Hip Fracture Patients with Dementia and

Delirium: Development of Clinical Pathway &

Nursing Assessment Tool at The Wesley

Private Hospital

Maretta Vincart

Clinical Nurse Educator

Established in 1977

ORTHOPAEDICS

2 Orthopaedic Wards

69 dedicated Orthopaedic

beds TOTAL NUMBER OF

ORHOPAEDIC SURGERIES

2012 = 4,108

2013 (sept) = 2,981

Fracture - Neck of Femur

Time Frame

Jan to Dec 12 Jan to Sept 13

Specific Area # Patients # Patients

Fracture of neck of femur, part

unspecified 12 6

Fracture of intracapsular section of

femur 2 0

Fracture of upper epiphysis

(separation) of femur 0 0

Fracture of subcapital section of

femur 63 44

Fracture of midcervical section of

femur 0 4

Fracture of base of neck of femur 6 2

Fracture of other parts of neck of

femur 22 14

Total 105 70

• High risk patients

• Assessment limitations

• Documentation

• Staff knowledge /

experience

INVESTIGATE CURRENT PRACTICE

COMPARE IT TO EVIDENCE BASED PRACTICE

MODIFY PAIN ASSESSMENTS / CARE PATHWAYS

IMPROVE NURSING CARE AND ASSESSMENT

Complications associated with dementia

Source: Australian Institute of Health and Welfare, Dementia in Australia , 2012.

Dementia rates

Estimated number of people with dementia

People with dementia, selected years 2005–2050

Source: Australian Institute of Health and Welfare, Dementia in Australia , 2012.

These patients are at risk for

•Falls

•Pressure injuries

•HAI’s

•Medication errors

•Loss of fitness

•Prolonged LOS

•Increased risk of re-admission

DELIRIUM

Patient History

Family Name:_________________________ MR/UR: _____________

Given names: _____________________________________________

Address: _________________________________________________

Postcode: ___________________ DOB: ______________________

Doctor: __________________________________________________

(or please affix Patient Identification Label here)

SPECIAL / CULTURAL NEEDS STAFF ONLY

Primary Language Interpreter Required Arrange Interpreter

Other Specific Needs:

ALL CARE BUT NO RESPONSIBILITY TAKEN FOR VALUABLES / PERSONAL BELONGINGS KEPT WITH PATIENTS Kept at

own risk Taken home

by: (Sign)

Visual Aids Glasses Contact Lenses Eye Prosthesis Record on

Falls Assessment

Walking Aids Specify: __________________________________________________

Hearing Aids Left Right

Dentures Upper Partial Full

Lower Partial Full

DISCHARGE PLANNING Name & Suburb of GP

Do you live in a: House Unit/Flat Retirement Village Hostel Nursing Home Discuss possible post discharge needs with patient / carer

Refer to Discharge Planning Referral Guidelines

Notify Discharge Planner, if applicable

Date: ____ / ____ / ____

Discuss Discharge Time of 10am with patient / carer

Live alone?

If yes, who will care for you on discharge Name:

Is this person in good health and able to assist

Caring for someone else?

Have problems caring for yourself ? Specify:

Currently use any community services?

Which services? Nursing Home Help Meals

Discharge time is by 10am. Can someone collect you by this time?

Transport required – Documented in notes

If not, how do you plan to get home? _________________________________

ENDURING POWER OF ATTORNEY / ADVANCE HEALTH DIRECTIVE

Advance Health Directive Please provide us with a copy File copy in record

Enduring Power of Attorney (Name & Phone No if applicable)

PATIENT OR CARER SIGNATURE

I CERTIFY THAT THE INFORMATION GIVEN IS CORRECT TO THE BEST OF MY KNOWLEDGE.

