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Barbara Acello, MS, RN
NursingDesk
Reference
the LoNg-teRm CaRe
The Long-T
erm C
are Nursing D
esk Reference
Acello
SECOND EDITION
SE
CO
ND
ED
ITIO
N
LTCNDR2
200 Hoods Lane | Marblehead, MA 01945www.hcmarketplace.com
the LoNg-teRm CaRe
Nursing Desk ReferenceBarbara Acello, MS, RN
SECOND EDITION
Solutions and information for virtually every scenario that occurs in your nursing home
Long-term care nurses can rely on this authoritative reference daily. It is packed with practical, need-to-know resident care information, essential policies and procedures, and vital regulatory and safety requirements specific to long-term care.
author Barbara acello, mS, RN, has updated each section of this bestseller with particular attention to hot-button issues such as pain, pressure ulcers, medication administration, infection control, hydration, and nutrition.
this comprehensive reference provides: •Detailedinformationaboutcommonlong-termcareclinicalissues •Valuabletoolsandpracticalinformationabouthundredsofclinical
conditions •Timelyandrelevantupdatesthathelpyoustaycurrent •Onego-toresourceforallyourclinicalneeds
Bonus CD-ROM included!the companion CD-Rom contains vital tools and forms that help nurses save time and effort. these ready-made resources include depression and social adjustment scales, lawsuit prevention checklists, and pain assessment questionnaires.
Also of interest…The Long-Term Care Legal Desk ReferenceLong-Term Care Pocket Guide for Charge NursesClinical Documentation
Barbara Acello, MS, RN
SecoNd editioN
NursingDesk
Reference
the LoNg-teRm CaRe
The Long-Term Care Nursing Desk Reference, Second Edition is published by HCPro, Inc.
Copyright © 2009, 2005 HCPro, Inc.
All rights reserved. Printed in the United States of America. 5 4 3 2 1
ISBN: 978-1-60146-275-6
No part of this publication may be reproduced, in any form or by any means, without prior written consent
of HCPro, Inc., or the Copyright Clearance Center (978/750-8400). Please notify us immediately if you have
received an unauthorized copy.
HCPro, Inc., provides information resources for the healthcare industry.
HCPro, Inc., is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint
Commission trademarks.
Barbara Acello, MS, RN, Author
Adrienne Trivers, Managing Editor
Elizabeth Petersen, Executive Editor
Emily Sheahan, Group Publisher
Jackie Diehl Singer, Graphic Artist
Audrey Doyle, Copyeditor
Adam Carroll, Proofreader
Matt Sharpe, Production Supervisor
Susan Darbyshire, Art Director
Jean St. Pierre, Director of Operations
Advice given is general. Readers should consult professional counsel for specific legal, ethical, or clinical
questions. Arrangements can be made for quantity discounts. For more information, contact:
HCPro, Inc.
P.O. Box 1168
Marblehead, MA 01945
Telephone: 800/650-6787 or 781/639-1872
Fax: 781/639-2982
E-mail: [email protected]
Visit HCPro at its World Wide Web sites:
www.hcpro.com and www.hcmarketplace.com
02/200921629
iiiTh e Lo n g-Te r m Ca r e nu r s i n g De s k re f e r e n C e, se C o n D eD i T i o n © 2009 HCPro, Inc.
Dedication ..................................................................................................................ix
Disclaimers .................................................................................................................x
Introduction ...............................................................................................................xi
Chapter 1: Standards of Practice ..............................................................................1
Standards of Practice .....................................................................................................................1
The Nonnegotiable Nature of the ANA Code for Nurses with Interpretive Statements ..................3
Overview of Standards of Gerontological Nursing Practice ............................................................4
The Nursing Process .....................................................................................................................6
Chapter Resources ........................................................................................................................8
Chapter 2: Personal and Professional Practice Issues ............................................9
Identification Badges .....................................................................................................................9
Protecting Yourself Legally ..........................................................................................................12
Nursing Licensure Board Investigations: Protecting Your Nursing License ..................................20
Employee Injuries .......................................................................................................................23
Ergonomics .................................................................................................................................24
Back Injuries ...............................................................................................................................27
Chapter Resources ......................................................................................................................33
Chapter 3: Assessment ............................................................................................35
Resident Monitoring and Ongoing Care ......................................................................................35
Long-Term Care Facility Laws .....................................................................................................37
Understanding the Inspection Process ........................................................................................38
The Resident Assessment Instrument ..........................................................................................43
Aging Changes ............................................................................................................................48
Admission Nursing Assessment ..................................................................................................49
Physical Assessment of the Geriatric Resident .............................................................................52
Assessing Pain in the Elderly .......................................................................................................54
Contents
Co n T e n T s
iv Th e Lo n g-Te r m Ca r e nu r s i n g De s k re f e r e n C e, se C o n D eD i T i o n© 2009 HCPro, Inc.
