Participate in the Implementation of Individualised Care Plans

Aims and Objectives Plan work activities according to an

individualised plan Establish and maintain appropriate

relationships with clients and carers Provide and monitor support according to the

individualised plan Contribute to ongoing relevance of the

individualised plan Respond to situations of risk to the client

within work role and responsibilities Complete documentation and reporting

Planning work activities

Organisational policies and procedures Policies set out the general standards of

service for that agency to achieve- must be accessible to all staff, clients and other interested parties.

Procedures are specific written instructions that explain what a staff member is to do, step by step in a particular situation.

It is YOUR responsibility to be familiar with the P & P within your work

Individualised Plans Also called Care Plans, Service plans, Client

plans. A care plan is an individualised plan of care

and gives directions for staff to follow in the provision of care.

The plan details the care requirements that a person needs on a daily basis. This type of document is generally used in long term care because it replaces the need to detail all care given each day in the resident’s case notes.

Individualised Plans Provide an accurate, concise notation of

the residents’ current condition. The care plan provide information about

the resident’s goals and care needs. The care plan is a recipe about how the

care needs to be provided. The notes provide baseline information

on which to record any improvement or deterioration in the resident’s condition.

Individualised plans The record provides evidence of care. The records will

provide information about what care was provided, by whom, when and any comments from the resident, doctor, or significant other.

The care plan is a dynamic document, meaning that it changes regularly dependent on the needs and changes in the resident. It should be used and reviewed on a regular basis. The care plan is a care tool to direct and guide staff in how the care needs to be provided to the resident.

Care plans need to be individually tailored to the care needs of the individual, there is no magic formula to suit all residents, however there are some basic guidelines which you can follow in order to formulate the care plan.

The Nursing Process and Care Planning Assessment Planning Implementation Evaluation

Assessment Observation of their needs by sight, hearing,

touch and smell • Communication with other members of

the team to make accurate assessment of the care needs of the resident. Sometimes care workers need to provide different care activities to the same resident. Either because the resident favours a particular care worker of that the worker has expert knowledge.

Assessment A thorough assessment must be compiled in a

variety of areas to determine the long term care needs and goals of client care. Areas of assessment include the following:

Physical care needs Psychological care requirements Socialisation needs of the individual Spiritual needs Assistance to maintain their personal affairs Relationships with family and others

Assessment forms currently used

Personal profile Communication Assessment Social and emotional needs

assessment Nutrition and Hydration

Assessment Mobility Assessment

including falls risk and manual handling assessments

Personal hygiene assessments, physical assessments oral hygiene assessments

Toileting assessments

Continence assessments Bladder and bowel

Psychogeriatric Assessment scale (PAS)

Behaviour Assessment – Verbal, Wandering, Physical agitation

Cornell depression scale Medication Assessments Complex care needs

Assessments – Pain scales, Waterlow scale for skin integrity, diabetes Assessment etc

Planning Once the assessment is completed goals of

care need to be developed. The goals determine whether a client will be able to restore or maintain their current level of care. The goal of care may be to improve the person’s current ability or simply to preserve their current function and level of independence.

 

Sample Care Plan Impaired Verbal Communication Identified need/Problem: Impaired verbal communication related to: Decreased oxygen to the brain. Unable to speak English Impaired articulation. Disorientation. Loose association of ideas, Inability to speak sentences. Slur or stutter.

Sample care plan Goal: Resident will communicate and

participate in activities of daily living using either verbal or non verbal modes.

Assess contributing factors. Note whether the problem is expressive (loss of speech), Sensory (unable to understand words, Conduction (slow comprehension) or Global (loss of comprehension and speech).

Implementation The nurses actions Like a written handover, how

everyone should be carrying out the care.

Ensures that everyone is doing the same level of care

Sample care plan Interventions:

• Determine native language spoken and cultural background. Assist patient to establish means of communication. Listen carefully to patient on verbal expressions. Validate meaning of non-verbal communication. Maintain eye contact. Keep communication simple. Plan for alternative methods of communication (written instructions

or picture boards). Maintain a calm unhurried manner- allowing time for the resident to

respond.

Evaluation This includes your monthly, two

monthly evaluation of how the person r the care is meeting their goals and preferences

It assists to determine if the staff are meeting the needs of the client.

