YESNO

Refer to #Managementof residents with

unstable vital signs

Cellulitis

Resident withsuspected cellulitis



UNSTABLE VITALS

STABLE VITALS

Is there any risk feature/s:

• Fevers • Rigors (uncontrollable shivering)

• Associated diabetic ulcer or deep wound• Significant comorbidity requiring stabilisation

• Altered mental status (different mental state to usual)

• Vomiting • Involves face or orbits • Lymphangitis (erythema

tracking up limb)

1. Confirm patient meets diagnostic criteria for cellulitis (review practice points 1 and 2)

2. Mark margin of cellulitis with skin marker3. Swab exudate if ulcerating cellulitis with discharge

and send for m/c/s4. Other investigations as indicated5. Strict elevation of cellulitic limb (caution if resident

is cognitively impaired)6. Oral antibiotics guided by allergies and prior

sensitivities (review practice point 3)7. If associated wound review Therapeutic Guidelines

for further management advice

Refer toHHS RaSS

at GP discretion

Does theresident develop risk

features or systemic symptomsor fail to respond to oral antibiotics

within 72 hours?

Continue oral antibiotics for5 days in uncomplicated cellulitis (extend treatment if infection not improved in this time) and review and treat risk factors for cellulitis


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Cellulitis practice points [5-7]

(1) Diagnostic criteria for cellulitis

1. Skin almost always hot, shiny, bright red with a well demarcated edge that spreads if left untreated2. Often painful to touch3. In severe disease may be associated with vesicles / bullae

(2) When to consider alternate diagnoses

1. Cellulitis of the lower limbs is usually unilateral - bilateral cellulitis is RARE - if bilateral findings are present consider alternate diagnoses including:

• oedema (with or without blisters)• deep venous thrombosis (DVT)• chronic venous insufficiency or venous eczema• liposclerosis• vasculitis

2. Chronic venous insufficiency involves localised or diffuse involvement of the gaiter area; erythema with dry, scaly or weepy skin; brown discolouration of skin common; if erythema present, it has a diffuse edge3. Presence of unilateral vesicular eruptions and pain requires consideration of Herpes zoster or shingles; early recognition and institution of antiviral therapy (e.g. acyclovir) may reduce incidence of post-herpetic neuralgia and improve time to resolution. Erysipelas (due to group A streptococci) may sometimes also be accompanied by vesicles, though it is differentiated from Herpes zoster by larger vesicles and bullae, often with haemorrhage, and lack of dermatomal distribution4. Presence of pruritus should prompt consideration of presence of underlying scabies

(3) Antibiotic selection in cellulitis: Consider allergies, organism sensitivities and comorbidities; consult Therapeutic guidelines if cellulitis is associated with a wound

1. If no penicillin allergy and no known MRSA: Use Dicloxacillin or Flucloxacillin 500mg orally 6 hourly for 5 days

2. If non-immediate penicillin allergy and no known MRSA: Use Cefalexin 500mg orally 6 hourly for 5 days

3. If immediate (i.e. anaphylactic) penicillin allergy: Use Clindamycin 450mg orally 8 hourly for 5 days

4. If known MRSA colonisation / infection: If known to be clindamycin-susceptible, use Clindamycin 450mg orally 8 hourly for 5 days; otherwise, use trimethoprim+sulfamethoxazole 160 + 800mg orally 12 hourly for 5 days

(4) Risk factors for cellulitis - prevention of recurrent cellulitis

Management of risk factors for cellulitis:1. Examine interdigital toe spaces and treat fissuring, scaling or tinea pedis2. Treat limb oedema3. If chronic venous insufficiency, consider use of compression stockings (review #Venous Leg Ulcer Flow Chart

- appendix 4) 4. Manage wounds or pressure injuries5. Improve glycemic control in diabetes6. Treat nutritional deficiency, with particular emphasis on adequate protein intake in those with normal renal

function and adequate micronutrient intake through a balanced dietMaintain skin integrity:1. Optimise mobility and minimise falls risk, particularly through removal of environmental trip or injury

hazards, use of an appropriate mobility support aid, attention to bowel and / or bladder incontinence2. Regular pressure area care for non-ambulant residents3. Ensure good hygiene and regular use of moisturiserIF above factors addressed and recurrent cellulitis continues to occur (3 to 4 episodes per year) then consider use of prophylactic antibiotics in consultation with an infectious diseases specialist.

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NO ALTERNATE CAUSE FOR CHEST PAIN IDENTIFIED

Chest pain



YES

Resident with chest pain

Check vital signs (review #Recognition of the deteriorating

resident)

Treat alternatecause as indicated

or if cause requires hospital

care refer to #Management of

residents with unstable vital

signs

GP and RACF to provide:1. Ongoing monitoring;2. Where consistent with goals of care,

review and treat precipitants of angina (review practice point 3);

3. Falls risk assessment and management plan including increased supervision of mobilisation: beware increased falls risk after GTN administration

Review#Checklist for

contact and ring GPWith GP: Does resident havean alternate identifiable causeother than cardiac ischemia?

(review practicepoint 1)

UNSTABLE VITALS

STABLE VITALS

CHEST PAIN RESOLVED AND VITAL SIGNS STABLE

UNSTABLE VITALS OR ONGOING CHEST PAIN

1. If resident has an existing individualised management plan for angina enact this now

2. Reassess vital signs and reassure resident3. If oxygen saturations are < 95 per cent apply oxygen

at 6L/min by Hudson mask (unless on home oxygen - then aim for saturations of 88 to 92 per cent)

4. If stable vital signs sit or lay patient down - if pain persists after 5 minutes, with GP ensure no contraindications to Glyceryl Trinitrate (GTN) (review practice point 2), check expiry date of GTN and then administer GTN sublingually (300 micrograms = ½ tablet or one 400 micrograms spray)

5. If pain not resolved in 5 minutes repeat vital signs and if remain stable give further GTN dose

6. If not contra-indicated administer aspirin 300mg orally (review practice point 2)

7. Reassess for ongoing pain and repeat vital sign assessment

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Chest pain practice points [8-11]

(1) Alternate causes for chest painNB. careful assessment is indicated for all chest pain; cardiac ischemia may present atypically in older persons and the pain may meet any of the below descriptors of alternate causes for chest pain

CHEST pain that has pleuritic nature (worse on inspiration):• Pulmonary embolism (PE) - consider if associated shortness of breath / hemoptysis / risks for PE• Pneumonia - consider if febrile / productive sputum• Pneumothorax - consider if recent fall / trauma or history of underlying pulmonary disease

CHEST pain that has sharp, tearing nature and is maximal at onset:• Aortic dissection

CHEST pain that is worse on lying down, relieved on leaning forward:• Pericarditis

CHEST pain that is reproduced on palpation or on movement:• Musculoskeletal causes eg. rib fracture

CHEST pain that is burning and retrosternal• may be due to gastroesophageal reflux; however, cardiac pain may also be described in these terms

(2) Contraindications to GTN or aspirin

GTN is contraindicated if:1. Systolic (top) blood pressure is < 110mmHg

2. Severe anemia (Hemoglobin or Hb < 80)

3. Severe aortic stenosis or obstructive cardiomyopathy

4. Sildenafil citrate (“Viagra”) or analogues administered in previous 24 hours

5. Known hypersensitivity to GTN

Aspirin contraindicated if: 1. Known hypersensitivity or allergy to aspirin or non-steroidal anti-inflammatory drugs

2. Aspirin sensitive asthma

3. Severe active bleeding

(3) Precipitants of angina

1. Acute coronary syndrome - suspect particularly if pain onset at rest or ongoing chest pain or acceleration of chest pain symptoms (unstable angina)

2. Exacerbations of chronic co-morbid conditions e.g. chronic obstructive pulmonary disease (COPD)

3. Development of an acute medical illness e.g. sepsis, anaemia, arrhythmias, hypertensive urgencies, thyrotoxicosis

4. Progression of valvular heart disease

5. Medications that precipitate tachycardia (e.g. anticholinergic medications)

(4) Chest pain resources

• HHS cardiology services• Heart Foundation clinical guidelines• https://www.heartfoundation.org.au/for-professionals/clinical-information/acute-coronary-syndromes?_

ga=2.38474465.393905571.1541984375-5918852.1541984375

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https://www.heartfoundation.org.au/for-professionals/clinical-information/acute-coronary-syndromes?_ga=2.38474465.393905571.1541984375-5918852.1541984375


NO

NO

YES

YES

STABLE VITALS and no drowsiness or vomiting

Chronic obstructive pulmonary disease (COPD)

UNSTABLEVITALSor new

drowsinessor vomiting

Resident with COPD andincreased shortness of breath

1. Sit resident upright in position of comfort



Review Advance Care Plan and refer to #Management of residents with


With GP input commence:

1. 2.5mg to 5mg nebulised salbutamol and then continue salbutamol regularly as per GP order - nebulised salbutamol is ideally delivered using compressed air rather than oxygen - this allows simultaneous delivery of controlled oxygen by nasal prongs where required (review point 4 below)

2. If GP identifies any of:• New more purulent sputum with increased breathlessness• Clinical signs of pneumonia

then commence either (check allergies prior): • Amoxycillin 500mg orally every 8 hours for 5 days OR • Doxycycline 200mg orally for first dose and then 100mg orally once

daily for 5 days3. GP to consider prednisone 30mg to 50mg daily for 5 to 7 days unless

contraindicated

4. Maintain oxygen saturations at 88 to 92 per cent (note: oxygen therapy should be controlled - usually 0.5L to 2.0L/minute via nasal prongs titrated to support oxygen saturations of 88 to 92 per cent in order to reduce death rates)

5. Monitor for increased shortness of breath or worsening symptoms or unstable vital signs (particularly for evidence of increasing drowsiness, oxygen saturations < 88 per cent despite supplemental oxygen or evidence of an increasing oxygen requirement)

Follow COPDaction plan and liaise with GP

Consideralternate causefor symptoms

Does residenthave a COPDaction plan?

Does residenthave clinical features ofan acute exacerbation ofCOPD? (review practice

point 1)

INCREASED SHORTNESS

OF BREATH OR WORSENING

SYMPTOMS OR UNSTABLE VITAL

SIGNS

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Chronic obstructive pulmonary disease (COPD) practice points [12-15]

(1) Criteria to diagnose exacerbations of COPD

Diagnosis of an exacerbation of COPD is clinical and NICE guidelines define this as:“A sustained worsening of the patient’s symptoms from their usual state that is beyond normal day-to-dayvariations and is acute in onset”.Commonly reported symptoms are:1. Worsening breathlessness2. Increased cough3. Increased sputum production4. Change in sputum colourSending sputum samples for culture is not recommended in routine practicePulse oximetry is of value if there are clinical features of an acute exacerbation

(2) Pharmacologic management of exacerbations of COPD

1. Increased doses of short-acting bronchodilators:In residents of aged care facilities, nebulised salbutamol may be more useful than hand-held delivery systems particularly in cognitively impaired

** Nebuliser should be driven by compressed air not oxygen (with supplemental oxygen given by nasal prongs simultaneously if required)2. Steroids:In the absence of significant contraindications, oral corticosteroids should be considered in those with an exacerbation with a significant increase in breathlessness which interferes with daily activities; prednisone 30mg to 50mg orally once daily should be prescribed for 5 to 7 days - there is no benefit in steroid therapy beyond 14 days

3. Antibiotics:Commence antibiotics if either of:

• NEW more purulent sputum with increased breathlessness or• Clinical signs of pneumonia

In the absence of the above symptoms there is no indication for antibiotics for COPD exacerbations

4. Oxygen:Controlled oxygen therapy is associated with a significant reduction in mortality when compared with high-flow oxygen in acute exacerbations of COPD

** Influenza and pneumococcal vaccination when well, reduce hospital admissions in this cohort

(3) Oxygen in residents with COPD

If delivered inappropriately may cause respiratory depression. CONTROLLED oxygen delivery (0.5 - 2.0L/minute via nasal prongs) is indicated for acute hypoxemia (O2 saturations < 88 - 92 per cent) in residents with exacerbations of COPD

(4) COPD resources

• For residents with frequent exacerbations consider referral to Respiratory or General Medicine outpatients of HHS - review HHS specific OPD referral guidelines

• Respiratory therapeutic guidelines v5, 2015• The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive

Pulmonary Disease 2018. Lung Foundation Australia and the Thoracic Society of Australia and New Zealand. v 2.53, 2018. Accessed 7/2018 at https://copdx.org.au/wp-content/uploads/2018/06/COPDX-V2-53-March-2018_2.pdf

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Review Advance Care Plan and refer to #Management of


Congestive cardiac failure (CCF)

Resident with suspectedCCF*

1. Sit resident upright in position of comfort and apply oxygen to maintain oxygen saturations at 92 to 96 per cent (if history of COPD or chronic lung disease aim for 88 to 92 per cent)



UNSTABLE VITALS

STABLE VITALS

YES NO

RACF and GP to institute guidelines for preventing

exacerbations CCF (review practice points 2 and 3)

Refer to HHS RaSS

at GP discretion

*Suspect CCF in residents who have any of the following symptoms or examination findings, where no alternate more likely cause is identified:1. Progressive exertional dyspnoea or shortness of breath2. Orthopnoea or resident props self up on a number of pillows to sleep3. Paroxysmal nocturnal dyspnoea or sudden shortness of breath during sleep4. Dry irritating cough that may occur particularly at night, where there is no other cause identified5. Progressive abdominal distension or ankle swelling6. An elevated jugular venous pressure7. Bilateral inspiratory crackles on chest auscultation (note wheeze may predominate)

1. Review and treat underlying causes (review practice point 1)

2. Pharmacologic therapy (review practice point 2)• If clinical evidence of fluid overload, consider

starting, or if existing, increasing diuretic therapy - usually frusemide in initial instance ▪ If significantly hypertensive with pulmonary

oedema, consider GTN sublingually3. Treat chest pain - refer to #Chest pain4. Non-pharmacologic management (review practice

point 3)

SYMPTOMS SETTLE AND CLINICAL SIGNS OF HEART FAILURE

RESOLVE?

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Congestive cardiac failure (CCF) practice points [16-19]

(1) Common underlying causes of CCF

1. High blood pressure2. Acute myocardial ischaemia (angina or myocardial infarction) - if chest pain present, refer to chest pain

pathway3. Medication-induced causes - cease contributing medications where possible e.g. calcium channel

blockers (e.g. verapamil or diltiazem); corticosteroids; NSAIDs; urinary alkalinisers4. Arrhythmias - suspect if new significant tachycardia, bradycardia or new irregular pulse rate5. Hyperthyroidism or hypothyroidism - check thyroid function tests6. Underlying infection7. Severe anaemia - check full blood count8. Acute valvular dysfunction

(2) Pharmacologic management of residents with exacerbations of CCF

1. Review and treat underlying precipitants (review above)2. Diuretic therapy indicated for fluid overload symptom control:

• early commencement in acute exacerbations of CCF associated with improved outcomes• individualise dose to patient status, history of renal impairment and usual maintenance dose of loop diuretic• if acutely short of breath then intravenous (IV) diuretics may be superior to oral; if shortness of breath

subacute then oral diuretics may be suitable• unless contraindicated, consider commencement of frusemide at 20mg to 40mg daily (in acute setting,

if already on maintenance dose of frusemide, usually require a dose equal to or double to the usual maintenance dose)

• if IV frusemide utilised - if good symptomatic response within 60 minutes switch to oral dosing; if no response, consider repeat IV dose

• monitor potassium and creatinine - check within 24 hours of initiation of therapy and then weekly during titration of diuretic

3. If significantly hypertensive with pulmonary oedema, consider use of GTN4. Treat chest pain - refer to #Chest pain5. When stable and no longer acutely unwell, distinguish between heart failure with impaired left ventricular function (systolic heart failure) and heart failure with preserved ejection fraction (or diastolic heart failure). Residents are likely to have systolic dysfunction if there is: a. Echocardiography demonstrating reduced left ventricular ejection fraction within the last 5 years b. Past history of myocardial infarction (documented history or multiple significant Q waves) c. Gallop heart sounds and displaced apex beat d. Marked cardiomegaly on CXRIn residents with systolic dysfunction, when clinically stable and euvoluemic, consider addition of:

a. Angiotensin converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB) - check serum potassium etc. b. Beta-blockers if evidence of left ventricular failure

Note: Beta-blockers are relatively contraindicated in acute phase if still in overt heart failure

(3) Non-pharmacologic management of residents with CCF

Monitor:1. Daily weighs - notify GP if 2kg or more weight gain over 1 to 2 days2. Postural drop in blood pressure - institute falls risk management plan3. Monitor fluid intake - where indicated, restrict to 1.5L per day (caution in summer)4. Restrict salt intake5. Establish Advance Care Plan

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HARD STOOL INRECTUM?

SOFT STOOL INRECTUM?

Is constipationongoing or present already

for 3 days?If yes, perform gentle digital

rectal examination (credentialedpractitioners only)

Constipation

Refer to #Managementof resident with unstable

vital signs



3. Review for risk features (review practice point 1)

UNSTABLE VITALS or RISK

FEATURES

STABLE VITALS

1. Assess for and treat underlying cause (review practice point 2)

2. Review for causative drugs and cease where possible (review practice point 3)

3. Review bowel chart4. Ensure:

• Implementation of non-pharmacological strategies (review practice point 4)

• Implementation of initial or maintenance pharmacological strategies (review practice point 5)

BLOOD OR MASS IN

RECTUM?