Depression ..................................................................................................................................60
Social Adjustment Rating Scale ...................................................................................................60
The Cincinnati Pre-Hospital Stroke Scale ....................................................................................61
Using the Cincinnati Pre-Hospital Stroke Scale ...........................................................................64
Predicting Stroke ........................................................................................................................68
Chapter Resources ......................................................................................................................71
Chapter 4: Pressure Ulcers and Wound Care ........................................................73
Common Steps in All Procedures ................................................................................................73
Risk Factors for Pressure Ulcer Development ..............................................................................76
Pressure Ulcer Stages ..................................................................................................................77
Pressure Ulcer Assessment and Documentation ..........................................................................80
Pressure Ulcer Management ........................................................................................................81
Pressure Ulcer Colonization and Infection ..................................................................................84
Changing Wound Dressings ........................................................................................................88
Wound Pain ................................................................................................................................90
Skin Tears ...................................................................................................................................94
Graduated Compression Stockings ...........................................................................................100
Risk of Tetanus in Pressure Ulcers, Skin Tears, and Chronic Wounds ........................................106
Chapter Resources ....................................................................................................................108
Chapter 5: Planning ...............................................................................................111
The Care Plan ...........................................................................................................................111
Holistic Care .............................................................................................................................116
Maintaining and Improving the Residents .................................................................................117
Assessment ...............................................................................................................................117
Developing the Care Plan ..........................................................................................................119
Additional Assessments and Information ..................................................................................120
Risk Factors ..............................................................................................................................122
Resident Noncompliance and Refusals ......................................................................................123
Developing Realistic Goals ........................................................................................................124
Quarterly Care Plan Reviews .....................................................................................................125
Meeting Residents’ Needs..........................................................................................................125
Making the Plan User-Friendly .................................................................................................125
Chapter Resources ....................................................................................................................126
Co n T e n T s
vTh e Lo n g-Te r m Ca r e nu r s i n g De s k re f e r e n C e, se C o n D eD i T i o n © 2009 HCPro, Inc.
Chapter 6: Clinical Values .....................................................................................127
Dehydration in the Elderly ........................................................................................................127
Preparing a Resident for an MRI ...............................................................................................128
Chapter Resources ....................................................................................................................131
Chapter 7: Medication Administration ................................................................133
Guidelines for Safe Medication Administration .........................................................................133
Medication Errors .....................................................................................................................137
Facts About Polypharmacy .......................................................................................................141
Medication and Treatment Orders .............................................................................................143
Drug-Induced Safety Problems .................................................................................................147
Resident Safety..........................................................................................................................149
Nursing Responsibilities for Managing Pain ..............................................................................150
Effective Pain Management .......................................................................................................154
Overview of Analgesic Therapy in Elderly Adults......................................................................159
Acetaminophen Toxicity ...........................................................................................................163
Antibiotic Administration .........................................................................................................165
Guidelines for Nursing Monitoring and Documentation ...........................................................168
Chapter Resources ....................................................................................................................170
Chapter 8: Intravenous Therapy ...........................................................................173
Intravenous Therapy Guidelines ...............................................................................................173
Complications of IV Therapy ....................................................................................................175
Calculating Intravenous Drip Rates ...........................................................................................178
Chapter Resources ....................................................................................................................179
Chapter 9: Transcultural Nursing .........................................................................181
Cultural Interpretation of Nonverbal Communication and Personal Space ................................181
The Effect of Culture on Family Relationships and Beliefs Regarding Institutionalizing the Elderly .....................................................................................................188
Chapter Resources ....................................................................................................................191
Co n T e n T s
vi Th e Lo n g-Te r m Ca r e nu r s i n g De s k re f e r e n C e, se C o n D eD i T i o n© 2009 HCPro, Inc.