NAME (PRINT) DATE: ____/____/____

SIGNATURE RELATIONSHIP TO PATIENT IF NOT COMPLETED BY PATIENT

STAFF ONLY: PREADMISSION ASSESSMENT ATTENDED BY: NAME (PRINT)

SIGN: DATE: ___/___/___

HISTORY REVIEWED AND/OR COMPLETED ON ARRIVAL IN WARD / UNIT:

CONDITION AT TIME OF REVIEW

POST OPERATIVE Yes No (If Yes, no further action. If No, complete assessment below)

PHYSICAL APPEARANCE: NAD Pale/Sweating Dyspnoeic Cyanotic Other: ______________

MENTAL STATUS: Orientated Vague Confused Other: ______________

EMOTIONAL STATUS: Calm Somewhat Distressed Very Distressed Other: ______________

NAME (PRINT) SIGNATURE

DESIGNATION WARD / UNIT DATE: ____/____/____

Patient History & Nursing Assessment

NEUROLOGY Specialist/s

Stroke / TIA When:

Any Residual weakness? Where:

Epilepsy Last Fit:

Parkinson’s Disease

Fits / faints / “funny turns” When:

Speech / swallowing problems Specify:

Cough or choke when eating or drinking

A fall or falls within the last 6 months How often:

Difficulty walking / unsteady on feet

Short term memory loss / dementia Specify:

GENERAL HEALTH & WELLBEING

How much do you weigh _________ kg

How tall are you ________cm ________ feet / ins

Had previous blood clots

Smoke ________ per day

If no, have you smoked in the past When Ceased:

Drink alcohol _________ standard drinks / day

Have pain Where:

Disturbed sleep patterns / Sleep apnoea Sedation CPAP

Have a mental health condition Specify:

Diagnosed with anxiety and/or depression Specify:

Would you like to speak to a Chaplain

Family Name: ________________________ MR/UR No: _______________

Given names: ___________________________________________________

Address: _______________________________________________________

Postcode: ___________________________ DOB: ____________________

Doctor: _________________________________________________________

(or please affix Patient Identification Label here)

FALLS RISK SCREEN

INSTRUCTIONS

Complete on admission.

Complete Falls Risk Monitoring Form (Page 4) 3rd

Daily or with any change in patients condition

CATEGORY CRITERIA YES NO

1. AGE Age 65 years or over

2. HISTORY History of, or admission diagnosis related to, falls or seizures

3. DIAGNOSIS For or post surgery or post Epidural anaesthetic.

IV Therapy, Drains, Catheters. Hb < 90, Stroke, TIA, CCF, Oncology, Orthopaedic;

4. MENTAL

STATUS

Disorientation, confusion; agitation

History of dementia: impaired memory; vague; unable to follow instructions

5. SENSORY Significantly impaired sight or sensation (pain)

6. MOBILITY IV/s, drain/s, telemetry, catheter/s in situ (or for insertion within next 24/24)

Impaired co-ordination / unsteady gait; limb weakness; prolonged bed rest; uses aid;

7. MEDICATIONS 4 or more medications OR

One or more of the following medications

O sedatives (including benzodiazepines)

O narcotic O analgesia O diuretics O anti-parkinsons

8. CONTINENCE Incontinence; change in continence status eg. removal of catheter, urgency / frequency / nocturia / recent aperients

A “YES” response to any of the above criteria indicates that the patient is “AT RISK” of falling

Initiate Appropriate Falls Prevention Strategies as identified on Nursing Risk Monitoring Form( Page 4)

Identify on Clinical Pathway or Nursing Care Record

REFER TO: ‘Falls Risk Assessment & Management’ Policy (Nursing Policy 3.03) & Falls Assessment & Guidelines.

VENOUS THROMBOEMBOLISM (VTE) RISK ASSESSMENT INSTRUCTIONS: THIS IS A GUIDE ONLY. IF UNSURE PLEASE CONSULT TREATING VMO.

More than one (1) criteria may be selected A positive response indicates the patient is at ‘High Risk’ of VTE

Refer: Standing Orders - mechanical prophylaxis Document in Patient Record using VTE Sticker

GENERAL CRITERIA

Ischaemic stroke Impaired mobility History of VTE or PE

Actively treated Cancer SOB at rest or little exertion Respiratory Failure

Exacerbation of respiratory disease Rheumatoid arthritis Systemic Lupus

Age > 60 years Obesity Thrombophilia

Oestrogen therapy Pregnancy Puerperium

ADDITIONAL CRITERIA FOR SURGICAL PATIENTS

Hip or knee arthroplasty Major trauma Hip fracture surgery

Major abdominal surgery age > 40 yrs Any surgery > 45 mins duration

VTE STICKER COMPLETED AND PLACED IN PROGRESS NOTES MALNUTRITION SCREENING ASSESSMENT © - Tick appropriate boxes and add for the total score