RESPONDS Reassessresponse

Refer to HHS RaSS

at GP discretion

Initiate maintenancemanagement (review practice

points 4 and 5)

NO RESPONSE

Resident with suspectedconstipation

1. If no evidence of intestinal obstruction or heart failure trial one of:

Glycerol suppository 2.8g PR - allow to remain insitu for 15-30 minutes or Movicol - up to 8 sachets in severe impaction (dissolved in 1L of water and consumed orally within 6 hours) daily for up to 3 days 2. If no response, consider digital

disimpaction

1. If no evidence of intestinal obstruction or heart failure, trial an osmotic laxative: Microlax enema PR or If immobile,1-2 sachets Movicol orally daily, each in 125mL water (care in cardiovascular disease) or If well-hydrated, sorbitol liquid 20mL orally once daily increasing if required to three times a day or lactulose 15mL to 30mL orally once to twice daily

2. If no response, add stimulant laxative (contraindicated in active inflammatory bowel disease or diverticulitis):• Coloxyl and senna two tablets orally twice daily or• Bisacodyl enema

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Constipation practice points [20-22]

(1) Risk features in constipation

(2) Causes of constipation

• Iron deficiency anemia

• Vomiting and abdominal pain

• Rectal bleeding• Rectal prolapse• Weight loss• Lower back pain that

is new or worsening

• Mechanical obstruction - ongoing vomiting and abdominal pain• Faecal impaction• Dehydration• Endocrine / metabolic disorders eg. hypothyroidism, chronic kidney disease,

diabetes, electrolyte disturbance e.g. hypercalcemia, hypokalemia• Neurologic disorders eg. Spinal cord pathology, Parkinson’s disease, autonomic

neuropathy, dementia, depression• Gastrointestinal and local painful conditions eg. anal fissure, abscess,

haemorrhoids, rectal prolapse• Dietary eg. reduced oral intake, fluid depletion, low fibre diet

(3) Drugs causing constipation

• Aluminium or calcium-containing antacids• Anticholinergics eg. tricyclic antidepressants, some antiparkinsonian drugs, antipsychotics, antispasmodics,

antihistamines• Calcium supplements• Calcium-channel blockers• Diuretics• Iron supplements• Non-steroidal anti-inflammatory agents (NSAIDs)• Opioid analgesics

(4) Non-pharmacological management

In all residents ensure:• Adequate fluid intake• Adequate dietary fibre intake• Toilet each morning and thirty minutes after meals or after a hot drink when gastrocolic reflex is maximal• Increase exercise if able• Improve access to toileting facilities: ensure privacy and comfort; mobility assistance

(5) Pharmacological management

There is limited evidence related to use of laxatives in older persons. Consider the following:

• Mobile residents with low-fibre diet: increase dietary fibre or add bulk forming laxatives - note: contra-indicated in intestinal obstruction / faecal impaction / colonic atony; avoid in immobile or fluid restricted residents

• Immobile residents: sorbitol 15mL-30mL once daily

• Opioid-induced constipation: coloxyl with senna 1-2 tablets regularly at bedtime (up to 4 tablets/day) - note: contraindicated in active inflammatory bowel disease or diverticulitis

• For palliative care residents prescribed opioid analgesia, consider methylnaltrexone - for dosing review Australian Medicines Handbook

• Avoid long-term use of stimulant laxatives

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STABLE VITALS

LOW or MODERATE

PROBABILITY

UNSTABLE VITALS

Deep venous thrombosis (DVT)

DOPPLER NEGATIVE

Resident with suspected DVT*


2. If not immediately life-threatening review #Check-list for contact and ring GP

NEGATIVE

POSITIVE

HIGH PROBABILITY

1. GP to arrange a doppler ultrasound2. If delay to doppler, GP to consider

therapeutic enoxaparin (clexane) if no contraindications: 1mg / kg (round down to nearest 10mg) subcutaneously twice daily to a maximum of 100mg bd; if Creatinine Clearance is less than 30mL/ min - enoxaparin is relatively contraindicated - consider consultation with HHS RaSS at GP discretion

3. If enoxaparin commenced, doppler may be undertaken within 24 to 48 hours

Investigate for alternate causes of symptoms if indicated; if no alternate

cause determined consider repeat doppler ultrasound in 1 week

Consider alternatecause for symptoms

Refer toHHS RaSS

at GP discretion

On GPassessment, does

the resident have a high or low probability of DVT?



resident with unstable vital

signs

Perform a sensitive

d-dimer test

DOPPLERPOSITIVE OR

UNABLETO OBTAIN

PRIVATEDOPPLER WITHIN

CLINICALLYAPPROPRIATETIME FRAME

* Suspect DVT in residents who have any of the following symptoms or examination findings, where no alternate more likely cause is identified:

1. Unilateral swelling of the entire leg2. Difference in calf circumference of > 3cm between left and right leg3. Unilateral pitting lower limb oedema4. Pain and tenderness along the course of major lower limb veins5. Dilated superficial veins of the involved lower limb

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Deep venous thrombosis (DVT) practice points [23-25]

(1) Assessing probability of DVT (modified Well’s criteria)

CLINICAL FEATURE SCORE

Tenderness along entire deep vein system +1

Swelling of entire leg +1

Affected calf at least 3cm larger in circumference than non-affected calf +1

Pitting oedema (confined to affected leg) +1

Collateral superficial veins (non-varicose) +1

RISK FACTORS PRESENT

Active cancer +1

Prolonged immobility or paralysis or recent plaster immobilisation of lower extremities +1

Recently bedridden for 3 days or more or major surgery within previous 12 weeks requiring general or regional anaesthesia

+1

Previously documented DVT +1

Alternative diagnosis at least as likely as DVT -2

INTERPRETATION:

IF TOTAL SCORE IS:

> 2 = High probability (80 per cent) of DVT1 - 2 = Moderate probability (33 per cent) of DVT< 1 = Low probability (5 per cent) of DVT

(2) DVT resources

• Private radiology providers may accept GP referrals of RACF residents for doppler ultrasound• Please contact your local private radiology provider to confirm and if resident requires ambulance transfer,

please confirm that they have the ability to accept stretcher patients prior to transfer AND that doppler ultrasound is available within a clinically appropriate time frame

• Your local HHS RaSS may be able to advise on potential avenues to access doppler ultrasound services

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End of life managementPlease utilise in conjunction with Queensland Government

Residential Aged Care End of Life Care Pathway (RAC EoLCP)

NO

YES

Resident suspected tobe in terminal phase of life

1. Review signs and symptoms associated with terminal phase of life (review practice point 1)

2. If not immediately life-threatening review #Check-list for contact and ring GP

NOT ALL AGREE

ALL AGREE

Obtainopinions

of ALL of the followingin relation to commencement

of RAC EoLCP:1. Resident (if resident does not have

capacity to make decisions consult residents Advance Care Plan or Advance

Health Directive)2. If the resident agrees (or if lacks capacity

to make decisions) involve residents substitute health decision maker

3. GP4. RACF clinical staff and

multidisciplinaryteam

1. Commence on RAC EoLCP (review appendix 2)

2. GP nominates palliative care provider and documents updated Advance Care Plan in consultation with resident or substitute health decision maker

Consider cause forsymptoms and refer to

appropriate clinicalpathway

GP and RACF staff provide ongoing palliative care +/- referral to

HHS community palliative care service at GP discretion (review practice point 2); if palliative care unable to review resident

in an appropriate time frame and GP requests second opinion, refer to

HHS RaSS

Refer toHHS community palliative care service

orHHS RaSS

at GP discretion

3 or more signs and

symptoms associated with terminal phase of life

are present?

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End of life management practice points [26]

(1) Signs and symptoms associated with terminal phase of life

If 3 or more of the below signs and symptoms are present, AND the GP, multidisciplinary team and resident (or their substitute health decision maker) ALL agree, it is appropriate to commence the End Of Life Pathway (RAC EoLP):

1. Experiencing rapid day to day deterioration that is not reversible

2. Requiring more frequent interventions

3. Becoming semi-conscious, with lapses into unconsciousness

4. Increasing loss of ability to swallow

5. Refusing or unable to take food, fluids or oral medications

6. Irreversible weight loss

7. An acute event has occurred requiring revision of treatment goals

8. Profound weakness

9. Changes in breathing patterns

**PLEASE note: in some cases residents may be commenced on the RAC EoLCP and then taken off the pathway if their condition improves

(2) Palliative care resources

Specialist community palliative care services work in collaboration with primary care providers and often provide:

1. Visits to the resident in the RACF2. 24 hour telephone on-call services3. Admission to inpatient palliative care beds where indicated

• HHS specific community palliative care services• How to use Residential Aged Care End of Life Care Pathway:

https://www.caresearch.com.au/caresearch/tabid/3599/Default.aspx• Guidelines for a palliative approach to care in Residential Aged Care:

https://www.health.gov.au/internet/main/publishing.nsf/Content/pcg-acs• Residential Aged Care palliative care resources:

https://www.caresearch.com.au/caresearch/tabid/2256/Default.aspx• End of life directions for aged care (ELDAC):

https://www.eldac.com.au/

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https://www.eldac.com.au/


Falls

NO

NO

YES

YES

Review Advance Care Plan and

refer to #Managementof residents with


Undertake structured head to toe assessment of

resident to identify:1. Potential cause of fall2. Injuries due to fall


Resident with fall orsuspected fall



3. Do not move resident until assessed for injuries unless immediate danger

UNSTABLE VITALS

RECURRENTFALLS

UNSTABLEVITALS

orDEVELOPS RISK

FEATURE

STABLE VITALS

Is there any risk feature:

• Severe pain• Any neck pain

• Significant bleeding• Inability to mobilise as usual

• Altered mental status• Bony deformity

• Known bleeding disorder or on anticoagulant or anti-platelet agents• Major head trauma

• Severe headache or vomiting

• Fall from >1 metre

1. Assess for and treat pain2. Assess for and treat underlying cause for fall3. Monitor vital signs including conscious level and

neurological observations every: i. 15 minutes for 1 hour; then if normal: ii. 30 minutes for 2 hours; then if normal: iii. 1 hour for 4 hours; then as per GP input4. Review falls assessment management plan and

initiate physiotherapy review where indicated5. If recurrent falls consider geriatrician review6. Notify substitute health decision maker of fall

Refer toHHS RaSS

at GP discretion

Does theresident

have suspected minorfracture, laceration,

bruising?

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Falls practice points [27-30](1) Structured assessment of resident post-fall (please use in conjunction with Residential Care Facility Falls Assessment and Management Plan (review appendix 3)

AIM to identify:1. Cause of fall2. Injuries related to fall3. Risk factors for further falls

Undertake: 1. Check of vital signs - A / B - Oxygen saturations - hypoxia - Respiratory rate C - Pulse rate - bradycardia or tachycardia - Blood pressure - hypotension or hypertension; if no injuries precluding, check for postural drop D - Conscious level - Glasgow Coma Score (GCS) or Alert-Verbal-Pain-Unresponsive (AVPU) - Blood glucose level E - Temperature - fever, hyperthermia or hypothermia

2. History of fall including:• Fall witnessed vs unwitnessed?• Resident recalls fall? Was resident unconscious?• Circumstances of fall: what was the resident doing? e.g. trip / slip, environmental hazard, change in posture,

recent meal, urination, defecation, turning of head, cough• Warning symptoms before fall: pre syncope, chest pain, headache, palpitations, shortness of breath, vertigo• After fall: localised pain, headache, vomiting• Comorbidities: coagulopathy, cardiac history, Parkinson’s disease, visual impairment, osteoporosis, seizure disorder• Medications: on anticoagulants (eg. warfarin, dabigatran, apixaban, rivaroxaban, bivalirudin, fondaparinux)

or anti-platelet (eg. aspirin, clopidogrel, prasugrel, dipyridamole) therapy, recently introduced medications, particularly those associated with postural drop (eg. antihypertensives, diuretics, autonomic blockers, antidepressants, hypnotics, anxiolytics, analgesics, psychotropics)

3. Examination after fall including:• Head - evidence of bruising, lacerations, facial bone tenderness, clinical evidence of base of skull fracture

(bruising over mastoid or around both eyes), pupil equality, nystagmus, visual or hearing impairment• C-spine - tenderness• Chest - tenderness, bruising of ribs, murmurs, arrhythmia, congestive heart failure• Abdomen - tenderness, bruising (don’t forget to examine flanks), tenderness of pelvic bones, organomegaly• Thoracolumbar spine - tenderness• Limbs - bony tenderness or deformity• Focal neurological deficits, muscle rigidity, tremor• Assess for delirium using Confusion Assessment Method (CAM) (review appendix 1)• If no spine tenderness or lower limb deformity - assess for postural drop in blood pressure, and assess ability

to mobilise safely with usual gait

(2) General falls prevention strategies

1. Regular environmental audits to identify falls risks2. Consider vitamin D and calcium supplementation and arrange dietitian review for residents with falls3. Residential Medication Management Review to identify medications that may be contributing to falls risk4. Consider use of hip protectors, ensure safe footwear, alarm mats where indicated5. Consider physiotherapy review to ensure appropriate mobility aid is utilised and implement physical training for

balance and strength optimisation

(3) Resources for residents with falls

• HHS falls specific services• Preventing falls & harm from falls in older people: best practice guidelines for Australian Residential Aged Care

Facilities, 2009. Available from: https://www.safetyandquality.gov.au/wp-content/uploads/2012/01/Guidelines-RACF.pdf

• QH Residential post fall clinical pathway

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Fever or suspected infection

NO


refer to #Management of


YES

Resident with fever /suspected infection




Refer to relevantpathway:

#Urinary tract infection

#Pneumonia#Cellulitis

#Gastroenteritis#Influenza-like illness

Refer toHHS RaSS

at GP discretion

Clinical review byGP - sourceidentified?

UNSTABLE VITALS

STABLE VITALS

SOURCE NOTIDENTIFIED

SOURCEIDENTIFIED

1. Where consistent with resident’s goals of care, arrange blood tests including: Full blood count, Urea, Electrolytes, Liver Function Tests, Blood cultures

2. Urine sent for m/c/s if: ACUTE ONSET OF DYSURIA (burning or stinging when passing urine) OR the resident has TWO or more criteria for a UTI, at least one of which is a major criterion - note: if resident has an indwelling catheter or suprapubic catheter, only one criterion (major or minor) is required:a) Major criteria:

• FEVER (review practice point 1)• ALTERED MENTAL STATE without another cause

b) Minor criteria:• New or worsening URGENCY or FREQUENCY• SUPRAPUBIC or FLANK PAIN or tenderness

• Gross HAEMATURIA (blood stained urine)• New or worsening urinary INCONTINENCE• RIGORS (uncontrollable shivering or shaking)

3. Where respiratory viral infection suspected, take nose and throat swabs for influenza and respiratory virus PCR

4. Where diarrhoea present, send stool sample for viral and bacterial PCR

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Fever or suspected infection practice points [5, 31, 32]

(1) When to suspect infection in residents of aged care facilities

Suspect infection in residents with:1. Decline in functional status as evidenced by any of: i. New or increasing confusion ii. New incontinence iii. Deteriorating mobility2. Reduced food intake3. Change in behaviour4. Fever (where this is defined as a single oral temperature of > 38 degrees Celsius or an increase in temperature > 1.5 degrees Celsius over resident’s baseline temperature)

(2) Antibiotic selection

Prior to initiation of antibiotics, appropriate clinical specimens should be taken to assist in diagnosis and targeting of antibiotic therapy.Antibiotic selection for infection should be guided by:1. Allergies - note: in reference to hypersensitivities: Immediate hypersensitivity refers to development of urticaria (hives), angioedema (facial / oral swelling), bronchospasm (wheeze) or anaphylaxis within 1 to 2 hours of exposure to a drug. Non-immediate hypersensitivity refers to development of a macular, papular (raised) or morbilliform rash occurring several days after starting treatment.2. Prior sensitivities of organisms in this resident if empiric therapy or by current sensitivities if directed therapy3. Comorbidities with particular emphasis on: i. Immunosuppression eg. chronic steroid use / other immunosuppressive drugs ii. Renal or hepatic dysfunction - there may need to be dose adjustment iii. Nutritional status iv. Potential for drug interactions, particularly where there is polypharmacy - for example, specific risk exists in co-prescribing macrolide antibiotics (e.g. clarithromycin, erythromycin) and azole antifungals (e.g. Fluconazole, voriconazole)4. Antibiotic guidelines for suspected infection source - use antibiotics suggested by relevant QH RACF pathway or Therapeutic guidelines: antibiotics version 16 or Review input from local referral hospital5. Residents ability to swallow or tolerate oral intake

(3) Resources for residents with fever or suspected infection

• Antibiotic expert group. Therapeutic Guidelines: antibiotics. Version 16, Melbourne: Therapeutic Guidelines Ltd. 2019.

• For advice on selection of antibiotics: contact your HHS infectious diseases physicians

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YES NO

Gastroenteritis



YES

Resident with suspectedgastroenteritis

1. Immediately institute strict infection control procedures and isolate resident (review practice point 1)



Refer to HHS RaSS at GP discretion

Is there evidence of risk feature/s:

• Severe abdominal pain• Rigors (uncontrollable

shivering / shaking)• Reduced conscious

state

Is there evidence of any referral features:

• Fevers• Blood in stools

• Acute confusion• Significant dehydration• Significant comorbidity

requiring stabilisation e.g. unstable diabetes

UNSTABLE VITALS

NO

DEVELOPS REFERRAL FEATURES

STABLE VITALS

DEVELOPS RISK FEATURES

or UNSTABLE VITALS

1. Confirm gastroenteritis most likely diagnosis (review practice point 2)2. Initiate appropriate investigations (review practice point 3)3. Refer to facility and state guidelines on management of gastroenteritis and to gastro-info kit and review public health notification criteria4. Monitor:

• vital signs regularly• fluid balance• comorbidities - if known diabetic monitor blood glucose

levels regularly5. Encourage oral fluids as appropriate to individual resident - if clinical evidence of dehydration consider supplemental subcutaneous fluids (review #Subcutaneous fluids and dehydration)6. Consider antiemetics7. Monitor for development of risk or referral features

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Gastroenteritis practice points [33, 34]

(1) Infection control procedures in gastroenteritis (refer to state and facility guidelines andGastro-info kit for more detailed information)

1. Reinforce hand hygiene with staff and visitors - ensure adequate supplies of liquid soap and alcohol-based hand rub

2. Isolate residents who are infected - if an appropriate single room is not available, implement room sharing (cohorting) of residents with the same infection

3. Allocate separate toilet for infected residents and utilise dedicated staff where possible4. Monitor staff for symptoms - remain off work for at least 48 hours after last episode of symptoms5. Restrict contact between affected and unaffected residents for at least 48 hours after last symptoms6. Restrict visitors - warn them of risks7. Increase personal protective measures - wear gloves, gowns/plastic aprons and masks when cleaning

rooms of infected residents and remove them before leaving the room8. Clean resident environments frequently and thoroughly with a neutral detergent and hot water prior to

disinfection with 0.1 per cent bleach solution

(2) Identification of gastroenteritis

Suspect potential gastroenteritis if resident has one or more of the following:1. Diarrhoea2. Increase of 3 or more bowel motions over an individual’s baseline3. 2 or more episodes of vomiting4. Nausea and abdominal pain or tenderness5. Consider diagnosis in those with functional decline

Consider alternate causes including:1. Subacute bowel obstruction2. Faecal impaction with overflow diarrhoea3. Faecal incontinence4. Diarrhoea secondary to medication5. Acute abdomen - suspect if severe abdominal pain or abdominal guarding or rigidity

Signs of dehydration include:1. Reduced urine output2. Heart rate above 110 beats per minute3. Dry mucous membranes (mouth and tongue)4. Reduced systolic (top) blood pressure

(3) Investigations in gastroenteritis (consult public health for local guidelines)

1. In all residents test for bacterial AND viral PCR studies2. In immunocompromised or those with recent hospitalisation or antibiotics add test for Clostridium difficile.

Also add test for Clostridium difficile in those residents with suspected sepsis OR with negative bacterial and viral PCR studies and ongoing diarrhoea

3. If chronic symptoms (more than 7 days) add examination for Giardia and Cryptosporidium

(4) Resources for residents with gastroenteritis

• Gastro-info outbreak co-ordinator’s handbook, Department of Health and Ageing, https://agedcare.health.gov.au/sites/g/files/net1426/f/documents/09_2014/d03221104_gastro_info_kit_outbreak_coordinators_handbook_webta.pdf

• Queensland Health. The Centre for Healthcare Related Infection Surveillance and Prevention (CHRISP). Queensland Health Infection Control Guidelines and Australian/New Zealand Standard 4187: 2003: https://www.health.qld.gov.au/clinical-practice/guidelines-procedures/diseases-infection/infection-prevention

• Local Public Health Unit contact details: https://www.health.qld.gov.au/system-governance/contact-us/contact/public-health-units

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https://agedcare.health.gov.au/sites/g/files/net1426/f/documents/09_2014/d03221104_gastro_info_kit_outbreak_coordinators_handbook_webta.pdf



https://www.health.qld.gov.au/clinical-practice/guidelines-procedures/diseases-infection/infection-prevention

https://www.health.qld.gov.au/clinical-practice/guidelines-procedures/diseases-infection/infection-prevention

https://www.health.qld.gov.au/system-governance/contact-us/contact/public-health-units


High blood pressure (BP)

YES

Refer to#Management of


Resident with systolic (top) blood pressure (BP) > 180

mmHg OR diastolic (bottom) BP > 110 mmHg

1. Check vital signs (review #Recognition of the deteriorating resident) and compare current BP to resident's usual BP


GP manages or refer toHHS RaSS

at GP discretion

GP and RACF manage resident; regular BP

measurement todetermine need for

antihypertensive adjustment or if on palliative pathway cease measurement of

blood pressure

Does theresident have

any warning symptoms:• Severe headache

• New neurological symptoms or signs / new weakness

• New onset confusion• Acute shortness of breath

• Chest pain

UNSTABLE VITALS NO

DOES NOTIMPROVE

IMPROVES

STABLE VITALS

UNSTABLE VITALS OR DEVELOPSWARNING

SYMPTOMS

1. Allow resident to rest quietly2. Ensure normal pain relief and blood pressure medications

have been given3. Undertake a pain assessment appropriate to cognition -

provide analgesia if resident has pain and assess for cause of pain

4. Record blood pressure hourly for 4 hours and monitor for above warning symptoms

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High blood pressure (BP) practice points [35-39]

(1) Residents with no symptoms and a high blood pressure

** The American College of Emergency Physicians policy for asymptomatic patients with high blood pressure states

1. In patients with no symptoms and a markedly elevated blood pressure routine Emergency Department medical intervention is not required

2. In patients with no symptoms and a markedly elevated blood pressure routine Emergency Department screening for acute target organ injury is not required

** There is evidence that CHRONIC control of blood pressure in the elderly reduces LONG-TERM risk of stroke and heart attack2-4 but decision to treat and treatment goals need to be individualised and include assessment of overall goals and risk assessment for falls.