Chapter 10: Infection Control ................................................................................193
Standard Precautions Overview ................................................................................................193
Additional Suggestions to Prevent Contamination.....................................................................200
Mode of Transmission of Pathogens ..........................................................................................202
Infection Control Considerations ..............................................................................................206
Cimex Lectularius (Bedbugs) ......................................................................................................208
Pseudomembranous Colitis ......................................................................................................212
Legionella .................................................................................................................................214
Necrotizing Fasciitis (Streptococcus A) .....................................................................................215
Chapter Resources ....................................................................................................................219
Chapter 11: Hydration and Urinary Elimination .................................................221
Dehydration..............................................................................................................................221
Understanding Hyponatremia and Hypernatremia in Dehydration ...........................................228
Prerenal Azotemia and Acute Renal Failure in Dehydration ......................................................231
Chapter Resources ....................................................................................................................234
Chapter 12: Nutrition .............................................................................................235
Dysphagia .................................................................................................................................235
Weight Loss and Malnutrition ...................................................................................................238
Liberalized Diets .......................................................................................................................242
Guidelines for Weighing Residents ............................................................................................244
Estimating Weight in Residents With Amputations ...................................................................246
Documenting Percentage of Meals Consumed ...........................................................................247
Calorie Counts and Food Intake Studies ...................................................................................251
Determining Calories Needed to Maintain Weight ....................................................................253
Identifying Body Frame Size .....................................................................................................254
Low Serum Cholesterol in the Elderly .......................................................................................255
Chapter Resources ....................................................................................................................256
Chapter 13: Interventions for Common Medical Conditions and Problems ....257
Causes of Delirium in the Elderly .............................................................................................257
Major Forms of Dementia .........................................................................................................261
Co n T e n T s
viiTh e Lo n g-Te r m Ca r e nu r s i n g De s k re f e r e n C e, se C o n D eD i T i o n © 2009 HCPro, Inc.
Falls ..........................................................................................................................................266
Urinary Incontinence ................................................................................................................269
Incidence and Prevalence of Seizures ........................................................................................274
Shock .......................................................................................................................................275
Nursing Management of Postpolio Syndrome ...........................................................................275
Fire Ants and Other Pests .........................................................................................................284
Low Bed Safety .........................................................................................................................288
Facility Noise ............................................................................................................................292
The Yacker Tracker ...................................................................................................................306
Special Populations ...................................................................................................................307
Chapter Resources ....................................................................................................................331
Chapter 14: Behavior Management .....................................................................335
The ABC Plan of Behavior Management ....................................................................................335
Restraints ..................................................................................................................................338
Reducing the Risk for Restraint Complications .........................................................................345
Managing Wandering Behavior .................................................................................................350
Sample Missing Resident Policy and Procedure .........................................................................357
Chapter Resources ....................................................................................................................360
Chapter 15: Emergency Intervention ...................................................................361
Obligation of the Nurse to the Resident in Emergency Situations ..............................................361
Emergency Control of External Hemorrhage .............................................................................362
Maintaining the Resident’s Airway .............................................................................................365
Use of Oxygen in an Emergency ...............................................................................................366
Fires in Resident Rooms ............................................................................................................368
The Safe Medical Devices Act of 1990 .......................................................................................369
Violence Directed at Employees ................................................................................................373
Chapter Resources ....................................................................................................................380
Chapter 16: Restorative Nursing Care .................................................................381
Restorative Nursing Care and the OBRA 1987 Legislation ........................................................381
Immobility ................................................................................................................................393
Co n T e n T s
viii Th e Lo n g-Te r m Ca r e nu r s i n g De s k re f e r e n C e, se C o n D eD i T i o n© 2009 HCPro, Inc.
Caring for Residents After Hip Surgery .....................................................................................394
Normal Joint Range of Motion ..................................................................................................396
Restorative Meal Service ............................................................................................................398
Restorative Approaches to Activities of Daily Living ..................................................................406
Chair and Wheelchair Positioning ............................................................................................407
Wheelchair Mobility .................................................................................................................409
Independence ...........................................................................................................................414
Chapter Resources ....................................................................................................................418
Chapter 17: Nursing Issues in Death and Dying .................................................419
The Patient Self Determination Act ...........................................................................................419
Death Certificates and Cause of Death Statements ....................................................................423
Chapter Resources ....................................................................................................................424
Chapter 18: Documentation ..................................................................................425
Documentation Standards and Guidelines ................................................................................425
Transfer to Another Long-Term Care Facility or Discharge to the Resident’s Home ....................441
Nursing Assessment and Documentation Guidelines ................................................................443
Example Electronic Media Policy ..............................................................................................453
Chapter Resources ....................................................................................................................455
Chapter 19: Lifting and Transferring ....................................................................457
Lifting and Moving: The Mechanical Lift ...................................................................................457
Safety Considerations for Mechanical Lifts ................................................................................462
Mechanical Lift Preventive Maintenance Guidelines ..................................................................467
Recommendations for Infection Control in Sling Use ................................................................468
Back Belts—Do They Prevent Injury? .......................................................................................469
Chapter Resources ....................................................................................................................473
How to Use the Files on Your CD-ROM ...............................................................475
ixTh e Lo n g-Te r m Ca r e nu r s i n g De s k re f e r e n C e, se C o n D eD i T i o n © 2009 HCPro, Inc.