Evaluation See ACFI Checklists

What are the Care Worker responsibilities READ the individualised care plans Evaluate them regularly Input into the care plans from your

individual knowledge of the client Contribute to case conferences

and feed back the effective actions you use

Appropriate relationships with clients

Communication Introducing yourself With client With staff With management With relatives and friends Documentation

Introducing yourself Be polite. Use open communication skills. Be genuine in your motivation. Provide name, position and the task you

want to carry out. Wait until you have consent. Respect the person’s right to refuse. Check your own emotions, feelings,

frustrations before you enter the room.

Communication with clients Respect basic human rights Be approachable Sometimes need to make the first move to

communicate Develop a trusting relationship Clear, calm, open language and body

language. Be culturally sensitive. Allow clients to make as many decisions as

they can.

Communication with staff Be understanding of the mood/stress of

other staff Be willing to work with them Use the “power with” not the “power

over” principle Be willing to learn from others, instead

of right every time. Work cooperately, plan and talk all shift.

Communication with Management Understand that reporting on is part of

your job role. Find convenient times to report. How urgent is the incident/ problem? Give your opinion in an appropriate

setting. Be respectful of the position your

manager holds. Provide clear communication or written

documentation.

Appropriate relationships with carers

Communication with Relatives and Friends Find out the policy on what you

can communicate and who can communicate the information.

Develop a rapport with relatives but do not breach confidentiality.

Communicate what your job role allows but do not communication information outside of your scope of practice.

Confidentiality and Privacy Personal information, which is obtained while caring

for a client, is confidential. The client has the right to decide who to share this information with. Confidentiality applies to information that a client or other care worker tells you verbally or gives you in writing. It also applies to things that you learn through observation. All information in a person’s health care record is confidential and may not be disclosed without permission from the client or their guardian. Information may be shared with other relevant health and aged care workers when they need the information in order to provide appropriate care.

Maintaining ConfidentialityA carer has a moral duty and often legal obligation to protect the privacy of an individual by restricting information obtained in a professional capacity to appropriate personnel and settings, and to professional purposes.

A nurse must, where relevant, inform an individual that in order to provide competent care, it is necessary for a carer to disclose information that may be important to the clinical decision making by other members of a health care team.

A carer must, where practicable, seek consent from the individual or a person entitled to act on behalf of the individual before disclosing information. In the absence of consent, the nurse uses professional judgement regarding the necessity to disclose particular details, giving due consideration to the interests, well–being, health and safety of the individual and recognising that the carer is required by law to disclose certain information.

Privacy In the context of Aged care and

Health care privacy means discretion and secrecy

Appropriate conversation Need to socially appropriate at all time. Need to direct your conversation at the

clients needs or carers needs- NOT YOUR OWN.

Do not swear, complain, or give out personal or sensitive information.

Be friendly with your work mates but remember they are not your best friend.

Do not reveal personal information to colleagues.

Supporting Independence

Contributing to the individualised plan

Problem solving skills 1. Define the problem

2.Generate Ideas

3. Investigate solutions

4. Choose an option

5.Plan to act

6. Evaluation

Use the problem solving technique to solve the following problem The co-worker that you are teamed with

likes to spend time talking to the clients, and leaves you the bulk of work.

It also means that you have trouble getting to know the clients you work with.

What could you, and your work team, do to resolve this situation?

Identifying risks to the client

Providing care Assessment

Observation Questioning Consultation Medical History Physical ability Lifestyle choices Family history and

dynamics Past experiences Social contacts

Risk Assessment

Scope of Practice

Role of an Aged Care Worker Multi skilled Flexible in work practices in care delivery Work as part of the multi-disciplinary

team Participate in planning & delivery of care Abide by the mission statement & job

description Responsibilities include- OHS,

documentation, provision of care.

Role & Responsibility To observe (collect physical data) the

patient; Report to supervisor/ RN any change in a

pts condition; Other areas the AIN is responsible for

reporting include: equipment faults, safety hazards, need for supplies, incidents/ accidents, breaches in confidentiality, absences from duty/ breaches in duty of care- abuse.