A. Have the patient lost weight recently without trying?

B. How much weight has the patient lost?

C. Has the patient been eating poorly due to decreased appetite?

Total Score

Yes go to question B. 0.5 – 5.0kg Score 1 No Score 0

No go to question C. 5.1 – 10.0kg Score 2

If Score is 2, refer to

Nutrition Dept Ext. 7435

Unsure Score 2 go to question C

10.1 – 15kg Score 3 Yes Score 1

Over 15kg Score 4

Unsure Score 2

NAME (PRINT) SIGN DATE ___/___/___

Admission Risk Assessments

Ad

mis

sio

n R

isk A

ssessm

en

ts

W 1

81

.00

• Initial assessment

• Cognitive assessment and

documentation

• Pain assessment tool not

suited to cognitively impaired

patients.

Family Name: _____________________ MR/UR: ______________

Given names: ___________________________________________

Address: _______________________________________________

Postcode: ______________ DOB: _________________________

Doctor: ________________________________________________

(or place Patient ID Label here)

Patients RELATIVE or CARER to complete

We value your input and involvement in your friend/relatives care. Can you please take a few minutes to answer the following questions to ensure we have all the

information necessary to provide the best care possible.

1. Does your relative/friend have any communication difficulties? (e.g cannot say what they want or have

trouble understanding information)

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

2. Does your relative/friend display any particular behaviours when they are experiencing discomfort or

pain?

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

3. Does your relative/friend have any special food requirements, likes or dislikes?

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

4. What are your relative/friend usual sleeping habits? (e.g. bed time, waking time, special blankets,

position, routines etc)

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

5. What are their usual hygiene habits? (e.g. showering, bathing, shaving, toileting, continence, denture

management etc)

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

If possible, could you please bring in some personal items of comfort (e.g. toiletries,

photos, books etc) so that we can reassure and create a familiar environment for

your relative or friend.

Carer Communication

Does your relative/friend have any specific cultural or religious practices?

_________________________________________________________________________

Please list any past hobbies/interests or employment:

_________________________________________________________________________

_________________________________________________________________________

Please provide names of significant others in the table provided below. These could

be individuals that have a significant role or meaning in your friend/relatives life.

These may include family members, special people or pets etc.

NAME RELATIONSHIP FREQUENCY OF CONTACT

ADDITIONAL COMMENTS:

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Name & Relationship of person completing form:

Form reviewed by: Name:___________________ Designation_________________ Ward: ______________

GUIDELINES FOR PAIN

ASSESSMENT FOR PERSONS

WITH COGNITIVE IMPAIRMENT

• Self report

• Painful conditions or treatments

• Observe behaviours

• Surrogate reporting

• Analgesic trial Reference : PAH Behavioural observation chart

• Importance of documentation

implementation to be user friendly

and effective for management of

hip fracture patients.

• Assessment tools to better patient

experience and outcomes.

• Implementation of initial cognitive

assessment (CAM/MINI MENTAL).

• Pathway modification to include

cognitive assessment.

• Implementation of pain assessment

tools suitable for the

confused/delirious/demented hip

fracture patients.

References/Works Cited

Delirium Care Pathways – Risk Factors 2011. Adapted from : Clinical Epidemiology and

Health Services Evaluation Unit 2006, Clinical Practice Guidelines for the Management of

Delirium in Older People, Victorian Government Department of Human Services, Melbourne,

Victoria : http://www.health.gov.au

Merkel S, Voepel-Lewis T, Shayevitz JR, et al:The GLACC: A behavioural scale for scoring

postoperative pain in young children. Pediatric nursing 1997; 23:293-797.

The ACI Orthogeriatric Model of Care 2010, ACI Aged Health Care Network:

http://www.health.nsw.gov.au/gmct

Australian Commission on Safety and Quality in Health Care – Vital Signs 2013: The State of

Safety and Quality in Australian Health Care Commonwealth of Australia 2013.

http://www.safetyandquality.gov.au

BioRICS NV: http://assessmentscales.com/scales/painad

WongBaker Faces Foundation: http://www.wongbakerfaces.org/

Dementia Care Australia Pty Ltd. Website: http://wwww.dementiacareaustralia.com.au

Australian Institute of Health and Welfare. Dementia in Australia 2012

Prince Charles Hospital – Behavioural Observation Chart & Fractured NOF Pathway