This book is dedicated to the memory of Arnie Silverman, President of Skil-Care Corporation, and Donna L.
Wong, PhD, RN, PNP, CPN, FAAN. These individuals touched my life deeply and provided me with many
years of assistance in enhancing the quality of my numerous publications. Both of these individuals have made
many positive, unselfish, and lasting contributions to long-term care practice. Their untimely passing had a pro-
found impact on my life during manuscript development, and their many contributions are sincerely appreci-
ated and will be sorely missed.
Dedication
x Th e Lo n g-Te r m Ca r e nu r s i n g De s k re f e r e n C e, se C o n D eD i T i o n© 2009 HCPro, Inc.
In addition to the care provided by physicians, some facilities are also fortunate to have the services of advanced
practice nurses (including nurse practitioners and clinical nurse specialists) and physician assistants. These
well-educated and highly qualified individuals provide excellent care to residents in long-term care facilities.
In many situations in this book, we note that physician notification is necessary. We are using the term “phy-
sician” for brevity only. This is not intended to minimize the important work of advance practice nurses and
physician assistants. When the reader is advised to notify the physician, facilities may also notify the advanced
practice nurse or physician assistant, if available, and as required by state law and facility policies. The proce-
dures listed in this book are for example purposes only. Always follow your facility policies and procedures and
physician orders.
The book is meant to be a source of useful reference information on a wide variety of subjects, not a compre-
hensive textbook. It addresses many issues and problems seen in long-term care facilities today. Each section of
the following chapters is meant to be a stand-alone topic, enabling you to quickly reference critical information.
The book is formatted and designed to make the material easy to find. However, because each subject is self-
contained, if the chapters are read sequentially, the sections may seem redundant. Please keep this in mind as
you review the material presented here.
Disclaimers
xiTh e Lo n g-Te r m Ca r e nu r s i n g De s k re f e r e n C e, se C o n D eD i T i o n © 2009 HCPro, Inc.
This book was developed to be a reference guide of up-to-date information that will help you survive and thrive
in the ever-changing long-term care facility environment. It is not meant to be an exhaustive or comprehensive
source of long-term care information, such as a textbook. The book was written using current clinical informa-
tion that is useful to nurses and nursing students and will complement more exhaustive sources of long-term
care nursing reference material.
As an experienced nurse, consultant, and author, I am considered an expert in some areas, including long-
term care. I have been called upon to assist in many long-term care–related lawsuits as an expert witness. An
expert witness assists the attorneys, judge, and jury by explaining technical nursing information and opera-
tional aspects of long-term care. Much of the information in this book is based on my experience with the legal
system, both in chart reviews and as a testifying expert at deposition and trial. With today’s litigious society,
I believe that nurses must stay informed regarding legal issues affecting nursing practice. Sadly, resident acu-
ity has increased, some areas of the United States have a nursing shortage, and caring for residents has become
much more difficult than it was in the previous decade. The number of lawsuits against long-term care facilities
has increased. Some law firms virtually survive because of lawsuits against long-term care facilities and their
employees. I write about some of the issues here in hopes that you will benefit from the information in your
personal practice and stay out of the courtroom, which is usually not a fun place to be.
There is so much important information to share. All of the information here is relevant to nurses in long-term
care practice, but the data may not be committed to memory. The book is designed to make the material easy to
find. The format consists of many short, concise narratives, charts, lists, and tables so that you can readily access
and apply or implement the information. Because each subject is self-contained, if the chapter is read sequen-
tially, the sections may seem redundant. However, everything is important. Determining which subject is the
most important in this book would be impossible. Some of the information is difficult to find in other nursing
sources. Information is grouped together in a logical format that will enable you to quickly locate the informa-
tion about subjects for which the long-term care nurse is accountable. Section headings will assist you in finding
the information quickly. Each chapter contains a listing of Web references for additional, related information.
In addition to the care provided by physicians, some facilities are also fortunate to have the services of advanced
practice nurses (including nurse practitioners and clinical nurse specialists) and physician assistants. These well-
educated and highly qualified individuals provide excellent care to residents in long-term care facilities. In many
situations in this book, we note that physician notification is necessary. We are using the term “physician” for
brevity only. This is not intended to minimize the important work of advance practice nurses and physician
Introduction
xii Th e Lo n g-Te r m Ca r e nu r s i n g De s k re f e r e n C e, se C o n D eD i T i o n© 2009 HCPro, Inc.
in T r o D u C T i o n
assistants. When the reader is advised to notify the physician, facilities may also notify the advanced practice
nurse or physician assistant if available and as required by state law and facility policies.