A systematic review of observational studies identified that hypertension is common in residents of aged care facilities and is commonly treated with antihypertensives; however, there was observed increasing polypharmacy, with associated risk of adverse events, without demonstrable benefit in terms of blood pressure control5

(2) Hypertensive emergencies

** There is evidence EMERGENCY DEPARTMENT PRESENTATION is indicated, if longterm goals of care are consistent with this, for hypertensive emergencies where high blood pressure is associated with any of:

1. Severe headache

2. New neurological symptoms or signs / new onset confusion

3. New weakness

4. Acute shortness of breath

5. Chest pain

(3) Resources for residents with hypertension

• HHS specific general medicine or hypertension units• Welsh T, Gladden J, Gordon A. The treatment of hypertension in care home residents: a systematic review of

observational studies. Journal of American Medical Directors Association. 2014. 15: 8-16.

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GP and RACF manage resident (review practice point 3), refer to

HHS RaSSat GP discretion if ongoing concerns

YES

BGL > 4

BGL < 4

Hypoglycaemia

1. Lie on side in recovery position2. Administer 1mg IMI glucagon

if available3. Refer to #Management of


1. Give one serve of fast acting carbohydrate (review practice point 1)


1. Give one serve of slow acting carbohydrate (review practice point 2)

2. Recheck BGL in 1 hour and then if > 4, hourly for 4 hours, then 4 hourly for 24 hours

3. Review #Check-list for contact and ring GP

Resident with Blood Glucose Level (BGL) of less than 4mmol/L

Is the residentconscious andco-operative?

Repeat BGL in15 minutes: is BGL

above 4?

NO

STABLE VITALS

UNSTABLEVITALS

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Hypoglycaemia practice points [40, 41]

(1) Fast-acting carbohydrates (2) Slow-acting carbohydrates

Normal diet 100mL Lucozade1 serve Poly Joule150mL Lemonade or other soft drink (not diet)3 teaspoons sugar dissolved in 50mL water7 small or 4 large glucose jellybeans150mL orange juice30mL cordial (not diet) mixed with 150mL water

Normal diet 250mL milk1 tub (200g) yoghurt1 slice bread2 sweet plain biscuits1 piece fruitnext meal (if being served within 30 minutes)

Thickened diet

1 tube pre-prepared thickened cordial (not diet)3 individual serves of jam (not diet)

Thickened diet

1 tub pureed fruit1 serve thickened milk drink

PEG tube Via feeding tube:100mL Lucozade1 serve Poly Joule150mL orange juice30mL cordial (not diet) mixed with 150mL water

PEG tube Via feeding tube:150mL enteral feed

(3) Diabetes management after treating hypoglycaemia

GP to review diabetes management for causes of hypoglycaemia and correct avoidable causes If cause identified and corrected (eg. missed, delayed or reduced intake), insulin dose adjustment is not required unless hypoglycaemia recurs; if reduced oral intake consider reducing mealtime insulin doses. If cause not identified or cannot be corrected, GP to consider:

i. hypoglycaemia that has occurred within 4 hours after mealtime insulin = reduce the dose of THAT mealtime insulin by 20 per cent the following dayii. if hypoglycaemia has occurred outside of 4 hours after mealtime insulin = reduce basal insulin dose by 20 per centiii. if on a sulphonylurea obtain specialist advice as hypoglycaemia can be recurrent or prolonged

(4) Resources for residents with hypoglycaemia

• HHS specific endocrinology services• The McKellar Guidelines for managing older people with diabetes in residential and other care settings

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https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=2ahUKEwiO0oyX0q_fAhVKU30KHdPEC6YQFjAAegQIAxAC&url=https%3A%2F%2Fwww.adma.org.au%2Fclearinghouse%2Fdoc_download%2F133-the-mckellar-guidelines-for-managing-older-people-with-diabetes-in-residential-and-other-care-settings_9dec2013.html&usg=AOvVaw2JB-cxJTvthq7rv4OQQOlL


Indwelling urinary catheter: preparation for insertion [42]

Resident assessed byGP as requiring IDC

GATHER REQUIRED EQUIPMENT:1. Clean and prepare dressing trolley2. Sterile equipment:

• Catheter pack• Gloves• Indwelling catheter x 2 (review practice point 1 for selection of catheter)• Syringe of appropriate size - check IDC balloon size• Lignocaine jelly (or if allergy to lignocaine use KY jelly) • Urinary drainage bag (if required) - establish if hourly measures or free drainage required• Water ampoules (number required as per balloon size of IDC)• Aqueous chlorhexidine 0.1 per cent solution (if allergy to chlorhexidine use 0.9 per cent normal saline)

3. Clean equipment:• Blue-lined disposable underpad• Mask• Plastic apron• Protective eye-wear• An IDC anchoring device such as Flexi-trak

SPECIFIC PREPARATION OF THE RESIDENT:1. Check resident identification, explain procedure to the resident2. Position the resident comfortably (generally the optimal position is for the resident to lie supine on their back

with the bed flattened, if this is able to be tolerated) AND ensure privacy

SPECIFIC PREPARATION OF EQUIPMENT AND OPERATOR:1. Don mask and plastic apron2. Use aseptic technique3. Open out wrapping of the catheter pack with an aseptic technique and place on dressing trolley4. Perform a two minute hand wash and then unwrap catheter pack. With exposed forceps prepare equipment

and add extra items5. Open unsterile outer wrapping of catheter and place sterile wrapped catheter onto sterile field6. Squeeze sterile water into bowl ready for balloon inflation7. Pour aqueous chlorhexidine 0.1 per cent and normal saline 0.9 per cent over cotton wool swabs8. Open sterile glove packet and open packet containing urinary drainage bag9. Position patient comfortably - arrange an assistant if necessary10. Wash hands for 30 seconds and dry11. Don sterile gloves12. Draw up sterile water into syringe and test catheter balloon - use only the amount of water labelled on the

catheter (omit if in-out catheter)13. Apply 2mL of lignocaine gel to the catheter tip14. Proceed to #Indwelling urinary catheter: insertion pathway

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Indwelling urinary catheter: insertion [42]

Resident assessed by GP as requiring IDC; if replacing IDC check with GP that IDC remains indicated

IN ALL RESIDENTS:1. Ensure procedure undertaken only if within scope of practice of operator2. Review #Indwelling urinary catheter: preparation for insertion3. Open fenestrated drape and place over resident’s genitals4. Place cleaning tray just below resident’s genitals on fenestrated drape

IN FEMALE RESIDENTS:1. Ensure urethral meatus sighted2. Swab labia majora centre, far side, near side, centre and repeat for labia minora - use a fresh swab for each

stroke3. Gently insert the syringe tip of the lignocaine jelly into the meatus, and insert remaining lubricant and

anaesthetic4. Wait 3 minutes before insertion of catheter5. Using forceps insert tip of catheter into urethral orifice until urine flows freely6. Insert further 3 cm and then inflate the balloon using sterile water injected into the balloon inlet of the catheter7. Gently withdraw catheter until balloon sitting in position at the bladder base8. If accidentally inserted into vagina - leave in situ until another catheter is positioned in bladder

IN MALE RESIDENTS:1. Using folded gauze squares, with non-dominant hand hold resident’s penis; retract foreskin if uncircumcised2. Using dominant hand pick up forceps and clean penis with saline swabs from penis tip downwards, one stroke

per swab; discard cleaning tray3. Place catheter tray on fenestrated sheet; holding penis at right angles to the resident's body gently insert

lignocaine gel syringe tip into urethral meatus; inject lignocaine gel into urethra and insert remaining lubricant and anaesthetic

4. Wait 3 minutes before insertion of catheter5. Using forceps pick up catheter, ensuring drainage end is in tray and gently insert tip of catheter into urethral

orifice - when resistance is felt, lower penis and gently continue insertion until Y-junction of catheter reaches the urethral meatus; NB. if unable to advance catheter with gentle pressure, abort the procedure and contact HHS RaSS. If urine flow occurs prior to reaching the Y-junction of the catheter continue to insert catheter to the Y-junction THEN inflate the catheter balloon using sterile water injected into the balloon inlet of the catheter (observe the resident for any signs of discomfort - if this causes discomfort, stop inflating balloon and ensure that catheter continues to be inserted to Y-junction - if this is confirmed, gently inflate balloon - if this recurrently causes discomfort, abort the procedure and contact the HHS RaSS). NEVER INFLATE THE BALLOON UNTIL URINE FLOWS FREELY AND STOP IF RESIDENT EXPERIENCES PAIN

6. When balloon inflated, gently withdraw catheter until resistance felt (balloon at bladder base)

1. Connect catheter end to drainage bag; remove fenestrated drape2. Secure catheter to resident’s leg (preferably using an appropriate anchoring device - assess and minimise

tension with the patient lying, sitting and standing to minimise pressure injury risk)3. Stabilise the drainage bag tubing with the clip provided to resident’s clothing4. In uncircumcised males, reposition the foreskin to cover the glans penis5. Return the resident to a comfortable position6. Wait for the catheter to finish draining before leaving the bedside

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Indwelling urinary catheter: insertion practice points [42, 43]

(1) Catheter selection

Lumen type:IDCs inserted in the RACF setting are generally double lumen catheters (a draining lumen for draining of urine and a balloon inflation lumen)Triple lumen or three-way catheters (with an additional lumen for irrigating) are generally not appropriate for use in the RACF setting - if a resident has a triple lumen catheter insitu please contact HHS RaSS

Size:Choose the smallest catheter size that will allow appropriate drainage**IDCs >/ = 18Fr size may increase risk of erosion of bladder neck and urethral mucosa with associated risk of stricture formationSelection of appropriate IDC size requires consideration of:1. Gender: influenced also by body habitus but in general minimum IDC size in females with clear urine or mild

debris is 12 Fr and in males with clear urine or mild debris is 16 Fr2. Urine consistency: presence of moderate to heavy debris, mucous or clots may require females to have a 16 Fr

and males to have a 18 Fr IDC

Type of catheter material:If latex allergy: use 100 per cent silicone catheterIf no latex allergy: a hydrogel catheter or 100 per cent silicone catheter may be used** There is no evidence to support routine use of antibiotic or silver impregnated catheters for long-term IDC placement

(2) Frequency of IDC changes

***Indication for ongoing IDC placement should be reviewed at regular intervals to ensure thatthe IDC is still required***Frequency of routine changes of indwelling catheters is controversial and should beindividualised; interval to IDC change should not exceed manufacturers’ recommendations forthe catheter type insertedConsider the following in determining frequency of changes:1. Likely duration of catheterisation and type of catheter (review manufacturer recommendations of frequency of

changes)2. Catheter function3. Encrustation4. Frequency of blockages5. Comfort6. Local policy***An IDC should ALWAYS be changed in those with a symptomatic urinary tract infection

(3) Preventing Catheter-Associated Urinary Tract Infection (CAUTI)

Prevention of CAUTI is best achieved by:1. Restricting IDC use to those with an ongoing clear indication and remove as soon as clinically safe to do so2. Aseptic technique on IDC insertion with particular attention to hand hygiene, use of sterile gloves, cleaning of

the genital region and a no touch technique of the catheter3. Avoiding breaks in the closed drainage system

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Indwelling urinary catheter - troubleshooting a blocked indwelling catheter (IDC) or suprapubic catheter (SPC)

Refer to #Management of residents with


YES

CATHETERDRAINING

CATHETERDRAINING

Resident with blocked indwelling catheter (IDC) or suprapubic catheter

(SPC)


2. If not immediately life-threatening review #Checklist for contact and ring GP if vital signs unstable

Undertake systematic examination of resident and IDC to determine cause of obstruction and allow management:

1. IDC / SPC tubing examined for kinking or clothing restricting drainage → unkink or remove clothing

2. Drainage bag - ensure it is:• hanging below level of bladder• not more than ¾ full• straps of bag not occluding the non-return valve

3. Urine - evidence of:• hematuria / debris / mucous? → attempt to

relieve blockage by “milking” catheter gently along its length

Potential occlusion of IDC eyelets by bladder mucosa - temporarily hold drainage bag above

level of bladder to release suction

Refer to #Urinary tract infection

pathway and change IDC or SPC - if

assistance required refer to

HHS RaSS

Change IDC / SPC - if assistance required refer to

HHS RaSS

Monitor catheter drainage;

encourage fluids (if clinically appropriate)

and record urine output

Does residentmeet criteria to check for

a UTI? (review practicepoint 1)

NO

UNSTABLE VITALS

STABLE VITALS

CATHETER REMAINSBLOCKED

CATHETER REMAINSBLOCKED

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Indwelling urinary catheter - troubleshooting a blocked IDC or SPC: practice points [5, 31, 32, 43-45]

(1) Criteria to check for a UTI

ONLY check for a UTI if the resident with a catheter has at least one of: FEVER (Temperature > 38 degrees Celsius or an increase of > 1.5 degrees Celsius above baseline temperature)

MENTAL STATUS CHANGE without another cause

SUPRAPUBIC or FLANK PAIN or tenderness

Gross HAEMATURIA (blood stained urine)

RIGORS (uncontrollable shivering or shaking)

** Urine odour and appearance are not predictive of UTI** Do not screen urine in asymptomatic residents because residents in aged care facilities have high rates of abnormal dipsticks without UTI necessarily being present

** Multiple randomised trials have shown no benefit from treating asymptomatic bacteriuria3

(2) Recurrent IDC / SPC blockage

If recurrent IDC / SPC blockages:

1. Check IDC / SPC on changing for signs of encrustation - if present check for Proteus mirabilis infection AND cease ural or urinary alkalinisers

2. Encourage fluids if clinically appropriate

3. Consider: a. Increased catheter lumen size b. Change to 100 per cent silicone catheter

4. Send urine for m/c/s if clinical evidence of a UTI

5. Document history of blocking - may require increased frequency of IDC / SPC change

6. If resident constipated treat as per #Constipation

(3) IDC / SPC resources

• HHS specific urology support services• Australian and New Zealand Urological Nurses Society catheter care guidelines:

https://www.anzuns.org/wp-content/uploads/2015/03/ANZUNS-Guidelines_Catheterisation-Clinical-Guidelines.pdf

• Queensland Spinal Cord Injuries Service Fact sheet: Preventing catheter blockages: a guide for health professionals: https://www.health.qld.gov.au/__data/assets/pdf_file/0026/427508/catheter-blockage.pdf

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https://www.health.qld.gov.au/__data/assets/pdf_file/0026/427508/catheter-blockage.pdf



Influenza-like illness (ILI)

Review Advance Care Plan and refer to #Management

of resident with unstablevital signs

DEVELOP RISK FEATURES

Resident with suspectedinfluenza-like illness (ILI)

1. Immediately institute strict infection control procedures (review practice point 1) and isolate resident


3. If not immediately life-threatening review #Check-list for contact AND ring GP

1. Collect nasopharyngeal swabs for influenza and respiratory virus PCR and if influenza confirmed, treat with oseltamivir for 5 days

• 75mg orally twice daily;• If known Creatinine clearance 30mL to 60mL/

minute reduce dose to 30mg twice daily; if known Creatinine clearance 10mL to 30mL/minute reduce dose to 30mg once daily; note if oseltamivir suspension not available in a timely manner, consult local public health or infectious diseases physicians for advice on dosing

2. If renal function unknown commence at 75mg orally twice daily and then dose adjust for renal function as soon as renal function results available

3. Monitor other residents for additional cases4. Refer to national guidelines on management of

influenza-like illness and notify public health of outbreaks (3 or more cases of ILI in residents or staff of facility within 3 days) (review practice point 3)

5. Monitor resident for development of risk features: difficulty breathing OR mental status changes OR significant comorbidity requiring stabilisation

GP manages or refer toHHS RaSS

at GP discretion

Does the residentmeet diagnostic criteria for influenza? (review practice

point 2)

YES

UNSTABLE VITALS

STABLE VITALS

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https://tgldcdp.tg.org.au/calculator?type=Calculators#ccbwcalc


Influenza-like illness (ILI) practice points [46]

(1) Infection control procedures in influenza-like illness (ILI) outbreaks(refer to national guidelines for more detailed information - review link in practice point 3)

1. Reinforce hand hygiene with staff and any visitors - ensure adequate supplies of liquid soap, alcohol-based hand rub and paper-towels

2. Respiratory hygiene and cough etiquette - encourage residents to cover their nose and mouth when they cough or sneeze, use tissues and dispose of them into a rubbish bin, and perform hand hygiene

3. Use personal protective equipment (PPE) when caring for infected residents - single use surgical masks, gloves, single use aprons and eye protection, and change between residents

4. Monitor staff for symptoms - staff with respiratory ILI should be excluded from work while infectious. The infectious period for influenza is at least 5 days after onset of acute illness, or until they are symptom free for 24 hours, whichever is longer

5. Isolate residents who are infected - if an appropriate single room is not available, implement room sharing (cohorting) of residents with the same infection (laboratory confirmed or very clear case definition)

6. Staff cohorting - allocate dedicated staff (all of whom should be vaccinated for influenza) to the care of unwell residents isolated in rooms. These staff should not move between their section and nonisolated areas of the facility, or care for other residents

7. Place contact and droplet precaution signs, liquid hand gel and PPE outside residents’ rooms (with a mechanism to allow for safe disposal of PPE items) to remind staff and visitors about the requirement for strict infection control procedures - ensure visitors are shown how to use PPE appropriately

8. Suspend group social activities in affected areas of the facility during an outbreak

9. Visitor restrictions during outbreaks - non-essential visits should be discouraged. Visitors should visit only one resident (with direct entry and exit from the resident’s room and no other movements within the facility), practice good hand hygiene and use PPE as appropriate. Visitors with respiratory symptoms are not to visit while unwell

10. Clean resident environments frequently with a neutral detergent followed by a disinfection solution (TGA-registered hospital grade disinfectant or 1000 ppm sodium hypochlorite)

(2) Identification of influenza-like illness (ILI)

SUSPECT ILI IF THE RESIDENT HAS:1. Sudden onset of symptoms (in the elderly these may be atypical and include anorexia, mental status

changes or worsening of underlying chronic obstructive lung disease or cardiac failure)AND

2. At least one respiratory symptom (new or worsened cough OR sore throat OR shortness of breath)AND

3. At least one systemic symptom (fever OR malaise OR headache OR myalgia)

(3) Influenza resources

• Guidelines for the prevention and control of influenza outbreaks in residential care facilities in Australia. Department of Health. http://www.health.gov.au/internet/main/publishing.nsf/Content/cdna-flu-guidelines.htm

• Local Public Health Unit contact details: https://www.health.qld.gov.au/system-governance/contact-us/contact/public-health-units

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NO

CAM NEGATIVE

New or worsened confusion

Refer to #Management of residents with


Resident with new confusion oraltered mental state



3. Initiate supportive care (review practice point 1)

Undertake systematic assessment includingblood tests for cause

of delirium (review practice point 3)1. Consider alternate causes (review

practice point 2) - may still represent sub-clinical delirium

2. Monitor vital signs including conscious level and neurological observations every:

i. 15 minutes for 1 hour then ii. 30 minutes for 2 hours then iii. 1 hour for 8 hours then iv. 2 hours for 6 hours then v. 4 hours for 8 hours then vi. 6 hours for 24 hours OR as per medical order

Refer to HHS RaSS

at GP discretion

GP and RACF manage cause of delirium - refer to relevant clinical

pathway

Is there animmediate risk to

staff or to resident/s safetyfrom violentbehaviour?