What is expected of you as an AIN

Fulfils the duties of the job description

Technical skills (i.e.. BP) communication skills (interaction with staff & clients)

Time management Team work Documentation skills

Personal attributes Conscientious Trustworthy Patient Thorough cooperative Respectful Caring Honest

Accurate Empathetic Reliable Flexible Organised Adaptable Flexible Passionate

Duty of Care

Rights of workers Safe work

environment Free from

harassment and discrimination

Work conditions and wages in accordance with IR laws

EEO

Accountability & Responsibility Duties as per job description Completion of specific tasks at the

required standard in a reasonable time frame.

Accountable means you are answerable for the things you do.

Who are you accountable and responsible to?

Activity Think of an organisation you know

and develop an Organisational chart which indicates who you report to.

Reporting to your Supervisor Be professional – Provide accurate Data eg: results from tests: UA Provide objective not subjective reporting Be proactive and seek a time to talk to your

Supervisor that is convenient. Allow that the Supervisor, while knowing your role,

may not be aware of every part of the job. When reporting provide some solutions that will work. Document your concerns so the Supervisor has

something to work from. Carry out the instructions you are given and report

back their results.

Reporting inappropriate behaviour

Clients Use data collected over time, Relate specific incidents or

behaviours of concern Report the time frame of the

behaviour Report any triggers of the

behaviour Use a non judgmental

approach Always maintain

confidentiality

Colleagues Provide accurate

information Be non judgmental when

reporting Provide time and location

incidents take place Always report privately Have an incident report

written out so the the Supervisor has all the facts

Incident reporting

Completing Documentation

Care Records Also known as:

Case notes Client file Residents notes

Commenced on admission

The purpose is: Centralised record for

all to document About care Information about the

client

Information contained in the care record

Progress notes Observation charts Care Plans Admission, discharge and transfer

notes Medical history and doctors notes

Progress notes Ongoing record of

the older persons day to day care and progress

Must document only facts, not interpretations of events

Progress notes: Ensure quality Assist when

making assessment

Ensures the worker works within the care plan

Continuity of care

Accountability Evaluating care The process of

reflecting, monitoring and improving care delivery

Guidelines for report writing Must be written on

all clients at least once a day

Plus exception report writing

The report must contain the time and date, must be signed and designation recorded

Report writing Permanent

records Factual Accurate Legible using

black or blue ink Use professional

language Be brief, simple

and to the point

Principles of report writing Record promptly or

ASAP after event has occurred

Use the 24 hour clock Only use approved

abbreviations Correct spelling and

grammar Do not leave any

spaces

Check previous entries

Make corrections properly

Rule a line through the error

Write the correction and initial your entry

Do not erase or use whiteout

Ensure the original entry can be read

Case scenario You have just finished caring for Mrs. Jones

You have showered her and she dressed herself She was happy and chatty You noticed a red spot on her lower R leg She ambulated into the bathroom with a PUF She ate a small amount of breakfast and is now

sitting in the lounge room Document in the progress notes

Confidentiality and access to records Client notes are

confidential and access is restricted to:

The storage of records must be locked to maintain confidentiality

Designated staff The clients ensuring

someone is with them e.g.. RN when they read their notes

Refer to Policy and Procedure of facility

Reasons for documentation Legal requirement Funding Management systems, staffing and

development Resident lifestyle Physical environment and safe

systems

Types of documentation Observation chart Bowel chart FBC Accident forms Care Plans Admission data Restraint charts Complaints form

Accident/Incident forms Legal requirement Identifying risks Hazard control Monitoring

behavioural trends

Monitoring work practices

Case Scenario You discover Mrs. Campbell lying on the bathroom

floor at 1650 hours You left her sitting by her bed 5 minutes previously She has sustained a skin tear 3cm to her L forearm

and has a bruise on her R knee You stay with the client and buzz for assistance The RN arrives and asks you to record a set of obs,

dress the skin tear and complete an incident form The RN contacts the DR and Mrs. Campbell's

daughter Complete the form

Verbal reports Given at the start

of each shift – handover or changeover

Staff finishing should also report any tasks or care not completed

Group Work Break into 5 groups List 4 changes you might observe when

caring for a client Each group to pick 1 system and report

back to the group Integumentary system Circulatory system Urinary system Digestive system Musculoskeletal system