Regulatory demands and resident acuity are increasing. The second edition of this book includes updated regu-
latory and quality assurance information to assist facilities in their mission of providing high-quality care. Safety
and infection control information has also been expanded. I deeply admire the many professionals who are
committed to our long-term care elderly, and sincerely hope the information is useful to facilities in providing
quality care and making a difference in the lives of the residents.
Acknowledgments
The Long-Term Care Nursing Desk Reference, Second Edition was written with a great deal of professional
collaboration.
As always, I am grateful for the unfailing support of my family, particularly my husband, Francis, whose able
assistance allows me to continue my writing endeavors. I could not spend many long hours at the computer
without the complete cooperation and support of my children and grandchildren.
Adrienne Trivers, HCPro Managing Editor, has nurtured this project through manuscript development to the
completed book you hold in your hand. Her foresight, acumen, and close contact with the industry identified a
need for this manual. I sincerely appreciate her vision of excellence in nursing publishing. Many unnamed indi-
viduals at HCPro handle the manuscript as it makes its way through the production process. Each individual
makes a contribution that ultimately enhances the value of the book, and I am eternally grateful for their efforts.
My sincere thanks to Ken Reynolds, LNHA, for his unfailing assistance and support as a reviewer, first reader,
and technical advisor. The following individuals and organizations have directly contributed to the development
of this book, and I sincerely appreciate their cooperation:
Nancy Bergstrom, PhD, RN
Phil DuBois, LNHA, and the staff of Market Square Health Care Center
Beverly Futrell, CNA
Genevieve Gipson, RN, MEd, RNC
Charlene Harrington, RN, PhD, FAAN
Steve Warren, Skil-Care Corporation
Please feel free to contact me through HCPro Publishers or by e-mail if you have questions or comments.
Barbara Acello, MS, RN
1Th e Lo n g-Te r m Ca r e nu r s i n g De s k re f e r e n C e, se C o n D eD i T i o n © 2009 HCPro, Inc.
Standards of Practice
A profession is an occupation or career, such as law, medicine, or engineering, that requires considerable edu-
cational preparation and specialized study. A professional is an individual who is engaged in certain activities or
careers, such as lawyers, doctors, nurses, and other professional people. Professionals are educated, qualified,
and often must be licensed to perform these duties. Professional behavior involves conforming to the standards
of the profession. A professional may be considered a skilled practitioner or expert.
All professions have standards and practices for their members. The standard of care is the degree of care or
competence that one is expected to exercise in a particular circumstance or role.1 In the nursing profession, the
American Nurses Association (ANA) and state licensure boards identify standards for registered nurses to fol-
low. Failure to provide care that meets or exceeds these standards may cause patient/resident harm and is cause
for disciplinary action against the licensee.
The standard of care is what a reasonable, prudent professional would do based on his or her education, expe-
rience, institutional policies and procedures, standards set by the relevant professional organization(s), text-
books, research, and professional literature. The standard of care is not what the best professional would do
but rather what any reasonable professional would do in the same or similar circumstances.
Technology and practices change rapidly. Facilities must strive to keep their policies and procedures up to
date. If facility policies and procedures are outdated, research and evidence-based practices supersede facility
policies and procedures. If a professional holds certifications and advanced education, he or she is held to the
same standard as other professional individuals with like qualifications. For example, if a registered nurse
holds a certification in gerontologic nursing care, he or she is held to a higher standard than nurses without
this certification.
Standards of PracticeChapTer one
Ch a p T e r o n e
2 Th e Lo n g-Te r m Ca r e nu r s i n g De s k re f e r e n C e, se C o n D eD i T i o n© 2009 HCPro, Inc.
Negligence is failure to exercise the degree of care considered reasonable under the circumstances, resulting in
an unintended injury to another party2—in other words, failing to meet the professional standard. Malpractice
constitutes mistakes or negligent conduct by a professional that result in damage or harm to others.3 The care
of each patient or resident involves many standards of care. No single standard encompasses all professionals
caring for the individual. Many standards apply to each profession and each situation.
Adhering to professional standards of practice or standards of care protects the residents from injury. It also
protects both the professional and healthcare facility from liability. This is an area in which your knowledge
must constantly be updated. Today’s healthcare system is weighed down by excess paper, including documents
generated by mail and those created by photocopying and faxing. Electronic technology is beginning to re-
place paper systems, improving communication and enhancing its effectiveness, as well as making it more
cost-effective.