Check fordelirium using

Confusion AssessmentMethod = CAM

(review appendix1)

UNSTABLE VITALS

STABLE VITALS

UNSTABLE VITALS

CAM POSITIVE

ONGOING CONCERN,VITAL SIGNS STABLE

CAUSE NOT IDENTIFIED

OR NOT WITHIN SCOPE OF

GP / RACF TO TREAT

CAUSE IDENTIFIED

AND TREATABLE

Call QAS on 000 and then refer to #Behavioural emergencies

pathwayYES

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New or worsened confusion practice points [47-51]

(1) Supportive care

1. Orientation prompts2. Family / volunteer involvement3. Adequate nutrition and hydration4. Regular mobilisation as tolerated5. Support of a normal sleep-wake cycle6. Ensure availability of hearing aids / glasses as indicated7. Provide explanation and reassurance to resident to counteract fear8. Provision of meaningful activity

(2) Causes for acute confusion

Cardiac Myocardial infarctionEnvironment Change in environment or staffing, physical restraint Gastrointestinal Faecal impactionInfections Urinary tract infection, pneumonia, sepsisMedications Sedatives, antihistamines, alcohol, anticholinergics, levodopa, dopamine agonists, alcohol or

benzodiazepine withdrawalMetabolic Hypoxia, hypoglycaemia, hyperglycaemia, hyponatremia, hypo- or hyper-calcemia, uremic

encephalopathy, vitamin B1 or B12 deficiency, hyper- or hypothyroidism, adrenal / pituitaryinsufficiency

Neurologic Encephalitis, meningitis, seizures; If there are focal neurological findings: stroke, subduralhaemorrhage

(3) Systematic assessment for cause of acute confusion

Look for and address potentially reversible causes:1. History: recent medication changes? dehydration (fluid intake, hot weather, diuretic use)? recent falls history? focal symptoms of infection or pain? bowel function? alcohol history? comorbidities? environmental changes?2. Examination:

• Vital signs - look for tachy- or brady-cardia, hypoxia, hypotension, fever or hypothermia, assess conscious state: AVPU (Alert, responds to Voice, responds to Pain or Unresponsive); postural drop in blood pressure (perform lying and standing blood pressures).

• Neurological examination for signs of new stroke• Assess for (modify assessment based on individual symptoms and comorbidities):

▪ Dehydration: dry mucous membranes ▪ Pain: use cognition appropriate pain assessment tool eg. PAINAD (review appendix 1) ▪ Urinary retention: percuss for bladder ▪ Faecal impaction: palpate abdomen and if required, perform rectal examination ▪ Focal chest findings on auscultation ▪ Pressure injuries / other sources of infection

3. Investigations: individualise approach based on resident’s wishes if has capacity / Advance Care Plan / Advance Health Directive / input of substitute health decision makers. At a minimum check:

• Blood glucose• Full blood count, UEC, calcium, LFT, thyroid tests• Blood cultures if fevers, hypothermia or rigors• Send mid stream or catheter acquired urine for M/C/S where UTI criteria met (review #Urinary tract infection)

(4) Acute confusion resources

• Australian Health Ministers’ Advisory Council. Delirium Care Pathways. Department of Health and Ageing, Canberra: 2011

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Pain

Refer to#Management

of residentwith unstable

vital signs

Resident withuncontrolled pain

1. Assess pain using a tool appropriate to cognition (review practice point 1)



Refer toHHS RaSS

at GP discretion

Consider referral to HHS chronic pain service

where available or if palliative goals of care toHHS palliative care service

Treat underlyingcause of pain

Doesresident have ANY of:

1. Severe pain (= Numeric Pain Score /PAINAD score of greater than or equal to 7 / Abbey Pain Scale score of

greater than or equal to 14) 2. Pain due to a condition requiring

hospital based management 3. No cause identified and

further hospital based investigations

indicated

Is causeof pain

identified?

Classify type of pain:

1. Nociceptive pain (review practice point 2)

2. Neuropathic pain (review practice point 3)3. Pain due to psychological /

psychiatric factors(review practice

point 4)

UNSTABLE VITALS NO

YES

NO

YES

STABLE VITALS

NO RESPONSE AND CHRONIC PAIN

NO RESPONSE AND ACUTE PAIN

Establish pain management plan that encompasses a multi-disciplinary approach with:1. Pharmacologic management based on type of pain - refer

to Australian Medicines Handbook Aged Care Companion or Therapeutic Guidelines: analgesia for guidance on pharmacological management of pain

2. Non-pharmacological therapies (review practice point 5)3. Assessment for response to pain management plan4. For visceral pain further investigation for underlying cause

of pain may facilitate optimal analgesic management

Structured assessment by GP and RACF nursing staff to determine cause

of pain

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Pain practice points [52-54]

(1) Pain tools appropriate to cognition

Pain assessment should be undertaken by a verbal pain report by resident where feasible. Initial assessment should be via a multidimensional pain tool (eg. Resident’s Verbal Brief Pain Inventory); once a comprehensive pain assessment is completed, a unidimentional pain assessment scale can be used for ongoing evaluation of pain and response to management. If cognitively intact, use Numeric Rating Scale; if cognitively impaired, use Abbey Pain Scale or PAINAD (review appendix 1)

(2) Nociceptive pain

Type of nociceptive pain

Location Description Management

Superficial somatic

Skin and mucosa

Burning / stinging / sharppain; well localised

ParacetamolOpioidsNon-pharmacological interventions – cognitivebehavioural therapy (CBT), heat, topical preparations

Deep somatic Muscles, joints and bones

Aching / gnawing; well localised

ParacetamolOpioidsNon-pharmacological interventions – warmth, exercise (if medically cleared)if persistent or acute onset in setting oftrauma consider imaging

Visceral Abdominal and thoracic organs

Deep cramping / squeezing pain; diffuse and not usually well localised;may be referred tocutaneous sites

Optimal analgesic approach influenced by underlying causeGP to consider investigations to determine underlying cause – this will guide analgesic approach

(3) Neuropathic pain

Definition: pain from damage to nervous systemFeatures: pain is often burning / shooting / tingling / electric shock and may be referred to area of skin that the nerve would normally supply; less responsive to common analgesicsManagement: 1. Less responsive to conventional analgesics 2. Adjuvant drugs eg. antidepressants / anticonvulsants / topical agents

(4) Pain due to psychological or psychiatric factors

Definition: Somatic complaints may be a presentation of depression (although severe pain may also cause depression) - screen for depressionManagement: If depression present - ensure organic screen undertaken to exclude physical causes of pain and / or depression then consider antidepressant therapy and CBT and involvement of HHS specific Older Persons Mental Health Service

(5) Non-pharmacological therapies

All pain management plans should encompass use of non-pharmacological therapies as appropriate. These may include:1. Exercise2. Physical therapies (heat packs / TENS machines)3. CBT4. Ensuring appropriate manual handling techniques5. Complementary therapies: massage, aroma therapy, meditation, music therapy

(6) Pain management resources

• Australian Pain Society. Pain in residential aged care facilities: management strategies. 2005. www.apsoc.org.au• Analgesia expert group. Therapeutic Guidelines: analgesia. Version 6, Melbourne, 2012.• HHS community palliative care services• HHS chronic pain services where available• Australian Medicines Handbook Aged Care Companion

https://shop.amh.net.au/products/books/aged-care-companion

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http://www.apsoc.org.au

https://shop.amh.net.au/products/books/aged-care-companion


Percutaneous endoscopic gastrostomy (PEG) tube:trouble-shooting a blocked PEG

Refer to #Management of residents with unstable

vital signs

TUBEUNBLOCKED

TUBEUNBLOCKED

PEG tube blocked

1. Check vital signs (review #Recognition of the deteriorating resident)If not immediately life-

threatening review #Checklist for contact

and ring GP

Observe resident for next feeding;

institute preventive care (review

practice point 1)

UNSTABLE VITALS

STABLE VITALS

1. Ensure tube clamp is open

2. Check tube for damage / kinks

1. Aspirate PEG tube with 20mL syringe connected directly to tube to remove as much liquid from within tube lumen proximal to blockage (review practice point 2) on details of connection of 20mL syringe to PEG tube

2. Attempt irrigation of tube with lukewarm water in a 20mL syringe - gently but firmly push and pull plunger back and forth (do NOT use force as this may rupture the feeding tube)

3. Repeat the irrigation attempts with clean warm water in a 20mL syringe and then reattempt flushing of the tube with warm water in a 20mL syringe

4. If tube remains blocked instil lukewarm water into the tube, clamp tube, and let water soak for up to 20 minutes - attempt flushing thereafter

5. DO NOT USE ACID or CARBONATED (fizzy) DRINKS / FLUIDS

6. Successful irrigation of the tube may take 20 to 30 minutes, so patience is key

TUBE REMAINS BLOCKED

TUBE REMAINS BLOCKED

Refer to HHS RaSS

at GP discretion

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Percutaneous endoscopic gastrostomy (PEG) tube: trouble-shooting a blocked PEG practice points [55-57]

(1) Causes and prevention of blocked PEG

1. Medicines not administered appropriately a. Review medications with pharmacist to determine compatibility of medications, best delivery mode and most appropriate timing of medications b. Use liquid or dispersible medicines where able c. Do not mix any medicine directly with enteral feeds - always stop continuous or cycled feeds and flush with water before giving medications2. Tube not flushed properly a. Flush tube well with (preferably warm) water (recommend minimum 30mL) before and after feeds and each medication b. Flush tube on changing flask (at least every 4 to 6 hours) if on continuous feeds c. Flush tube at least once per day if not in use3. Putting carbonated beverages through the tube a. Carbonated beverages can interact with feeds / medications and cause precipitation of proteins in feeds within tube, making the blockage worse and leading to more clogging at a later time4. Putting in fluids that are too thick a. Thoroughly blend powdered formula prior to passing through tube b. A pump may be needed when using thick feeds5. Continuous feeds with irregular PEG flushes a. If the resident has continuous feeds for longer than 4 hours per day, the PEG tube should be flushed once every 4 hours to avoid tube blockage; this would ideally occur via a side port to avoid the need for interruption of feeds

(2) Connecting a 20mL syringe for flushing PEG tubes

A 20mL syringe is ideal for unblocking a PEG tube; the option for connection utilised will depend on whether the gastrostomy tube is ENfit compatible and what equipment is available in the RACF;Options include:1. Use of a 20mL ENfit syringe if the gastrostomy tube is ENfit compatible or an ENfit adaptor is available2. If the gastrostomy tube is not ENfit compatible:

• attach a Foley adaptor to the gastrostomy tube and use a 20mL Luer Lock syringe OR• use a 20mL Luer Slip syringe via the medication port of the gastrostomy (if there is one) - this often requires

an assistant to ensure that the other feed port does not pop open whilst attempts are made to unblock the tube

(3) PEG tube resources

• Gastrostomy tube care: https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0017/251063/gastrostomy_guide-web.pdf

• Contact service that inserted PEG if possible: - Gastroenterology team of HHS referral hospital or - Interventional radiology team for RIGs (Radiologically Inserted Gastrostomy) or - HHS gastrostomy support services

• PEG support and education from private companies: - Abbott: Nurse Educator - 0409 397 621 (Sydney based); Halyard / Avanos (formerly Kimberly Clark):

Telephone support and education resources - 0418 314 329; Nutricia: Nurse educator / PEG support including after hours support - 0407 046 272 / 0425 254 284; Nestle support - 1800 671 628

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https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0017/251063/gastrostomy_guide-web.pdf


Percutaneous endoscopic gastrostomy (PEG) tube:trouble-shooting a leaking PEG

Refer to #Management of residents

with unstable vital signs

ONGOING LEAKING WITH

NO CAUSE IDENTIFIED OR

IDENTIFIEDCAUSE

REQUIRES SPECIALIST

INPUT

PEG tube leaking or

irritation at PEG site


2. Review #Checklist for contact and ring GP

Examine for evidence of cause of leakage and treat cause as appropriate:1. Retention balloon deflated or completely ruptured. Perform

balloon volume check. Reinflate balloon with water and recheck volume immediately - this will indicate if balloon is ruptured; if balloon is not ruptured, recheck balloon volume after 2 hours to determine if there is a slow leak. If balloon rupture or deflation is confirmed, a PEG tube change is indicated

2. Bolster too loose or too tight: should be set to allow the external flange to be lifted 2 to 5mm from the skin with gentle traction - if more tighten, if less loosen

3. Infection (review practice point 2) - send swab of site and treat

4. GP to consider commencing proton pump inhibitor if not already used (dispersible preferred)

5. Side torsion or excessive tension on tube causing ulceration and enlargement of tract (review practice point 3) - correct with appropriate dressing / device to stabilise tube

6. Examine infusion plug for cracks or breaks - if present, replace

7. Poor gastric emptying e.g. secondary to gastroparesis or constipation or bowel obstruction; gastric venting may provide symptomatic relief while cause is being investigated

8. Protect skin using barrier wipe e.g. Cavilon no-sting barrier wipe 3MTM 3rd daily; note: avoid use of hydrogen peroxide

Observe resident for next feeding;institute preventive care (review #PEG

tube: troubleshooting a blocked PEG practice point 1)

Refer to HHS RaSS

at GP discretion

NO

UNSTABLE VITALS

STABLE VITALS YES

NO ONGOING LEAKING

Is thereevidence of:

1. Buried bumper syndrome(review practice point 1)

2. Splits or cracks of PEG tubing3. Discolouration and irregular

beading of thePEG tube

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Percutaneous endoscopic gastrostomy (PEG) tube: trouble-shooting a leaking PEG practice points [58,59]

(1) Buried bumper syndrome

Caused by excessive tension between the external and internal bolsters, causing inflammation and ultimately breakdown of the tract and migration of the internal bolster through the gastric mucosa;Suspect if:1. Tube is fixed (unable to push tube in and out: gentle traction should allow the external flange to be lifted 2 to

5mm from the skin)2. Abdominal pain and tenderness at site3. Increased peristomal leakage4. Breakdown of site5. Inability to infuse water / feeds through tube6. Bleeding at PEG site7. Recurrent peristomal infections

(2) Infection of PEG site

• May be fungal or bacterial• Do a swab of the PEG site if infection is suspected and

send for m/c/s• Suspect bacterial infection if PEG site surrounded by:

1. Redness2. Tenderness3. Purulent discharge (pus)

• Treat with antibiotics (review #Cellulitis)• For fungal infections - treat with topical antifungals

(3) Side torsion or excessive tension

Side torsion refers to excessive tension on PEG tubing resulting in lateral pressure on one side of the PEG tract, causing pressure injury and secondary enlargement of the tract; manage by use of appropriate stabilisation device

(4) PEG tube management resources

• General information: - https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0017/251063/gastrostomy_guide-web.pdf

• Contact service that inserted PEG if possible: - Gastroenterology team of HHS referral hospital or - Interventional radiology team for RIGs (Radiologically Inserted Gastrostomy) - HHS gastrostomy support services

• Membership of the local ostomy association may afford the resident free equipment and medical supplies for management of gastrostomy needs

a. Excessive lateral tension on the PEG tubing (caused when caught under bedding, bedrail or the resident’s body puts excessive lateral pressure against the tract of the PEG tube) resulting in pressure injury and enlargement of PEG tract; b. Shifting the tube to the opposite side reveals an acute ulceration with exudate on the side to which the torsion is applied2

Bacterial cellulitis1 Fungal infection1

1 Sourced with permission from lyer, K.R. and T.C. Crawley, Complications of enteral access. Gastrointest Endosc Clin N Am, 2007. 17(4): p. 717-29.2 Sourced with permission from McClave, S.A. and R.L. Neff, Care and long-term maintenance of percutaneous endoscopic gastrostomy tubes J Parenter Enteral Nutr, 2006. 30(1 Suppl): p. S27-38.

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https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0017/251063/gastrostomy_guide-web.pdf

https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0017/251063/gastrostomy_guideweb.pdf


Pneumonia



Resident with suspectedpneumonia



3. Is the resident approaching end of life (review #End of life management)?

Refer toHHS RaSS

at GP discretion

Consider alternate cause for symptoms

Is there evidence of risk feature/s:

• Respiratory rate > 30/min • Systolic (top) blood pressure < 90mmHg• Oxygen saturation < 92 per cent (or if resident has chronic obstructive pulmonary disease (COPD) < 90 per cent) • Altered mental state (different from usual) • New or increased agitation

Residenthas any one of:

• New or increased: - Cough - Sputum

• Abnormal findings on chest examination• Pleuritic chest pain

(worse on taking a breath in)Fever (review practice

point 1)

Residenthas any of:

• Inability to tolerate oral/ PEG intake

• Pulse > 100/minute• Immunosuppressed

(e.g. on steroids)

UNSTABLE VITALS orapproaching end of life

YES

YES

STABLE VITALS

DEVELOPS RISK FEATURES

FAILS TO IMPROVE

1. Initiate appropriate investigations and commence oral antibiotics (review practice points 2 and 3)

2. Undertake supportive care (review practice point 4)

3. Monitor for above risk features4. Expect improvement within 48 hours

NO

NO

YES NO

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Pneumonia practice points [60-62]

(1) Fever definition

Fever is defined as temperature higher than 38 degrees Celsius ORan increase of more than 1.5 degrees Celsius above resident’s baseline temperature

(2) Antibiotics for residents with pneumonia

Treat with oral antibiotics for 7 days:

If uncomplicated and NO penicillin allergy and NO suspicion of aspiration use: amoxycillin 1g orally every 8 hours

If aspiration suspected and NO penicillin allergy use: amoxycillin-clavulanate 875mg + 125mg orally every 12 hours

If non-immediate penicillin allergy use: cefuroxime 500mg orally every 12 hours

If immediate penicillin allergy or clinical concern for atypical organism use: doxycycline 100mg orally every 12 hours

NB: management of residents within hospital rather than within the facility in the absence of risk features does not decrease mortality which remains at ~30 per cent

(3) Investigations for residents with pneumonia

Consider following investigations:1. CXR if diagnostic uncertainty 2. Sputum m/c/s 3. Urinary antigens for Pneumococcus and Legionella

(4) Supportive care for residents with pneumonia

1. Monitor fluid balance closely and consider subcutaneous fluids if required - pneumonia with associated fever and tachypnoea can lead to significant insensible water loss

2. Review and treat risk factors for pneumonia: i. Assess swallow - change fluids to those appropriate to swallow ii. Assess neurological function iii. Attend to oral hygiene iv. Control gastro-oesophageal reflux - elevate head of bed v. Update immunisation as required for influenza and pneumococcus when recovered from acute episode3. Analgesics and antipyretics for pain and fever4. Review medications and consider withholding or adjusting dose, where appropriate, of sedative medications

(5) Resources for residents with pneumonia

• Antibiotic expert group. Therapeutic Guidelines: antibiotics. Version 16, Melbourne: Therapeutic Guidelines Ltd. 2019.