ANA standards require that documentation be based on the nursing process. It must be ongoing and accessible
to all members of the healthcare team. An experienced reader can readily identify the various components of the
nursing process when reading the medical record. Years ago, nurses often neglected documentation, focusing
instead on resident care. If they were busy with resident care, documentation suffered. “Put the patient ahead
of the paper” was a common expression. Today, management must support nurses in finding a way to do both.
Documentation is part of the resident’s care, and nurses no longer have the luxury of choosing between provid-
ing care and keeping records.
Documentation validates that care was given. Sometimes, it proves that the facility was providing care it was
paid to provide. It is an essential element of communication. Accurate and complete documentation is essential
so others can determine what has been done. All healthcare practitioners rely on the data in the medical record
when they are planning future clinical approaches to resident care.
As healthcare professionals, we all have a broad knowledge of many subjects. We have specific, specialized
knowledge in our selected areas of expertise and practice. Nevertheless, knowing all we need to know about
every subject is impossible. For the most part, our generalized knowledge sustains us, but sometimes we must
learn more about applicable, current standards in subjects outside our specialty area. At the very least, profes-
sionals must familiarize themselves with new drugs. Aside from that, you may be faced with situations in which
you will need to research standards, even if you think you know them cold. Some of the simplest standards
may be the most difficult to find, and you may need to be resourceful to find what you need. Sources of infor-
mation about current standards can be obtained from the following:
sT a n D a r D s o f pr a C T i C e
3Th e Lo n g-Te r m Ca r e nu r s i n g De s k re f e r e n C e, se C o n D eD i T i o n © 2009 HCPro, Inc.
Licensure boards and certifying bodies •
Nurse practice acts •
Professional organizations and associations •
Educational institutions•
Professional journals•
Current textbooks•
Policy and procedure manuals •
State and federal regulatory agencies for your facility •
ConclusionKnowing and following the standards of practice for your profession and employment setting will ensure that
residents receive quality care. Applying professional practice standards does the following:
Protects resident (and employee) safety•
Achieves desirable resident (care) outcomes•
Facilitates access to appropriate services and levels of healthcare•
Identifies the scope of accountability for nursing care•
Reduces nurse and facility liability •
References to ANA standards of practice are listed throughout this book and are relevant in all states. See http://
nursingworld.org or call 1-800-274-4ANA to order ANA standards and other publications.
The Nonnegotiable Nature of the ANA Code for Nurses with Interpretive Statements
SummaryThe ANA Code for Nurses with Interpretive Statements (Code for Nurses) lists and describes the goals, values, and
ethical precepts that direct the profession of nursing. The ANA believes the Code for Nurses is nonnegotiable
and that each nurse has an obligation to uphold and adhere to the code of ethics.
BackgroundHealthcare ethics are concerned with the rights, responsibilities, and obligations of healthcare professionals,
institutions of care, and clients. Upon entering the profession of nursing, nurses accept the responsibilities
and trust that have accrued to nursing over the years and also the obligation to adhere to the profession’s
code of ethics. The Code for Nurses, published by the ANA, is the standard by which ethical conduct is
guided and evaluated by the profession. It provides a framework within which nurses can make ethical
Ch a p T e r o n e
4 Th e Lo n g-Te r m Ca r e nu r s i n g De s k re f e r e n C e, se C o n D eD i T i o n© 2009 HCPro, Inc.
decisions and discharge their professional responsibilities to the public, to other members of the health team,
and to the profession.
The Code for Nurses is not open to negotiation in employment settings, nor is it permissible for individuals,
groups of nurses, or interested parties to adapt or change the language of this code. The Code for Nurses
encompasses all nursing activities and may supersede specific policies of institutions, employers, or practices.
Therefore, the content of the Code for Nurses is nonnegotiable.
Overview of Standards of Gerontological Nursing Practice
Caring for elderly residentsGerontological nursing focuses on identifying the resident’s strengths and assisting the resident in using these
strengths to maximize his or her independence. The aging adult is involved in decision-making to the fullest
extent possible.
Factors the gerontological nurse must consider when caring for aging residents include the following:
Consequences and complications of the aging process•
Individual effects of the aging process on each client; the different rates at which people age•
The effect of losses on the client•
Social, economic, psychological, and biological factors•
The response of the client to the illness and treatment•
The cumulative effect of multiple chronic illnesses and degenerative processes•
The client’s cultural values•
Societal attitudes and cultural values associated with aging•
Basic gerontological nursing practiceBasic gerontological nursing practice is performed in a number of settings. Responsibilities of the gerontological
nurse include the delivery of direct care, the management and development of nonprofessional caregivers, and
the evaluation of care and services for the client. All professional nurses caring for geriatric clients must have the
basic knowledge and skills to do the following:
Develop the care plan by using the nursing process•
Establish a therapeutic relationship with the client and family•
Recognize age-related changes •
Collect data to determine health status and functional ability•
Function as a member of the interdisciplinary team•
sT a n D a r D s o f pr a C T i C e
5Th e Lo n g-Te r m Ca r e nu r s i n g De s k re f e r e n C e, se C o n D eD i T i o n © 2009 HCPro, Inc.