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Shortness of breath (SOB)

Review Advance Care Plan and refer to #Management of


Resident with acuteonset shortness of

breath (SOB)

1. Sit resident upright in a comfortable position, reassure and assess severity - look for red flags in shortness of breath (review practice point 1)


3. Apply oxygen to maintain oxygen saturations at 92 to 96 per cent (if history of COPD aim for 88 to 92 per cent)


Refer to HHS RaSS

at GP discretion

Refer to specific management pathway

Does structuredhistory and clinical

assessment with GP identify cause? (review practice

point 2)

UNSTABLE VITALS OR RED FLAGS PRESENT

STABLE VITALS

AND RED FLAGS

ABSENT

CAUSE IDENTIFIEDor specific management

pathway exists

CAUSE NOT IDENTIFIEDor no specific management

pathway exists

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Shortness of breath (SOB) practice points [63]

(1) Red flags in residents with shortness of breath

1. New inability to speak or only able to speak in single words2. New altered level of consciousness3. Cyanosis (blue discolouration to tongue, skin, lips or digits)4. Physical exhaustion or inability to maintain respiratory effort5. Use of accessory muscles of breathing (breathing associated with contraction of the sternocleidomastoid or

scalene muscles in the neck, contraction of abdominal muscles)6. Retraction of supra-clavicular or suprasternal fossae or of lower ribs during inspiration7. Inability to lie supine8. Profound sweating9. Agitation (new)10. Pulse rate more than 130 or less than 40 beats per minute11. Respiratory rate more than 30 or less than 6 breaths per minute

(2) Clinical history and examination findings in residents with shortness of breath (SOB)

Cause History Examination / bedside investigationsUpper airway obstruction

Sudden onset during eating Swelling of lips / tongue / throatAltered level of consciousness

Snoring noise on in-breath (stridor)

Angina or myocardial infarct

Dull central chest pain +/- radiation of pain or heaviness to jaw or armsNote ischemic chest pain may present atypically in older persons

SweatingPallorBilateral basal inspiratory crackles

Congestive cardiac failure (CCF)

Orthopnoea (increased SOB on lyingflat)Paroxysmal nocturnal dyspnea(waking at night with SOB)Weight gainPrior history of CCF

New irregular or very slow pulseJugular venous distensionBilateral basal inspiratory cracklesAnkle oedema or swelling

Exacerbation of COPD or asthma

Prior history of COPD or asthmaSmoking history

Bilateral polyphonic wheezeBeware the silent chest or residents sitting forwards in “tripod” position.

Pneumonia Pleuritic (worse on inspiration) chest painFeverCough with purulent sputum

Elevated temperatureFocal consolidation or bronchial breath sounds

Pulmonary Embolism (PE)

Past history of PE or DVTPleuritic (worse on inspiration) chest painHistory of cancerCalf pain or swelling

Unilateral calf tenderness or swelling (may be absent)Often have a clear chest

Pneumothorax Recent history of falls with rib painRecent medical procedure near chestHistory of previous pneumothorax

Reduced breath sounds on affected side

Diabetic ketoacidosis Frequent, high volume urinationIncreased fluid intakeHistory of diabetes

High blood glucose levelHigh urinary ketones

Anemia Past history of anemiaBlood loss: most commonly in the stools

PallorLow hemoglobin

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YES

Subcutaneous fluids and dehydration



Resident withdehydration



3. With GP undertake a systematic assessment for cause and severity of dehydration

NOTE: there is no evidence to support use of subcutaneous fluids at end of life

1. GP orders appropriate fluid (usually 0.9 per cent saline)

2. Insert subcutaneous device after appropriate skin preparation to a non-oedematous position as shown in diagram opposite (review practice point 1 for site selection)

3. Secure with appropriate dressing4. Prime IV giving set, attach to subcutaneous

device and commence infusion (review practice point 2 for rate)

5. Monitor site and hydration6. Change site regularly (review practice point 3)

1. Encourage oral fluids as appropriate to each individual resident

2. Cease subcutaneous fluids3. Monitor fluid balance and blood sugar

closely

Refer to HHS RaSS

at GP discretion

Checkfor risk features:

• Severe dehydration• Pre-existing cardiac failure

• Pulmonary oedema• Lymphoedema

• Terminal care where this is thesole indication• Coagulation

defects

UNSTABLEVITALS

RISK FEATURESPRESENT

PATIENT STABLE AND RECOMMENCES ORAL

INTAKE?

NO RISK FEATURES

STABLE VITALS

Subcutaneousfluids are appropriate

AND resident has one of:• Mild dehydration• Poor oral intake

• Nausea and vomiting• Diarrhoea

• Dysphagia?

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Subcutaneous fluids and dehydration practice points [64-66]

(1) Choosing a site

CONSIDER:1. Resident mobility2. Comfort and access3. Skin condition4. Use of a safety device for administration of subcutaneous fluids

(e.g. BD Saf-T-Intima)

AREAS WITH ADEQUATE SUBCUTANEOUS FAT:1. Anterior abdomen2. Anterior thigh3. Upper outer arm

AREAS THAT SHOULD NOT BE USED:1. Limbs with lymphoedema2. Overlying bony prominences3. Areas of skin previously exposed to radiotherapy4. Near a joint5. Near a surgical or chronic wound site6. Sites of infection or inflammation

(2) Rate of administration

Should be individualised based on degree of dehydration and comorbiditiesGenerally up to 1mL/minute at each site, resulting in a rate of up to 60mL/hourIf using 2 sites up to 3L in a 24 hour period may be administered (with 1.5L being administered at each site)** SITE SHOULD BE CHECKED EVERY 4 HOURS FOR BRUISING, REDDENING, OEDEMA, LEAKING, PAIN, POOLING OR UNRESOLVED BLANCHING

(3) Changing sites

** FOR MAXIMUM ABSORPTION RATE ROTATE SITE REGULARLY (AT A MINIMUM AFTER EVERY 2L OF FLUID)** INDICATIONS FOR CHANGE OF INFUSION SITE INCLUDE:1. Pain at administration site2. Redness or inflammation of skin surrounding site3. Dislodged needle4. Localised oedema (swelling) / bleeding / bruising

(4) Appropriate fluids

Fluids identified in controlled trials to be safe to administer via subcutaneous routes include 0.9 per cent saline (normal saline); 0.45 per cent saline (half-normal saline) and 5 per cent dextrose (although the latter may be associated with hyponatremia)

**Necrosis (sloughing) of skin may occur if inappropriate fluids are used - inappropriate fluids include markedly hypertonic or hypotonic fluid or those containing high concentrations of potassium chloride

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YES

YES

Tracheostomy tubes**Ensure all residents with a tracheostomy have an accessible Advance Care Plan to guide management

Resident with tracheostomy and breathing difficulties 1. Remove cap if present

2. Apply 100 per cent oxygen to BOTH face and tracheostomy stoma

3. Call for help - if significant respiratory distress or cyanosis: Call QAS on 000

4. Remove speaking valve if present and remove inner cannula to clean before reinserting

1. Deflate tracheostomy cuff if present

2. Reassess breathing and oxygenation: Look, listen and feel at mouth and tracheostomy

Tracheostomy tube ispatent:

perform tracheal suction and ventilate via

tracheostomyif not breathing;continue ABCDE

assessment and if symptoms not entirely resolved or if abnormal

vital signs call QAS on 000 unless otherwise stated in Advance Care Plan or Advance Health Directive

Support ventilation andawait QAS arrival

NO

NOT IMPROVED

NO

IMPROVED

Is residentbreathing?

Can youpass a suction

catheter?

Call QAS on 000Commence CPR if no pulse or signs of life unless otherwise stated in Advance Care Plan or Advance Health Directive

TO VENTILATE RESIDENT:If previous laryngectomy (suspect if no tube present in stoma) use

the smallest face mask applied to neck stoma with bag-valve-mask

ventilation If no prior laryngectomy, trial ventilation by usual oral route

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Tracheostomy tubes practice points [67, 68]

(1) Tracheostomy care

Ensure that staff looking after residents with tracheostomies have completed competencies on their management

Complications are reduced by ensuring:1. Resident is encouraged to cough own secretions - if unable to clear own secretions, initiate suctioning

with non-fenestrated inner cannula2. Provide humidification with swedish nose or Airvo3. Keep stoma clean and dry and provide regular pressure care4. Regularly check and clean inner cannula at least every 4 hours5. Do not allow secretions to pool around stoma

(2) Tracheostomy tube features

(3) Residents with a history of laryngectomy

** NOTE: Patients with a history of laryngectomy are NECK BREATHERS - this means they can ONLY breathe through the stoma in their neck. If they require bag-valve-mask ventilation (or breathing or oxygen support) use the smallest mask available via the neck stoma ONLY - provision of oxygen / ventilatory support via the mouth will not result in oxygenation

(4) Tracheostomy resources

• HHS ENT Outpatient clinics• Some HHSs have ENT Clinical Nurse Consultants who provide education to RACF staff on tracheostomy

management - please contact your HHS RaSS for further information• Equipment support: private companies that provide tracheostomy equipment may provide equipment education

or support (e.g. Fisher and Paykel) - please contact your local representative and enquire

Cuff

Flange

Pilot balloon

Inner cannula

Hub

Pilotballoon

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Urinary tract infections (UTI)

NO

NO

YES

Review Advance Care Plan and refer to #Management

of residents with unstable vital signs 1. Obtain urine sample for

microscopy, culture and sensitivities2. If indwelling catheter (IDC) or

suprapubic catheter (SPC) insitu, change catheter

Resident withsuspected urinary tract

infection (UTI)



1. Commence oral antibiotics with choice influenced by flank tenderness, allergies and prior organism sensitivities (review practice point 2)

2. Analgesia as required

3. Note: Increased falls risk may occur due to urgency / frequency / delirium - increase supervision and modify environment to reduce risk of falls

4. Monitor for systemic symptoms or change in vital signs (QID vital signs for 72 hours)

Look for alternate cause of

symptoms and do not send urine

sample for culture

If no alternate cause of

symptoms found, refer to

HHS RaSS at GP discretion

Doesresident meet criteriato check for a UTI?


Is there eitherongoing vomiting orrigors (uncontrolled

shivering /shaking)?

Is theredevelopment of

vomiting or rigors or failureto respond to oral antibiotics by 72 hours OR development

of unstable vital signs at any time?

UNSTABLEVITALS

STABLE VITALS

YES

NO

YES

Refer toHHS RaSS

at GP discretion

GP and RACF to continue ongoing care and monitoring

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Urinary tract infections (UTI) practice points [5, 31, 32, 69]

(1) Criteria to check for a UTI

ONLY check for a UTI if the resident has either: ACUTE ONSET OF DYSURIA (burning or stinging when passing urine) OR the resident has TWO or more criteria for a UTI (at least one of which is a major criterion) or if the resident has an IDC or SPC at least one criteria of: Major criteria:

• FEVER (where this is defined as a single oral temperature of > 38 degrees Celsius or an increase in temperature >1.5 degrees Celsius over resident’s baseline temperature)

• ALTERED MENTAL STATE without another cause Minor criteria:

• New or worsening URGENCY or FREQUENCY• SUPRAPUBIC or FLANK PAIN or tenderness• Gross HAEMATURIA (blood stained urine) without another cause• New or worsening urinary INCONTINENCE• RIGORS (uncontrollable shivering or shaking)

** Urine odour and appearance are not predictive of UTI** Do not screen urine in asymptomatic residents because residents in aged care facilities have high rates of abnormal dipsticks without UTI necessarily being present** Do not screen urine based on an isolated episode of behavioural change** Multiple randomised trials have shown no benefit by treating asymptomatic bacteriuria

(2) Antibiotic selection in a UTI (review #Fever / suspected infection for principles)

IF FLANK TENDERNESS ABSENT and above criteria met = CYSTITIS:Duration of antibiotics:

Females = 5 days; Males = 7 daysFor empirical therapy of uncomplicated cystitis use: nitrofurantoin 100mg orally, 6 hourly (NB: Should be avoided in residents with renal impairment and an estimated GFR < 45mL /minute or in those using concurrent urinary alkalising agents, which may reduce effectiveness of nitrofurantoin)Where nitrofurantoin cannot be used, use cefalexin 500mg orally every 12 hours

IF FLANK TENDERNESS PRESENT, above criteria met = PYELONEPHRITISDuration of antibiotics:

Females and males = 10 to 14 daysIf NO penicillin allergy use: amoxycillin and clavulanate 875mg + 125mg orally every 12 hoursIf penicillin hypersensitivity use: ciprofloxacin 500mg orally, every 12 hours for 7 days

(3) Prevention of UTI

Avoid condom catheters and review indication for IDC regularly; there is no indication forprophylactic antibiotics administered with IDC changeTopical vaginal oestrogen decreases incidence of UTI in post-menopausal women

(4) Resources for residents with UTI

Antibiotic expert group. Therapeutic Guidelines: antibiotics. Version 16, Melbourne: Therapeutic Guidelines Ltd. 2019.

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Is thecause of thewound clear?

Wound management


refer to#Management of


Institute appropriate wound management asdetermined by cause

of wound (review appendix 3 for wound

managementresources)

Residentwith wound



3. Are red flags present?• Unstable vitals• Significant wound bleeding

unable to be controlled with pressure

• Acutely ischemic limb (pale, pulseless, painful)

• Underlying suspected bony injury

• Significant other injury

Institute appropriate acute wound management principles:1. Control bleeding2. Assess pain and administer

analgesia if required3. Irrigate with normal saline4. Assess wound edge apposition: for

skin tears if skin flap remains viable gently replace tissue flap avoiding tension on flap; for lacerations use steristrips, wound adhesive or sutures to improve apposition, as indicated; steristrips and tapes should be avoided in management of skin tears as they may cause damage on removal

5. For appropriate dressings, refer to appendix 4 skin tears resource or to Therapeutic Guidelines: ulcer and wound management

6. Review resident’s tetanus immunisation status and administer booster +/- tetanus immunoglobulin as per Australian Immunisation Handbook

1. If fall precipitated the wound: refer also to #Falls pathway

2. If wound within scope of practice of RACF and GP to manage: monitor wound healing

GP to refer toHHS OPD service

Refer toHHS RaSS

Is the woundacute or chronic (review practice

point 1)

Determinelocation and

type of chronic wound (review practice

point 2)

YES

ACUTENO

NO

YES

YES

CHRONIC

WOUND FAILS TO RESPOND OR IS HIGH

RISK WOUND INITIALLY (review practice point 3)

WOUND OUTSIDE OF SCOPE OF PRACTICE OF RACF AND GP, OR

WOUND COMPLICATION DEVELOPS?

RESIDENT DEVELOPS SYSTEMIC

SYMPTOMS OR SIGNS

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Wound management practice points [70-73]

(1) Acute versus chronic wounds

Acute wounds here refer to wounds in which healing is anticipated to progress normally through an orderly and timely repair process with resolution of the wound within no more than 4 weeksChronic wounds are wounds in which there is impaired healing and include diabetic foot ulcers, pressure ulcers, arterial and venous ulcers

(2) Determining the type of chronic wound

Type of wound is determined on basis of history, examination and appropriate investigations. For any chronic wound where the resident has had exposure to pressure forces, establish if the wound is a pressure injury and ensure an appropriate pressure injury prevention plan is in place. Any wound that fails to respond to appropriate wound management should be considered for biopsy to exclude a neoplastic cause, particularly if wound present for > 3 months. Wounds are considered HIGH RISK if there is any of: exposed bone or bone is easily probed, tissue necrosis overlies bone, gangrene is present, persistent sinus tract, underlying open fracture, underlying internal fixation, bites, or if the wound persists or recurs. Wounds are also considered HIGH RISK if occurring in immunosuppressed or diabetic patients

TYPE OF WOUND Arterial Ulcer Venous Ulcer

Diabetic Ulcer (=NeuropathicUlcer)

HISTORY History of smoking, intermittent claudication

History of any of: Thrombophlebitis, DVT, varicose veins, lower extremity injury, surgery to leg; aching and swelling worse at end of day and relieved with leg elevation

History of diabetes, numbness, paraesthesiae, burning or loss of sensation in feet

PAINOften very painful requiring strong analgesics; pain increases with exercise and leg elevation

Pain often dragging ache worse with mobilisation and relieved by leg elevation

Painless or burning pain

TYPICAL LOCATION

Distal lower limbs especially overlying bony prominences Lower 1/3 of leg

Sites of pressure in foot e.g. metatarsal heads, heels and toes

ULCER APPEARANCE

Round or punched out ulcer with sharply demarcated border, base often pale or discoloured nonviable tissue

Shallow, irregular margins, often with fibrinous material at ulcer bed

Surrounding callus, variable depth

SURROUNDING SKIN

Cold, pale feet; loss of hair; shiny taut skin

Peripheral oedema; venous dermatitis (pigmentedskin); +/- atrophy blanche or white scar formation

Frequently callused

VASCULAR STATUS

Capillary refill time > 4-5 seconds; pulses weak or absent

Capillary refill time < 3 seconds; pulses generally present

Capillary refill time < 3 seconds if no associated arterial disease; potential for bounding pulses

ANKLE BRACHIAL INDEX (ABI)

ABI: 0.6 to 0.9 = peripheral arterial occlusive disease; < 0.5 = critical arterial disease

Normal ABI 0.9 or higherNormal ABI 0.9 if no associated arterial disease

**Modified from: Queensland Health and Royal Flying Doctors Primary Clinical Care Handbook. 7th edition. 2011. Cairns, p360.

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Appendix 1: RACF resident assessment tools

AVPU: Assessment tool for conscious state [74]AVPU (an acronym for Alert, Voice, Pain, Unresponsive) is a simple assessment scale to assess the conscious level of residents.

The following RACF resident assessment tools are provided as a resource for use if required; RACF providers may have their own preferred assessment tools.

A = the resident is fully awake

V = the resident responds to verbal stimulation only

P = the resident responds to painful stimulation only

U = the resident is completely unresponsive

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Cognition appropriate pain assessment tool: PAINAD [75]PAINAD or Pain Assessment in Advanced Dementia Scale, is a pain assessment tool designed for assessment of pain in those with advanced cognitive impairment.

Instructions: • Observe the resident for 5 minutes prior to scoring • Score according to chart below • If resident assessed to be in pain, repeat scoring after administration of analgesia to determine

effectiveness of analgesia• Scoring:

- Total score ranges from 0 to 10 points - If PAINAD score:

▪ 1 to 3 = mild pain ▪ 4 to 6 = moderate pain ▪ 7 to 10 = severe pain

BehaviourPoints

Score0 1 2

Breathing (score when not talking)

Normal breathing = quiet, effortless, smooth breathing

Occasional labored breathing (= episodic bursts of harsh, difficult respirations) or short periods of hyperventilation (short periods of rapid, deep breaths)

Noisy laboured breathing (= loud or gurgling or wheezing breathing that looks strenuous) or Long period of hyperventilation or Cheyne-Stokes respirations (rhythmic waxing and waning of breathing from very deep to shallow respirations with periods of apnoea or cessation of breathing)

Negative speech

None = speech has neutral or pleasant quality

Occasional moan or groan or low-level speech with a negative or disapproving quality (= muttering, mumbling, whining, grumbling or swearing in a low volume with a complaining, sarcastic or caustic tone)

Repeated troubled calling out; loud moaning or groaning or crying

Facial expression

Smiling or inexpressive

Sad or frightened or frowning

Facial grimacing

Body language

Relaxed Tense or distressed or pacing or fidgeting

Rigid or fists clenched or knees pulled up or pulling or pushing away or striking out

Consolability No need to console

Distracted or reassured by voice or touch

Unable to console, distract or reassure

Total Score

The PAINAD was developed and tested by clinicians and researchers at the New England Geriatric Research Education and Clinical Center, a Department of Veterans Affairs center of excellence with divisions at EN Rogers Memorial Veterans Hospital, Bedford, MA, and VA Boston Health System.

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Cognition appropriate pain assessment tool: ABBEY PAIN SCALE [76]Abbey Pain Scale (Pain Assessment in Advanced Dementia Scale) is a pain assessment tool designed for assessment of pain in those who are unable to clearly articulate their needs.

Instructions:

• While observing the resident score behaviours 1 to 6 – the scale is best used while the resident is being moved (e.g. during pressure area care) rather than while static

• Score according to chart below • If resident assessed to be in pain, repeat scoring after administration of analgesia to determine

effectiveness of analgesia• Scoring:

- Total score ranges from 0 to 18 points - If Abbey Pain Score:

▪ 0 to 2 = no pain ▪ 3 to 7 = mild pain ▪ 8 to 13 = moderate pain ▪ 14+ = severe pain

BehaviourPoints

Score0 1 2 3

Vocalisation = whimpering, groaning, crying Absent Mild Moderate Severe

Facial expression = looking tense, frowning, grimacing, looking frightened

Absent Mild Moderate Severe

Change in body language = fidgeting, rocking, guarding part of body, withdrawn


Behavioural change = increased confusion, refusing to eat, alteration in usual patterns


Physiological change = temperature, pulse or blood pressure outside normal limits, perspiring, flushing or pallor


Physical changes = skin tears, pressure areas, arthritis, contractures, previous injuries


Total score

Source: Abbey J, De Bellis A, Piller N, Esterman A, Giles L, Parker D, Lowcay B. Funded by the JH & JD Gunn Medical Research Foundation 1998–2002

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Delirium screening tool: Confusion Assessment Method (CAM) [77]The Confusion Assessment Method (CAM) is a tool that facilitates screening for delirium. Instructions: • Score according to chart below • Scoring - delirium is suggested if:

- All items in box 1 are answered YES and - At least one item in box 2 is answered YES

Box 1: I. Acute onset and fluctuating course

a. Is there evidence of an acute change in mental status from the resident’s baseline? OR

b. Did the abnormal behaviours fluctuate during the day (i.e. tend to come and go or increase and decrease in severity)?

Yes No

II. InattentionDid the patient have difficulty in focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said?

Yes No

Box 2: Perform if both of above are answered yesI. Disorganised thinking

Was the resident’s thinking disorganised or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?

Yes No

II. Altered level of consciousnessOverall, how would you rate the patient’s level of consciousness? AlertVigilantLethargic (drowsy, easily aroused)Stupor (difficult to rouse)Coma (unrousable)

Score as yes if level of consciousness lower than alertScore as no if alert

Yes No

Confusion Assessment Method. © 2003, Hospital Elder Life Program, LLC. Not to be reproduced without permission.

No responsibility is assumed by the Hospital Elder Life Program, LLC for any injury and / or damage to persons or property arising out of the application of any of the content at hospitalelderlifeprogram.orgProv

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65

Neuropsychiatric inventory [78, 79]Answer the questions (next page) based on changes that have occurred since the resident first began to experience a change in behaviours

Circle “yes” only if the symptom has been present in the past monthOtherwise circle “no”

For each item marked “yes”:

A. Rate the severity of the symptom (how it affects the resident):

1 = mild (noticeable, but not a significant change) 2 = moderate (significant, but not a dramatic effect)3 = severe (very marked or prominent, a dramatic change)

B. Rate the distress the caregiver / staff experiences due to that symptom:

0 = not distressing at all1 = minimal (slightly distressing, not a problem to cope with)2 = mild (not very distressing, not always easy to cope with) 3 = moderate (fairly distressing, not always easy to cope with) 4 = severe (very distressing, difficult to cope with) 5 = extreme or very severe (extremely distressing, unable to cope with)

SCORING:

Total NPI-Q severity score = sum of individual symptom scores (range 0-36) Total NPI-Q distress score = sum of individual symptom scores (range 0-60)

Higher scores indicate more behavioural disturbance. However, there is no “cut-off” point for abnormal findings, as each symptom that is present may be significant in its own right.

Modified from: Kaufer DI, Cummings JL, Ketchel P, Smith V, MacMillan A, Shelley T, et al. Validation of the NPI-Q, a brief clinical form of the Neuropsychiatric Inventory. J Neuropsychiatry Clin Neurosci 2000;12:233–9, in Cummings J, Cherry D, Kohatsu N et al. Guidelines for managing alzheimer’s disease: part I - assessment. American Family Physician, 2002. 65(11): 2263-2272.

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Symptom: Has this symptom occurred in the last month? Severity Distress

Delusions: Does the resident believe that others are stealing from them / planning to harm them in some way?

Yes / No

1 2 3 0 1 2 3 4 5

Hallucinations: Does the resident act as if they hear voices or talks to people who are not there?

Yes / No

1 2 3 0 1 2 3 4 5

Agitation or aggression: Is the resident stubborn and resistive to help from others?

Yes / No

1 2 3 0 1 2 3 4 5

Depression or dysphoria: Does the resident act as if they are sad or in low spirits or cries?

Yes / No

1 2 3 0 1 2 3 4 5

Anxiety: Does the resident become upset when separated from you? Do they have any other signs of nervousness such as shortness of breath, sighing, being unable to relax, or feeling excessively tense?Yes / No

1 2 3 0 1 2 3 4 5

Elation/Euphoria: Does the resident appear to feel too good or act excessively happy?Yes / No

1 2 3 0 1 2 3 4 5

Apathy/Indifference: Does the resident seem less interested in their usual activities or in the activities and plans of others?Yes / No

1 2 3 0 1 2 3 4 5

Disinhibition: Does the resident seem to act impulsively?Yes / No

1 2 3 0 1 2 3 4 5

Irritability/Lability: Is the resident impatient and cranky? Do they have difficulty coping with delays or waiting for planned activities?Yes / No

1 2 3 0 1 2 3 4 5

Motor Disturbance: Does the resident engage in repetitive activities such as pacing around the facility, handling buttons, wrapping string or doing other things repeatedly?Yes / No

1 2 3 0 1 2 3 4 5

Nighttime Behaviours: Does the resident awaken you during the night, rise too early in the morning, or take excessive naps during the day?Yes / No

1 2 3 0 1 2 3 4 5

Appetite/Eating: Has the resident lost or gained weight, or had a change in the type of food liked?Yes / No

1 2 3 0 1 2 3 4 5

Copyright J Cummings 1994; all rights reserved

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RESIDENTIAL AGED CARE END O

F LIFE CARE PATHWAY (RAC EoLCP)

Instructions for Completing the Pathway

Section 1: Commencing a Resident on the Pathway O GP, PCMO, PCNS, RN

Section 2: Medical Interventions and Advance Care Planning M O GP, PCMO, PCNS, RN

Section 3: Care Staff Interventions

Part A - Care Management To be completed by RN or Enrolled Nurse (EN)

Part B - Comfort Care Chart To be completed by attending Nursing and Care Staff A new chart is to be commenced daily

Part C - Further Care Action Sheet Nursing and Care Staff are to document any further actions taken to improve comfort care

Section 4: Multidisciplinary Communication Sheet All members of the multidisciplinary team can document here

Section 5: After Death Care To be completed upon death of a resident by the attending nurse

Note: Dependent upon individual RACF practices, it may be preferred to use existing facility documentation tools to record Sections and

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Page of

Residential Aged CareEnd of Life Care Pathway

(RAC EoLCP)

(Af x identi cation label here)

URN:

Family name:

Given name(s):

Address:

Date of birth: Sex: M F I

Medicare No.:Facility: .........................................................................................................

v.

Mat

. No.

: SW

The Brisbane South Palliative Care Collaborative (BSPCC) RAC EoLCP ™ was developed as part of a project funded by

the Department of Health and Ageing.

This End of Life Care Pathway (EoLCP) document is a consensus based, best practice guide to providing care for residents in Residential Aged Care Facilities (RACFs) during the last days of their lives. The entire document forms part of the resident’s medical record.

To commence the pathway, authorisation should be obtained from the resident’s General Practitioner (GP). If the GP cannot be contacted, interim authorisation can be obtained from one of the following: Palliative Care

[Enter District/Facility/Service Here]

For illustrative purposes only

Appendix 2 : Residential Aged Care End of Life Care Pathway [26]

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Section 1: Commencing a Resident on the Pathway

The signs and symptoms listed below are considered to indicate that the terminal phase of life is imminent. (‘Guidelines for a Palliative Approach in Residential Aged Care’ Australian Government Department of Health and Ageing 2 )

It is appropriate to start the pathway if three or more of these signs and symptoms are applicable to the resident. The nal decision to commence the pathway is a clinical one, supported by the views of the GP, multidisciplinary team and, if possible, the resident and or their representative .

Please note, in some cases residents may be commenced on the pathway and then taken off the pathway if their condition improves.

Signs and symptoms associated with the terminal phase Yes No

Experiencing rapid day to day deterioration that is not reversible

Requiring more frequent interventions

Becoming semi conscious, with lapses into unconsciousness

Increasing loss of ability to swallow

Refusing or unable to take food, uids or oral medications

Irreversible weight loss

An acute event has occurred, requiring revision of treatment goals

Profound weakness

Changes in breathing patterns

Agreement to commence on pathway

Verbal ( ) Print name Title Signature Date

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(RAC EoLCP)


URN:

Family name:

Given name(s):

Address:


Medicare No.:

substitute decision maker


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Section 2: Medical Interventions and Advance Care Planning

As a minimum, a reassessment of the commencement criteria should occur every three days.

Intervention Yes No Pending N/A

Essential medications, via appropriate route, charted

PRN medications ordered as per guidelines

Nonessential medications discontinued

Subcutaneous infusion(s) commenced if appropriate

Inappropriate interventions and observations discontinued (e.g. BSL, blood pressure monitoring)

Advance Care Planning Yes No Pending N/A

Current condition and commencement of EoLCP discussed with resident resident’s representative

Issues surrounding intravenous parenteral and PEG feeding have been discussed with the resident resident’s representative

Future care plan discussed with resident resident’s representative (e.g. transfer to hospital, use of antibiotics)

‘Acute Resuscitation Plan’ ‘Not for Resuscitation’ order discussed and agreed to by resident resident’s representative

If recording a ‘no’ or ‘pending’ response, please document reasons for this on the multidisciplinary communication sheet to facilitate follow up action.

Verbal ( ) Print name Title Signature Date Time

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(RAC EoLCP)


URN:

Family name:

Given name(s):

Address:


Medicare No.:



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Section 3: Part A - Care Management

The following information may already be documented in the resident’s chart. Please check that the information in the chart is current and document any changes as necessary.

Spiritual / Religious / Cultural Needs Yes No Pending N/A

Have the spiritual religious cultural needs of the resident been addressed?

Has the resident resident’s representative expressed a preferred Funeral Director?

Communication with resident / resident’s representative* Yes No Pending N/A

Have contact details of resident’s representative been updated?

Have attempts been made to inform the resident’s representative that the resident is dying?

Have issues around impending death been discussed with resident’s representative ?

Has resident’s representative been approached regarding grief and loss issues?

Comfort Planning Yes No Pending N/A

Need for special mattress assessed?

Comfort Care Chart commenced?

Other (please state)


Print name Title Signature Date Time

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(RAC EoLCP)


URN:

Family name:

Given name(s):

Address:


Medicare No.:



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Sect

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IS BIND

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Res

iden

tial A

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eEn

d of

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thw

ay(R

AC

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(Af

x id

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Sect

ion

3: P

art B

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Cha

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gain

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ach

item

, as

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imum

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Psy

chos

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may

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ice

daily

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ther

Act

ions

(F/A

) tak

en, o

ther

than

rout

ine

care

(R/C

) to

be re

cord

ed o

n th

e ‘F

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Actio

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(Sec

P

art C

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each

day

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ox:

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esse

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Initi

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DO

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RIT

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TH

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IND

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Page of 12

Res

iden

tial A

ged

Car

eEn

d of

Life

Car

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thw

ay(R

AC

EoL

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(Af

x id

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inform

ation

only

-

Contac

t HIU

@he

alth.q

ld.go

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74

Sect

ion

3: P

art B

- C

omfo

rt C

are

Cha

rt R

ecor

d an

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st e

ach

item

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Min

imum

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umen

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chos

ocia

l iss

ues

may

onl

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sses

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t tw

ice

daily

Fur

ther

Act

ions

(F/A

) tak

en, o

ther

than

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(R/C

) to

be re

cord

ed o

n th

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urth

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are

Actio

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eet’

(Sec

P

art C

)

A n

ew c

hart

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com

men

ced

each

day

Scor

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ch b

ox:

A =

ass

esse

d an

d no

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requ

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A =

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app

licab

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Dat

e:02

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ptom

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ifcu

lties

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tly re

spira

tions

Pain

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utan

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can

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als

DO

NO

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ITE IN TH

IS BIND

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MAR

GIN

Page of 12

Res

iden

tial A

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Car

eEn

d of

Life

Car

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thw

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AC

EoL

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(Af

x id

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Contac

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75

Sect

ion

3: P

art C

- Fu

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Ple

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reco

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as a

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fect

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If ‘N

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as ta

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Initi

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Yes

No

DO

NO

T W

RIT

E IN

TH

IS B

IND

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MAR

GIN

Page of 12

Res

iden

tial A

ged

Car

eEn

d of

Life

Car

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thw

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AC

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(Af

x id

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Contac

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76

Sect

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3: P

art C

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Tim

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If ‘N

o’, w

hat f

urth

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as ta

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No

DO

NO

T WR

ITE IN TH

IS BIND

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MAR

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Page 1 of 12

Res

iden

tial A

ged

Car

eEn

d of

Life

Car

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thw

ay(R

AC

EoL

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(Af

x id

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UR

N:

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ily n

ame:

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en n

ame(

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F

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inform

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Contac

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77

Sect

ion

4: M

ultid

isci

plin

ary

Com

mun

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Shee

t P

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e th

is s

heet

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mat

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and

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rven

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.

Dat

eTi

me

Com

men

tsIn

itial

s

DO

NO

T W

RIT

E IN

TH

IS B

IND

ING

MAR

GIN

Page 11 of 12

Res

iden

tial A

ged

Car

eEn

d of

Life

Car

e Pa

thw

ay(R

AC

EoL

CP)

(Af

x id

enti

catio

n la

bel h

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UR

N:

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ily n

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ame(

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ess:

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e of

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F

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Med

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Provide

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inform

ation

only

-

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t HIU

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78

Section 5: After Death Care

The following information may already be documented in the resident’s chart. Please check that the information in the chart is current and document any changes as necessary.

Date of death: / / Time of death: :

Yes No Pending N/A Date

Resident’s representative informed of death

GP informed of death

Procedures for ‘ nal act of care’ according to RACF policy

Infusion device removed and returned

Resident inventory completed

Removal of deceased resident from RACF according to policy

Staff residents informed of death as appropriate

Bereavement lea et information given to NO or other

Pharmacy informed of death

Allied Health Professionals informed of death

Loan equipment returned


Print name Title Signature Date Time

State of ueensland ( ueensland Health) 2 1 . Contact CIM health.qld.gov.au. This work is licensed under a Creative Commons Attribution Non Commercial No Derivatives . Australia licence. To view a copy of this licence, visit http: creativecommons.org licensesby nc nd . au

DO

NO

T WR

ITE IN TH

IS BIND

ING

MAR

GIN

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(RAC EoLCP)


URN:

Family name:

Given name(s):

Address:


Medicare No.:



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Appendix 3: Residential Care Facility Falls Assessment and Management Plan [29, 30]

(Affix identification label here)

URN:

Family name:

Given name(s):

Address:


Page 1 of 2

Residential Care Facility Falls Assessment and

Management Plan

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Facility: ...........................................................................................................

RESID

ENTIAL C

ARE FALLS ASSESSM

ENT AN

D M

ANAG

EMEN

T PLAN

Adult

• Complete this form within 24 hours of admission, when there is a change in condition, medication, or after a fall; and reassess as per local policy

• Care plans never replace clinical judgement. Care outlined must be altered if not clinically appropriate for the individual care recipient

• Every person documenting on the form must supply a sample of their initials in the signature log (page 2)

Falls Risk AssessmentIdentify risk factorsTick (ü) Yes or No

(if Yes to any, care recipient is ‘at risk’ of a fall)

If YES to any Initiate actionsTick when actioned (if indicated)

Risk Factors

Date

Actions

Date

Time Time

Initial Initial

Screen: The care recipient has had a fall in the last 6 months

Y Y Y

• Refer to physiotherapist for gait and balance assessment

N N N

The care recipient is observed to be unsteady Y Y Y

N N N

The care recipient uses a non-prescribed mobility aid

Y Y Y

N N N

The care recipient has a neurological disorder that affects balance; or uses a mobility aid and has not been reviewed within 12 months

Y Y Y

N N N

The care recipient is visually impaired Y Y Y • Ensure glasses / visual aid is within reach

N N N • Refer for visual assessment (where appropriate)

The care recipient requires supervision or assistance with transfers or ADL

Y Y Y• Complete ADL assessment (if required)

N N N

The care recipient has new onset incontinence Y Y Y

• Refer to GP for investigation (e.g. MSU) N N N

The care recipient has existing incontinence, frequency or requires assisted toileting

Y Y Y • Initiate toileting routine

N N N• Consider use of continence aids• Referral for continence assessment

(as appropriate)The care recipient reports postural symptoms (e.g. regular dizziness, light headedness, recent history of syncope)

Y Y Y • Measure lying and standing BP

N N N • Refer to GP (as appropriate)

The care recipient is on one of the following medications: antihypertensive, antidepressant, sedative, benzodiazepine, antipsychotic

Y Y Y

• Refer to GP / Pharmacist for medication review (as appropriate)

N N N

The care recipient is on more than 4 medications Y Y Y

N N N

The care recipient has a minimal trauma fracture and / or history of osteoporosis

Y Y Y • Refer to Dietitian (where appropriate)

N N N • Refer to GP to assess causes of osteoporosis and treatment options (if appropriate)

The care recipient has new onset or increased confusion / delirium

Y Y Y • Notify GP for further investigations

N N N • Conduct or refer for cognitive assessment

The care recipient is usually confused Y Y Y

• Conduct or refer for cognitive assessment N N N

Following assessment, inform care recipient / carers of assessment outcome; and proceed to develop management plan (page 2)

Order fr

om O

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URN:

Family name:

Given name(s):

Address:


Page 2 of 2

Residential Care Facility Falls Assessment and

Management PlanAdult

• Initial when strategies are implemented• Care plans never replace clinical judgement. Care outlined must be altered if not clinically appropriate for the individual care recipient• V indicates a variance from clinical care and must be documented in the clinical notes

Falls Prevention Management PlanAll clinicians who initial are to sign signature log Key Allied Health Medical Nursing Pharmacy

CategoryDate

Time

Communication In partnership with care recipient and / or carer discuss falls risk factors and goals of care to prevent fallsInstruct care recipient to call for assistance when getting out of bed / mobilising (if required)

Communicate care recipient’s ‘at risk’ status at handover

GP review of antiplatelet / anticoagulant medication for at risk care recipientsEnvironment / Equipment

Orientate to surroundings, routine and location of bathroom and toilet

Ensure clutter free and safe environment (e.g. night time lighting)

Ensure the chair and bed height / position are suitable for the care recipient’s needs

Apply brakes to bed, wheelchair and commode correctly

Ensure bed rails are at appropriate height for care recipient’s needs, if prescribed

Keep buzzer in reach; educate care recipient on buzzer usage

Keep care recipient’s routine belongings within reach

Keep care recipient’s mobility aid well maintained and within reach if applicable

Review care recipient footwear and / or foot problemsObservations Ensure frequent rounding and surveillance

Consider supervision during toileting / showering / mobilisation

Ensure suitable toileting protocols are in place

Implement Allied Health recommendations

.............................................................................................................................................................................................................