Participate with clients, families, and other healthcare providers in making ethical decisions•
Act as an advocate for the aging client and family members•
Teach clients and families about measures that promote independence, maintain and restore health, and •
promote comfort
Act as a source of referrals to other professionals or agencies, as appropriate•
Apply existing knowledge in geriatrics to nursing practice and interventions•
Protect the client’s rights and autonomy•
Participate in continuing education, state and national professional organizations, and certification•
Apply the standards of gerontological nursing practice to improve clients’ quality of care and quality of life•
Standards of gerontological nursing careMeasuring nursing care also evaluates accountability. The ANA Standards of Gerontological Nursing Practice
provides a tool to measure accountability. Measurement criteria are listed for each standard so that nurses may
assess their own performance and managers can assess staff members’ performance.
Types of standardsThe first standards were published in 1981. In 1994, the standards were revised to reflect the current scope of
practice and address health promotion, health maintenance, disease prevention, and self-care. The standards
now address the full scope of gerontological nursing practice in two parts: Standards of Clinical Gerontological
Nursing Care (Standards of Care) and Standards of Gerontological Nursing Performance.
Standards of CareThe Standards of Care include:
Assessment: Collection of resident health data•
Diagnosis: Analysis of assessment data to determine diagnosis•
Outcome identification: Identification of outcomes individualized to the client•
Planning: Development of a care plan that prescribes interventions necessary to attain expected outcomes•
Implementation: Implementation of the interventions listed in the care plan•
Evaluation: Evaluation of the client’s progress toward attainment of expected outcomes•
Standards of Gerontological Nursing PerformanceThe standards for professional performance describe a competent level of behavior, including activities related
to quality of care, performance appraisal, education, collegiality, ethics, collaboration, research, and resource
utilization. Gerontological nurses are expected to engage in appropriate activities for their level of education,
position, and practice setting. Gerontological nurses should seek activities such as membership in professional
organizations, specialty certification, further education, or advanced practice education.
Ch a p T e r o n e
6 Th e Lo n g-Te r m Ca r e nu r s i n g De s k re f e r e n C e, se C o n D eD i T i o n© 2009 HCPro, Inc.
The Nursing Process
The nursing process consists of four steps:
1. Assessment of the resident’s health data
a. Analysis of data and formulation of a nursing diagnosis
2. Planning priorities for resident care
3. Implementation of the plan according to priorities and planned outcome criteria
4. Evaluation of the resident’s response and revision of the plan as necessary
Although a review of the nursing process may seem elementary, use of the nursing process is a critical element
in the delivery of effective long-term care. Managerial personnel will find that units run more efficiently and
effectively if the nursing department promotes and adheres to this model of care. A breakdown of the nursing
process commonly leads to negative outcomes and litigation. The process begins with assessment—a key ele-
ment that is often missing in residents with negative outcomes. Since assessment provides the foundation for
the nursing process, the remainder of the process is ineffective without it. When making clinical judgments,
nurses must base their decisions on the consideration of consequences, which prescribe and justify nursing
actions.4 Nurses often have a mental block when it comes to using care plans. This undoubtedly comes from
nursing school. Working to actively overcome this mental block is critical. When the care plan is implemented
in accordance with the standards of good clinical practice, it becomes a powerful tool in providing quality care
to residents. The care plan should be used to guide staff in implementing interventions that enhance and pro-
mote each resident’s path toward achieving or maintaining his or her highest practicable level of well-being.
Assessment consists of an initial and ongoing examination of the resident’s status. Upon completion of the
assessment, the nurse makes a complete diagnostic statement to guide the care plan. Nursing diagnoses are
statements describing the resident’s response to illness, injury, or diagnosis. Nursing diagnoses are listed
according to priority and are based on a mutual resident-nurse decision. Realistic care plan priorities are devel-
oped to meet the resident’s individual needs. The plan is implemented, with the nurse constantly assessing
the effectiveness and ineffectiveness of the approaches. The resident’s progress is evaluated based on designated
outcome criteria. The plan is continually reassessed, modified, and updated to assist the resident in achieving
the established goals. Using the nursing process is an excellent means of ensuring high-quality nursing care.