Allied Health / Medical Review (e.g. MO, Physio, OT, Podiatry, Dietitian, Pharmacist)

Specific Care Recipient Centred Goal (e.g. prefers to wear closed in shoes when transferring/mobilising)

Other Care (specify)

Signature LogInitial Print name Designation Signature Initial Print name Designation Signature

Order fr

om O

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DO

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IS BIND

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DO

NO

T W

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E IN

TH

IS B

IND

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GIN

Page 1 of 2


URN:

Family name:

Given name(s):

Address:


Residential Care FacilityPost Fall Clinical Pathway

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RESID

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• Clinical pathways never replace clinical judgement• Care outlined in this clinical pathway must be altered if it is not clinically appropriate for the individual care recipient• This pathway is to be used for any care recipient who has had a fall• V indicates a variance from the pathway, document in clinical notes

Immediate actions » Commence DRSABCD (Danger, Response, Send for help, Airway, Breathing, CPR, Defibrillate - if available) or as per local procedure » Call for assistance » Do not move the resident until assessed for injuries and safety » Observe for symptoms of head and / or muscular skeletal injury e.g. any change in behaviour, change in level of consciousness, headache or vomiting, any deterioration - call 000 where required and / or immediately verbally contact GP for advice

Details of fall and initial actionsDate:

/ /

Time found:

:

Respiratory rate: O2 Saturation:

%

Blood pressure:

/

Heart rate: GCS score: Temperature:

°C

BGL:

Was the resident unconscious? Yes No Obvious major skeletal deformities / fracture / injury? Yes No

Major head trauma? Yes No Did the resident show signs of increased confusion? Yes No

All care givers who initial are to sign signature log Key Medical Nursing Category Initial VMedical assessment

• Verbally contact the GP Who was notified? ...................................................................................................... Date ....................... Time ................

• Verbally notify the GP if any of the following applies to the resident: known coagulopathy on anticoagulant / antiplatelet therapy fall from greater than 1 metre in height suspected head injury recent surgery/procedure other: ............................................................................

Investigations /observations

Document in observation chart at the following intervals

• Suspected head injury or unwitnessed fall What: neuro obs, respiratory rate, O2 saturation, blood pressure, heart rate, BGL (as per local policy)

When: Day 1 Day 2

¼ hourly for 1 hour, if normal "

½ hourly for 2 hours, if normal "

hourly for 8 hours, if normal "

2nd hourly for 6 hours, if normal "

4th hourly for 8 hours, if normal "

6th hourly for 24 hours

or observation as per medical order

• No head injury What: respiratory rate, O2 saturation, blood pressure, heart rate, BGL (as per local policy)

When: hourly for 4 hours, if normal "

2nd hourly for 6 hours, if normal " 4th hourly for 8 hours

or observations as per medical order

• If there is a reduction in GCS score of ≥2 points or deterioration of observations (any change in behaviour, headache, vomiting or indications of internal bleed) call 000 immediately and verbally contact GP immediately

Management plan (within 24 hours)

Note that there may be late manifestations of head injury or other injury after 24 hours

• Notify family of incident as soon as possible (as agreed upon with family)

• Surgical intervention / treatment plan as per GP order

• Document incident and outcomes in rcare recipient’s clinical record

• Log incident report

• Communicate incident, outcomes and planned care at handover / transfer of care

• Review Falls Assessment and Management Plan

Signature log (every person documenting in this pathway must supply sample of their initials in the signature log below)Initial Print name Designation Signature

Office M

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1712

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Page 2 of 2

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spira

tory

rate

, O

2 sa

tura

tion,

bl

ood

pres

sure

, he

art r

ate,

GC

S,

tem

pera

ture

, B

lood

Glu

cose

Le

vel (

BG

L)

• D

ocum

ent t

he

follo

win

g:

»co

nsci

ousn

ess

»m

ajor

hea

d tra

uma

»ob

viou

s m

ajor

ske

leta

l de

form

ities

/ ob

viou

s fra

ctur

e /

inju

ry

»si

gns

of

conf

usio

n

Susp

ecte

d he

ad in

jury

or u

nwitn

esse

d fa

llW

hat:

»ne

uro

obs,

resp

irato

ry ra

te, O

2 sa

tura

tion,

blo

od

pres

sure

, hea

rt ra

te, B

GL

(as

per l

ocal

pol

icy)

Whe

n - D

ay 1

: »¼

hou

rly fo

r 1 h

our,

if no

rmal

" »½

hou

rly fo

r 2 h

ours

, if n

orm

al "

»ho

urly

for 8

hou

rs, i

f nor

mal

" »2n

d ho

urly

for 6

hou

rs, i

f nor

mal

" »4t

h ho

urly

for 8

hou

rs.

»or

obs

erva

tions

as

per m

edic

al o

rder

Whe

n - D

ay 2

: »6t

h ho

urly

for 2

4 ho

urs.

»or

obs

erva

tions

as

per m

edic

al o

rder

No

head

inju

ryW

hat:

»re

spira

tory

rate

, O2

satu

ratio

n, b

lood

pre

ssur

e,

hear

t rat

e, B

GL

(as

per l

ocal

pol

icy)

Whe

n: »ho

urly

for 4

hou

rs, i

f nor

mal

" »2n

d ho

urly

for 6

hou

rs, i

f nor

mal

" »4t

h ho

urly

for 8

hou

rs.

»or

obs

erva

tions

as

per m

edic

al o

rder

• N

otify

fam

ily o

f inc

iden

t (as

ag

reed

upo

n w

ith fa

mily

)

• S

urgi

cal i

nter

vent

ion

/ tre

atm

ent p

lan

as p

er

GP

orde

r

• D

ocum

ent i

ncid

ent a

nd

outc

omes

in re

side

nt’s

clin

ical

re

cord

• Lo

g in

cide

nt re

port

• C

omm

unic

ate

inci

dent

, ou

tcom

es a

nd p

lann

ed c

are

at h

ando

ver

• R

evie

w F

alls

Ass

essm

ent a

nd

Man

agem

ent P

lan

Res

iden

t Fal

l(w

itnes

sed

orun

witn

esse

d

Inve

stig

atio

ns /

obse

rvat

ions

• Ve

rbal

ly n

otify

G

P to

con

duct

as

sess

men

t

• Ve

rbal

ly n

otify

G

P if

any

of th

e fo

llow

ing

appl

y to

th

e re

side

nt:

»kn

own

coag

ulop

athy

»on

ant

icoa

gula

nt /

antip

late

let

ther

apy

»fa

ll fro

m g

reat

er

than

1 m

etre

he

ight

»su

spec

ted

head

in

jury

»re

cent

sur

gery

/ pr

oced

ure

• D

ocum

ent w

ho w

as

notifi

ed a

nd w

hen

Office M

ax 43

1712

2

Provide

d for

inform

ation

only

-

Contac

t HIU

@he

alth.q

ld.go

v.au

83

Pre

ssur

e In

jury

Flo

w C

hart

Pre

ssur

e ul

cer

clas

sifi c

atio

n sy

stem

*

Ref

eren

ces:

AW

MA

. Pan

Pac

ifi c

Clin

ical

Pra

ctic

e G

uid

elin

e fo

r P

reve

ntio

n an

d M

anag

emen

t of P

ress

ure

Inju

ry.

Osb

orne

Par

k, W

A: C

ambr

idge

Med

ia 2

012

• A

AW

C. A

AW

C g

uid

elin

e of

pre

ssur

e ul

cer

guid

elin

es.

Mal

vern

, PA

: AA

WC

201

0 •

Ste

chm

iller

et a

l. G

uide

lines

for p

reve

ntio

n of

pre

ssur

e ul

cers

. Wou

nd

Rep

Reg

en 2

008.

16:

151-

168

• W

OC

N. G

uid

elin

e fo

r p

reve

ntio

n an

d m

anag

emen

t of p

ress

ure

ulce

rs. M

ount

Lau

rel N

J:W

OC

N 2

010

• R

NA

O. R

isk

asse

ssm

ent a

nd p

reve

ntio

n of

pre

ssur

e ul

cers

. (R

evis

ed).

Toro

nto,

ON

: RN

AO

201

1 •

NIC

E. T

he u

se o

f pre

ssur

e-re

lievi

ng d

evic

es fo

r th

e p

reve

ntio

n of

pre

ssur

e ul

cers

. Lon

don:

RC

N 2

004

• R

oyal

Col

lege

of N

ursi

ng. M

anag

emen

t of

pre

ssur

e ul

cers

. Lon

don:

RC

N a

nd N

ICE

2005

• W

hitn

ey e

t al.

Gui

delin

es fo

r tre

atm

ent o

f pre

ssur

e ul

cers

. Wou

nd R

ep R

egen

200

6. 1

4:66

3-79

• U

nder

take

a p

ress

ure

inju

ry ri

sk

asse

ssm

ent

(e.g

. Wat

erlo

w, B

rade

n)

-on

adm

issi

on -at

regu

lar i

nter

vals

-up

on a

cha

nge

in h

ealth

sta

tus

• If

a cl

ient

is fo

und

to b

e ‘a

t ris

k’, a

sses

s sk

in a

t lea

st d

aily

• S

uspe

cted

sta

ge 1

pre

ssur

e in

jurie

s sh

ould

be

reas

sess

ed 2

0 m

inut

es a

fter

pres

sure

is re

lieve

d

• R

egul

arly

ass

ess

for p

ain

and

deve

lop

a

pain

man

agem

ent p

lan

if ap

prop

riate

Red

uced

phy

sica

l mob

ility

Loss

of s

ensa

tion

Impa

ired

cogn

ition

or l

evel

of c

onsc

ious

ness

Inco

ntin

ence

Poo

r nut

ritio

n or

rece

nt w

eigh

t los

s

Dry

ski

n or

ski

n in

con

stan

tco

ntac

t with

moi

stur

e

Acu

te o

r sev

ere

illnes

s

• Irr

igat

e w

ith w

arm

cle

an w

ater

or n

orm

al s

alin

e

• C

lean

the

wou

nd g

ently

• R

emov

e ne

crot

ic o

r dev

italis

ed ti

ssue

*

*M

echa

nica

l or s

harp

deb

ridem

ent s

houl

d o

nly

be d

one

by tr

aine

d cl

inic

ians

• S

elec

t a d

ress

ing

whi

ch w

ill:

-m

aint

ain

a m

oist

wou

nd b

ed -m

anag

e w

ound

exu

date

-pr

otec

t the

sur

roun

ding

ski

n -m

inim

ise

shea

r, fri

ctio

n &

pre

ssur

e -to

pica

l neg

ativ

e pr

essu

re m

ay b

enefi

tst

age

III &

IV u

lcer

s

• U

se a

hig

h sp

ecifi

catio

n re

activ

e or

activ

e su

ppor

t sur

face

for c

lient

s w

ith

pres

sure

inju

ries

• S

tage

III,

IV, u

nsta

geab

le o

r dee

p tis

sue

inju

ries

requ

ire a

n al

tern

atin

g pr

essu

re, l

ow

air-

loss

, con

tinuo

us lo

w p

ress

ure

syst

em, o

r ai

r-fl u

idiz

ed b

ed; c

lose

obs

erva

tion;

and

a

repo

sitio

ning

regi

me

• A

void

pos

ition

ing

dire

ctly

on

bony

pr

omin

ence

s or

pre

ssur

e in

jurie

s

• A

void

she

ar a

nd fr

ictio

n

• Li

mit

the

amou

nt o

f tim

e th

e he

ad o

f bed

is e

leva

ted

• U

se p

illow

s an

d fo

am w

edge

s to

ele

vate

or

repo

sitio

n bo

ny p

rom

inen

ces

e.g.

hee

ls, h

ips

• P

rovi

de h

igh

prot

ein

nutri

tiona

l sup

plem

ents

, in

clud

ing

argi

nine

, for

thos

e w

ith a

sta

ge 2

or

grea

ter p

ress

ure

inju

ry

• A

mul

tidis

cipl

inar

y ap

proa

ch is

nee

ded,

in

clud

e p

hysi

othe

rapy

, occ

upat

iona

l the

rapy

, nu

rsin

g, d

ietit

ian

and

med

ical

pra

ctiti

oner

Leve

l of r

isk

and

risk

fact

ors

pres

ent

Pre

vent

ion

stra

tegi

es

Wou

nd a

sses

smen

t an

d m

anag

emen

t (si

ze,

stag

e, l

ocat

ion,

tis

sue,

ex

udat

e, s

urro

undi

ng s

kin,

in

terv

entio

ns)

Pro

gres

s an

d ou

tcom

e of

in

terv

entio

ns, i

nclu

ding

use

of

a v

alid

ated

hea

ling

scal

e

Ris

k fa

ctor

s fo

r a

Pre

ssur

e In

jury

Doc

umen

t

heal

thy

skin

Cham

pions

for S

kin I

ntegr

ity

pro

moting

CR

ICO

S N

o. 0

0213

J

© QUT 2013 17812

U

nsta

geab

le/

Unc

lass

ifi ed

S

uspe

cted

dee

p tis

sue

inju

ry.

Fu

ll th

ickn

ess

tissu

e lo

ss in

whi

ch

ac

tual

dep

th o

f the

ulc

er is

co

mpl

etel

y ob

scur

ed b

y sl

ough

and

/or e

scha

r. S

tagi

ng c

anno

t be

dete

rmin

ed u

ntil

slou

ghan

d/o

r esc

har a

re re

mov

ed.

S

uspe

cted

dee

ptis

sue

inur

y

Pur

ple

or m

aroo

n lo

calis

ed

ar

ea o

f dis

colo

ured

inta

ct s

kin

or

bl

ood-

fi lle

d bl

iste

r, du

e to

dam

age

of u

nder

lyin

g tis

sue

from

pre

ssur

e an

d/o

r she

ar.

The

area

may

be p

rece

ded

by ti

ssue

that

is p

ainf

ul,

fi rm

, mus

hy, b

oggy

, war

mer

or c

oole

r as

com

pare

dto

adj

acen

t tis

sue.

S

tage

IV

Full

thic

knes

s lo

ss w

ith

expo

sed

bone

, ten

don

or

mus

cle.

Slo

ugh

or e

scha

r may

be

pre

sent

. Oft

en in

clud

es

un

derm

inin

g an

d tu

nnel

ing.

Dep

th v

arie

s by

ana

tom

ical

loca

tion.

S

tage

III

Fu

ll th

ickn

ess

tissu

e lo

ss.

S

ubcu

tane

ous

fat m

ay b

e

visi

ble

but b

one,

tend

on o

r

mus

cle

are

not e

xpos

ed.

S

loug

h m

ay b

e pr

esen

t but

does

not

obs

cure

the

dept

h of

tiss

ue lo

ss.

May

incl

ude

unde

rmin

ing

and

tunn

ellin

g.D

epth

var

ies

acco

rdin

g to

ana

tom

ical

loca

tion.

S

tage

II

Par

tial t

hick

ness

loss

of d

erm

is

pr

esen

ting

as a

sha

llow

ope

n ul

cer

w

ith a

red

or p

ink

wou

nd b

ed.

M

ay a

lso

pres

ent a

s an

inta

ct o

r

open

/rup

ture

d se

rum

-fi ll

ed b

liste

rTh

e bl

iste

r is

shin

y or

a d

ry s

hallo

w u

lcer

with

out

slou

gh o

r bru

isin

g (

if br

uisi

ng is

pre

sent

in th

e bl

iste

r it

indi

cate

s de

ep ti

ssue

inju

ry).

S

tage

I

Inta

ct s

kin

with

no

n-bl

anch

able

redn

ess

of

a lo

caliz

ed a

rea,

usu

ally

ov

er a

bon

y pr

omin

ence

.

The

area

may

be

pain

ful,

fi rm

,so

ft, w

arm

er o

r coo

ler a

s co

mpa

red

toad

jace

nt ti

ssue

.

Ass

essm

ent

Wou

nd B

ed M

anag

emen

tM

anag

emen

tP

reve

ntio

n

• In

divi

dual

s fo

und

at ri

sk s

houl

d ha

ve a

prev

entiv

e pl

an in

pla

ce

• P

rovi

de a

hig

h-sp

ecifi

catio

n fo

am o

r act

ive

supp

ort m

attre

ss fo

r at r

isk

clie

nts

• O

ff-lo

ad h

eels

for a

t ris

k cl

ient

s

• A

void

pos

ition

ing

dire

ctly

on

bony

pro

min

ence

s

• R

epos

ition

as

frequ

ently

as

requ

ired,

con

side

ring

re

spon

se, c

ondi

tion

and

supp

ort s

urfa

ce

• A

void

foam

ring

s, d

onut

s or

fl ui

d fi l

led

bags

• Li

mit

the

amou

nt o

f tim

e w

ith h

ead

of b

ed e

leva

ted

• A

void

pot

entia

lly ir

ritat

ing

subs

tanc

es o

n th

e sk

in

• A

void

mac

erat

ion

of s

kin

– us

e ba

rrie

rpr

epar

atio

ns o

r cre

ams

• M

aint

ain

optim

al n

utrit

iona

l sta

tus

Sym

pto

ms

ofpre

ssure

dam

age

Loca

lised

hea

t, oe

dem

a, re

dnes

s

Ski

n fe

els

fi rm

or

bogg

y to

touc

h

Dar

kly

pigm

ente

dsk

in m

ay b

e m

aroo

nor

pur

ple

rath

erth

an re

d

This

pro

ject

is fu

nded

by

the

Aus

tral

ian

Gov

ernm

ent D

epar

tmen

t of H

ealth

and

Age

ing

unde

r the

Enc

oura

ging

Bet

ter P

ract

ice

in A

ged

Car

e (E

BPA

C) p

rogr

amR

efer

ence

NP

UA

P 2

007

http

:/w

ww

.npv

ap.o

rg/r

esou

rces

.htm

Appendix 4: Wound Assessment and Management resources [70]

Provide

d for

inform

ation

only

-

Contac

t HIU

@he

alth.q

ld.go

v.au

84

Ski

n Te

ar M

anag

emen

t Flo

w C

hart

Ass

essm

ent

STA

R c

lass

ifi ca

tion

syst

em

Man

agem

ent

Pre

vent

ion

Ref

eren

ces:

Aye

llo E

, Sib

bald

R, P

reve

ntin

g p

ress

ure

ulce

rs a

nd s

kin

tear

s, in

Evi

den

ce-b

ased

ger

iatr

ic n

ursi

ng p

roto

cols

for

bes

t pra

ctic

e, E

Cap

ezut

i, et

al.,

E

ds. 2

008,

Spr

inge

r: N

ew Y

ork.

• L

eBla

nc K

, Bar

anos

ki S

, Ski

n te

ars:

Ad

v S

kin

Wou

nd C

are,

201

1. 2

4(9

S):

2-15

• R

atlif

f C, F

letc

her K

, Ski

n Te

ars:

O

stom

y W

ound

Man

agem

ent,

2007

. 53

(3)

http

://w

ww

.o-w

m.c

om

/art

icle

/696

8 •

Car

ville

K e

t al.,

STA

R: A

con

sens

us fo

r sk

in te

ar c

lass

ifi ca

tion.

P

rimar

y In

tent

ion,

200

7. 1

5(1

): 18

–28

• J

oann

a B

riggs

Inst

itute

, Top

ical

ski

n ca

re in

age

d ca

re fa

cilit

ies.

Bes

t Pra

ctic

e, 2

007.

11(

3)

• W

ound

s U

K.

Bes

t Pra

ctic

e S

tate

men

t: C

are

of th

e O

lder

Per

son’

s S

kin

Wou

nds

UK

201

2 , 2

nd e

d.

This

pro

ject

is fu

nded

by

the

Aus

tral

ian

Gov

ernm

ent D

epar

tmen

t of H

ealth

and

Age

ing

unde

r the

Enc

oura

ging

Bet

ter P

ract

ice

in A

ged

Car

e (E

BPA

C) p

rogr

am

• A

ll cl

ient

s sh

ould

hav

e a

risk

asse

ssm

ent f

or s

kin

tear

s on

adm

issi

on

• A

sses

s an

d do

cum

ent s

kin

tear

s us

ing

a re

cogn

ised

ass

essm

ent a

nd c

lass

ifi ca

tion

syst

em

e.g.

STA

R1

• A

sses

s th

e su

rrou

ndin

g sk

in fo

r sw

ellin

g,

disc

olou

ratio

n or

bru

isin

g

If s

kin fl a

p is

pal

e, d

usk

y or

dar

kened

:

• R

eass

ess

in 2

4-48

hou

rs o

r at t

he fi

rst

dres

sing

cha

nge

* A

sses

smen

t sho

uld

only

be

unde

rtak

enby

trai

ned

staf

f

1

Car

ville

et a

l. 20

07

His

tory

of p

revi

ous

skin

tear

s

Bru

isin

g, d

isco

lour

ed, t

hin

or

fragi

le s

kin

Cog

nitiv

e im

pairm

ent /

dem

entia

Impa

ired

sens

ory

perc

eptio

n

Dep

ende

ncy

Mul

tiple

or h

igh

risk

med

icat

ions

e.

g. s

tero

ids,

ant

icoa

gula

nts

Impa

ired

mob

ility

Poo

r nut

ritio

nal

stat

us

Dry

ski

n / d

ehyd

ratio

n

Pre

senc

e of

fric

tion,

she

arin

g an

d/

or p

ress

ure

• C

ontro

l ble

edin

g

• C

lean

se th

e w

ound

gen

tly w

ith w

arm

wat

er o

r no

rmal

sal

ine,

pat

dry

• R

ealig

n ed

ges

if po

ssib

le -do

not

stre

tch

the

skin

-us

e a

moi

st c

otto

n-tip

to ro

ll sk

in in

to p

lace

• A

pply

a lo

w a

dher

ent,

soft-

silic

one

dres

sing

to

wou

nd, o

verla

ppin

g th

e w

ound

by

at le

ast 2

cm

• D

raw

arr

ows

on th

e dr

essi

ng to

indi

cate

the

dire

ctio

n of

dre

ssin

g re

mov

al

• M

ark

the

date

on

the

dres

sing

• A

pply

lim

b pr

otec

tor

• A

sses

s sk

in re

gula

rly a

nd im

plem

ent

a pr

even

tion

prot

ocol

for t

hose

at r

isk

• U

se s

oap-

free

bath

ing

prod

ucts

• A

pply

moi

stur

iser

twic

e da

ily

• U

se c

orre

ct li

fting

and

pos

ition

ing

tech

niqu

es

• A

void

wea

ring

rings

that

may

sna

g th

e sk

in

• W

hen

repo

sitio

ning

use

ass

istiv

e de

vice

s su

ch a

s sl

ide

shee

ts

• P

rote

ct fr

agile

ski

n w

ith e

ither

lim

b

prot

ecto

rs o

r lon

g sl

eeve

s or

pan

ts

• P

ad o

r cus

hion

equ

ipm

ent a

nd fu

rnitu

re

• A

void

usi

ng ta

pes

or a

dhes

ives

, use

tubu

lar

rete

ntio

n ba

ndag

es to

sec

ure

dres

sing

s

Leve

l of r

isk

and

risk

fact

ors

pres

ent

Pre

vent

ion

stra

tegi

es

Man

agem

ent s

trate

gies

Cat

egor

y of

ski

n te

ar/s

, siz

e, lo

catio

n,

tissu

e ty

pe, e

xuda

te,

surr

ound

ing

skin

Pro

gres

s an

d ou

tcom

e of

inte

rven

tions

Ris

k fa

ctor

s fo

r a

Ski

n Te

ar

Doc

umen

t

heal

thy

skin

Cham

pions

for S

kin I

ntegr

ity

pro

moting

CR

ICO

S N

o. 0

0213

J

© QUT 2013 17812

Cat

egor

y 1a

A s

kin

tear

whe

re th

e ed

ges

can

be re

alig

ned

to th

e no

rmal

an

atom

ical

pos

ition

(with

out

undu

e st

retc

hing

) and

the

skin

or

fl ap

col

our i

s no

t pal

e,

dusk

y or

dar

kene

d.

Cat

egor

y 1b

A s

kin

tear

whe

re th

e ed

ges

can

be re

alig

ned

to th

e no

rmal

an

atom

ical

pos

ition

(with

out

undu

e st

retc

hing

) and

the

skin

or

fl ap

col

our i

s pa

le, d

usky

or

dark

ened

.

Cat

egor

y 2a

A s

kin

tear

whe

re th

e ed

ges

can

not b

e re

alig

ned

to th

e no

rmal

an

atom

ical

pos

ition

and

the

skin

or

fl ap

col

our i

s no

t pal

e, d

usky

or

dar

kene

d.

Cat

egor

y 2b

A s

kin

tear

whe

re th

e ed

ges

can

not b

e re

alig

ned

to th

e no

rmal

ana

tom

ical

pos

ition

and

th

e sk

in o

r fl a

p co

lour

is p

ale,

du

sky

or d

arke

ned.

Cat

egor

y 3

A s

kin

tear

whe

re th

e sk

in fl

ap

is c

ompl

etel

y ab

sent

.

Ski

n Te

ar A

udit

Res

earc

h (S

TAR

). S

ilver

Cha

in N

ursi

ng A

ssoc

iatio

n an

d S

choo

l of N

ursi

ng a

nd M

idw

ifery

, Cur

tin U

nive

rsity

of T

echn

olog

y. R

evis

ed 4

/2/2

010

Provide

d for

inform

ation

only

-

Contac

t HIU

@he

alth.q

ld.go

v.au

85

Art

eria

l Leg

Ulc

er F

low

Cha

rt

heal

thy

skin

Cham

pions

for S

kin I

ntegr

ity

pro

moting

Ass

essm

ent

Wou

nd B

ed M

anag

emen

tM

anag

emen

tP

reve

ntio

n

Ref

eren

ces:

Sco

ttis

h In

terc

olle

giat

e G

uide

lines

Net

wor

k, D

iagn

osis

and

man

agem

ent o

f per

iphe

ral a

rter

ial

dis

ease

. 200

6, E

dinb

urgh

: SIG

N •

Hop

f H e

t al.

Gui

delin

es fo

r the

trea

tmen

t of a

rter

ial i

nsuf

fi cie

ncy

ulce

rs. W

ound

Rep

Reg

en, 2

006.

14

(6):6

93-7

10 •

Nat

iona

l Clin

ical

Gui

delin

e C

entr

e, L

ower

lim

b p

erip

hera

l art

eria

l dis

ease

. Dia

gnos

is a

nd m

anag

emen

t. N

ICE

Clin

ical

Gui

delin

e 14

7, 2

012:

Lon

don

•

Hop

f H e

t al.

Gui

delin

es fo

r pre

vent

ion

of lo

wer

ext

rem

ity a

rter

ial u

lcer

s. W

ound

Rep

Reg

en, 2

008.

16

(2):1

75-1

88 •

RN

AO

, Ass

essm

ent a

nd m

anag

emen

t of f

oot u

lcer

s fo

r p

eop

le w

ith d

iab

etes

. 200

5

This

pro

ject

is fu

nded

by

the

Aus

tral

ian

Gov

ernm

ent D

epar

tmen

t of H

ealth

and

Age

ing

unde

r the

Enc

oura

ging

Bet

ter P

ract

ice

in A

ged

Car

e (E

BPA

C) p

rogr

am

His

tory

• M

edic

al

• M

edic

atio

ns•

Wou

nd

• P

sych

osoc

ial /

act

iviti

es o

f dai

ly li

ving

Char

acte

rist

ics

of t

he

wou

nd (s

ee ta

ble

bel

ow)

Dia

gnos

tic

inve

stig

atio

ns

All

patie

nts

with

a le

g ul

cer s

houl

d be

scr

eene

d

for a

rter

ial d

isea

se, i

nclu

ding

an

Ank

le B

rach

ial

Pre

ssur

e In

dex

(AB

PI)

* A

sses

smen

t sho

uld

only

be

unde

rtak

en b

y a

trai

ned

heal

th p

rofe

ssio

nal A

rter

ial l

eg u

lcer

s ty

pic

ally

:

• Occ

ur o

n th

e an

terio

r shi

n,

ankl

e bo

nes,

hee

ls o

r toe

s

• Hav

e pa

in w

hich

is re

lieve

d

whe

n le

gs a

re lo

wer

ed b

elow

th

e le

vel o

f the

hea

rt

• Hav

e ‘p

unch

ed o

ut’

wou

nd e

dges

• May

hav

e m

umm

ifi ed

or d

ry

and

blac

k to

es

The

surr

oundin

g sk

inor

tis

sue

ofte

n h

as:

• Shi

ny o

r dry

ski

n

• Dev

italis

ed s

oft t

issu

ew

ith d

ry o

r wet

cru

st

• Thi

cken

ed to

e na

ils

• A p

urpl

ish

colo

ur w

hen

the

leg

is lo

wer

ed to

the

grou

nd

• Los

s of

hai

r

• Coo

l ski

n

• C

lean

se th

e w

ound

gen

tly w

ith w

arm

w

ater

or n

orm

al s

alin

e. P

at d

ry.

• In

gen

eral

, deb

ride

necr

otic

or

devi

talis

ed ti

ssue

: how

ever

, do

not

debr

ide

dry

gang

rene

or e

scha

r

* D

ebrid

emen

t sho

uld

be u

nder

take

non

ly b

y a

trai

ned

heal

th p

rofe

ssio

nal

• M

aint

ain

a m

oist

wou

nd e

nviro

nmen

t, ho

wev

er, i

f dry

gan

gren

e or

esc

har i

s pr

esen

t, it

is b

est l

eft d

ry

• To

pica

l ant

imic

robi

al d

ress

ings

may

be

bene

fi cia

l whe

n w

ound

s ar

e ch

roni

cally

or

hea

vily

col

onis

ed

• P

rom

ote

oxyg

enat

ion

thro

ugh

avoi

danc

e of

: -sm

okin

g -de

hydr

atio

n -co

ld -st

ress

and

pai

n

• R

efer

to v

ascu

lar s

urge

on fo

r re

stor

atio

n of

blo

od fl

ow b

y re

vasc

ular

isat

ion,

if a

ppro

pria

te

• En

sure

opt

imal

pai

n m

anag

emen

t st

rate

gies

• R

educ

e ris

k fa

ctor

s: -ce

ase

smok

ing

-co

ntro

l dia

bete

s m

ellit

us -co

ntro

l ele

vate

d lip

ids

-co

ntro

l hyp

erte

nsio

n -an

ti-pl

atel

et th

erap

y -co

ntro

l wei

ght

• R

efer

to v

ascu

lar s

urge

on fo

r as

sess

men

t if a

ppro

pria

te

• E

xerc

ise

the

low

er li

mbs

• P

rote

ct le

gs a

nd fe

et:

-en

sure

sof

t, co

nfor

min

g,pr

oper

fi tti

ng s

hoes

- re

fer t

o po

diat

rist f

or g

ener

al fo

otca

re,

orth

odic

s an

d of

fl oad

ing

as n

eces

sary

- pr

otec

t leg

s (e

.g. p

adde

d eq

uipm

ent,

long

clo

thin

g) -us

e pr

essu

re re

lief d

evic

es e

.g. h

igh

dens

ity fo

am o

r air

cush

ion

boot

s fo

r th

ose

with

lim

ited

mob

ility

• K

eep

the

legs

war

m (e

.g. s

ocks

, rug

s)

• Ea

t a n

utrit

ious

die

t• u

ncer

tain

ty o

f di

agno

sis

• a lo

w A

BP

I < 0

.8 o

r a

high

AB

PI >

1.2

• sym

ptom

s im

pact

on

qual

ity o

f life

• mul

tiple

aet

iolo

gy

• sig

ns o

f inf

ectio

n

• ulc

er a

ppea

rs

isch

aem

ic

• fai

lure

to h

eal

Cha

ract

eris

tics

of a

n A

rter

ial L

eg U

lcer

Whe

n to

Ref

er

CR

ICO

S N

o. 0

0213

J

© QUT 2013 17812

Provide

d for

inform

ation

only

-

Contac

t HIU

@he

alth.q

ld.go

v.au

86

Veno

us L

eg U

lcer

Flo

w C

hart

heal

thy

skin

Cham

pions

for S

kin I

ntegr

ity

pro

moting

Ass

essm

ent

Wou

nd B

ed M

anag

emen

tM

anag

emen

tP

reve

ntio

n

Ref

eren

ces:

AW

MA

, Aus

tral

ian

and

New

Zea

land

Clin

ical

Pra

ctic

e G

uid

elin

es fo

r P

reve

ntio

n an

d M

anag

emen

t of V

enou

s Le

g U

lcer

s, 2

011,

AW

MA

: Bar

ton.

AC

T •

RC

N, T

he

man

agem

ent o

f pat

ient

s w

ith v

enou

s le

g ul

cers

, 200

6, R

CN

: Lon

don

• R

NA

O,

Ass

essm

ent a

nd M

anag

emen

t of V

enou

s Le

g U

lcer

s, 2

004,

RN

AO

: Tor

onto

•

SIG

N, M

anag

emen

t of c

hron

ic le

g ul

cers

, 201

0, S

IGN

: Edi

nbur

gh

This

pro

ject

is fu

nded

by

the

Aus

tral

ian

Gov

ernm

ent D

epar

tmen

t of H

ealth

and

Age

ing

unde

r the

Enc

oura

ging

Bet

ter P

ract

ice

in A

ged

Car

e (E

BPA

C) p

rogr

am

Venou

s le

g ulc

ers

typic

ally

Occ

ur o

n th

e lo

wer

third

of t

he le

g

Hav

e pa

in u

sual

ly re

lieve

d by

el

evat

ion

of th

e le

gs a

bove

hea

rt le

vel

Are

sha

llow

and

hav

e irr

egul

ar,

slop

ing

wou

nd m

argi

ns

Pro

duce

mod

erat

e to

hea

vy e

xuda

te

• M

ultil

ayer

ed h

igh

com

pres

sion

ther

apy

shou

ld b

e ap

plie

d fo

llow

ing

diag

nosi

s of

an

unco

mpl

icat

ed v

enou

s le

g ul

cer

* C

ompr

essi

on th

erap

y sh

ould

onl

y be

app

lied

by a

trai

ned

prac

titio

ner

• C

heck

ank

le c

ircum

fere

nce

mea

sure

s m

ore

than

18c

m

• A

pply

moi

stur

iser

to th

e lo

wer

lim

b

• A

pply

pad

ding

ove

r bon

y pr

omin

ence

s

• A

pply

com

pres

sion

sys

tem

as

per

man

ufac

ture

rs’ g

uide

lines

• R

emov

e ba

ndag

ing

if th

ere

is:

-sl

ippa

ge o

f ban

dage

-de

crea

sed

sens

atio

n of

low

er li

mb

-to

es g

o bl

ue o

r pur

ple,

or l

eg s

wel

ls a

bove

or b

elow

the

band

age

-in

crea

sed

pain

in th

e fo

ot o

r cal

f mus

cle

that

is u

nrel

ieve

d by

leg

elev

atio

n fo

r 30

min

utes

ab

ove

hear

t lev

el

-in

crea

sed

shor

tnes

s of

bre

ath

or d

iffi c

ulty

br

eath

ing

• M

onito

r P

rogr

ess:

Tra

ce w

ound

bef

ore

star

ting

com

pres

sion

ther

apy,

then

eve

ry 2

–4 w

eeks

, or

whe

n ra

pid

chan

ges

occu

r

• U

se o

f com

pres

sion

sto

ckin

gs fo

r life

re

duce

s le

g ul

cer r

ecur

renc

e (C

lass

3

(40m

m H

g) if

tole

rate

d, o

r hig

hest

leve

l to

lera

ted

)

* A

trai

ned

prac

titio

ner s

houl

d fi t

com

pres

sion

sto

ckin

gs

• R

epla

ce c

ompr

essi

on s

tock

ings

eve

ry6

mon

ths

• P

rovi

de e

duca

tion

to c

lient

s an

d ca

rers

on c

ompr

essi

on s

tock

ing

appl

icat

ion

and

rem

oval

tech

niqu

es

• R

efer

to v

ascu

lar s

urge

on if

app

ropr

iate

• M

onito

r reg

ular

ly, e

very

3 m

onth

s

• A

pply

moi

stur

iser

twic

e da

ily

• El

evat

e th

e af

fect

ed li

mb

abov

e he

art

leve

l dai

ly

• En

cour

age

ankl

e an

d ca

lf m

uscl

e ex

erci

ses

• R

epea

t Dop

pler

AB

PI e

very

3 m

onth

s, o

r w

hene

ver c

hang

ing

the

type

of c

ompr

essi

on

ther

apy

Cha

ract

eris

tics

of a

Ven

ous

Leg

Ulc

er

Whe

n to

Ref

er

CR

ICO

S N

o. 0

0213

J

© QUT 2013 17812

His

tory

• M

edic

al

• M

edic

atio

ns•

Wou

nd

• P

sych

osoc

ial /

act

iviti

es o

f dai

ly li

ving

Char

acte

rist

ics

of t

he

wou

nd (s

ee ta

ble

bel

ow)

Dia

gnos

tic

inve

stig

atio

ns:

• A

ll pa

tient

s w

ith a

leg

ulce

r sho

uld

be

scre

ened

for a

rter

ial d

isea

se, i

nclu

ding

an

Ank

le B

rach

ial P

ress

ure

Inde

x (A

BP

I)*

• R

eass

ess

the

AB

PI e

very

3 m

onth

sor

if c

linic

ally

indi

cate

d

* Com

pres

sion

ther

apy

is c

ontra

indi

cate

dif

the

AB

PI

is <

0.8

or >

1.2

* A

sses

smen

t sho

uld

only

be

unde

rtak

enby

a tr

aine

d he

alth

pra

ctiti

oner

• Irr

igat

e w

ith w

arm

wat

er o

r nor

mal

sal

ine.

Pat

dry

• C

lean

the

wou

nd g

ently

(a

void

mec

hani

cal t

raum

a)

• R

emov

e ne

crot

ic o

r dev

italis

ed ti

ssue

(e.g

. aut

olyt

ic d

ebrid

emen

t)*

• EM

LA® c

ream

can

redu

ce p

ain

asso

ciat

ed

with

deb

ridem

ent

* M

echa

nica

l or s

harp

deb

ridem

ent s

houl

don

ly b

e do

ne b

y a

trai

ned

prac

titio

ner

• S

elec

t a d

ress

ing

that

will

: -m

aint

ain

a m

oist

wou

nd b

ed -m

anag

e w

ound

exu

date

-pr

otec

t the

sur

roun

ding

ski

n

The

surr

oundin

g sk

inof

ten h

as:

Hae

mos

ider

in (b

row

n) s

tain

ing

Hyp

erke

rato

sis

(dry

, fl a

ky s

kin)

Veno

us s

tasi

s ec

zem

a

Inve

rted

cha

mpa

gne

bottl

e le

g ap

pear

ance

Unc

erta

inty

in d

iagn

osis

Com

plex

ulc

ers

(m

ultip

le a

etio

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88

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