Documentation and quality of the residents’ care plans are greatly enhanced if they reflect the use of the
nursing process.
In long-term care, the resident is completely assessed at the time of admission. The resident is at high risk for
negative outcomes at this time because he or she is not familiar with the facility, staff are not familiar with the
resident, and medical problems may be unstable. A nursing care plan is initiated immediately, describing care
sT a n D a r D s o f pr a C T i C e
7Th e Lo n g-Te r m Ca r e nu r s i n g De s k re f e r e n C e, se C o n D eD i T i o n © 2009 HCPro, Inc.
for obvious medical problems and high-risk conditions. (This is a temporary plan that will be replaced with a
comprehensive interdisciplinary care plan when the Minimum Data Set [MDS] is completed.) The plan should
describe the immediate care of the resident after admission or a significant change in status.
All direct care staff should be involved in the care planning process. They have the most frequent contact with
residents and are often knowledgeable about a resident’s daily life, needs, problems, and strengths. Staff who
have not participated in care plan decisions should be informed about how the care and services they provide is
intended to improve, maintain, or minimize decline in the resident’s condition and well-being. This information
is essential to their understanding of the care they provide and the expected outcomes for the resident. Without
knowing the reasons they are performing particular tasks, direct care staff may not understand the relationship
between the care and services they provide for a resident and the expected outcomes for that resident.
The care plan should be:
Created promptly on admission, listing high-risk conditions and obvious/evident problems•
Reflective of a review of the medical record, identifying medications that require monitoring and other •
potential problems that may not be triggered by the MDS, such as use of warfarin (Coumadin)
Further refined after various admission assessments•
Updated as often as necessary to ensure the plan is current•
Promptly updated and modified for illness or change in condition•
Readily and freely accessible to direct caregiving staff•
Used as the basis of making assignments and giving reports to direct care staff•
Reviewed each shift with appropriate direct care personnel (problems, goals, approaches)•
Reviewed as often as necessary by caregiving staff•
Implemented (problems, goals, approaches)•
Evaluated (effectiveness of problems, goals, approaches)•
Revised if approaches are ineffective, inappropriate, or no longer relevant•
Gerontological nursing practice involves assessing the health and functional status of aging adults, planning
and providing appropriate nursing and other healthcare services, and evaluating the effectiveness of such
care. Emphasis is placed on maximizing functional ability in activities of daily living; promoting, maintain-
ing, and restoring health; preventing and minimizing disabilities of acute and chronic illness; and maintaining
life in dignity and comfort until death. Gerontological nursing focuses on the resident and his or her family.5
Documentation should reflect the nursing process, including observations, assessments, care given and resident
response, and revision of the plan of care as appropriate.
Ch a p T e r o n e
8 Th e Lo n g-Te r m Ca r e nu r s i n g De s k re f e r e n C e, se C o n D eD i T i o n© 2009 HCPro, Inc.
Chapter Resources
References1. Merriam-Webster’s Dictionary of Law (Merriam-Webster’s, Incorporated, 1996).
2. The American Heritage® Dictionary of the English Language, Fourth Edition (Houghton Mifflin
Company, 2000).
3. Ibid.
4. American Nurses’ Association, Code for Nurses. (Washington, DC: American Nurses Publishing, 2001)
5. American Nurses’ Association, Scope and Standards of Gerontological Nursing Practice. (Washington, DC:
American Nurses’ Publishing, 1997).
Web resources•AgencyforHealthCarePolicyandResearch:www.ahrq.gov•AmericanNursesAssociation:www.nursingworld.org•EthicalConductforHealthcareInstitutions:www.hospitalconnect.com•CenterforHealthCareEthics:http://chce.slu.edu•CentreforAppliedEthics:www.ethics.ubc.ca•CenterforClinicalEthics:http://wings.buffalo.edu/faculty/research/bioethics•HealthOntheNetFoundation:www.hon.ch•InstituteforHealthcareImprovement:www.ihi.org/IHI•KennedyInstituteofEthics:www.georgetown.edu•NationalCouncilofStateBoardsofNursing,Inc.:www.ncsbn.org•NationalGuidelineClearinghouse:www.guideline.gov•NursingHomeProjectDescription:www.qualitynet.org/dcs/ContentServer?pagename=Medqic/MQPage/Homepage •InstituteforHealthcareImprovement:www.ihi.org/ihi•QualityTools:www.ahrq.gov•SharingInnovationsinQualityProfessionalStandardsandGuidelines:http://siq.air.org•StandardofCare:www.standardofcare.com•TexasMedicalFoundation:TheQualityImprovementOrganization(QIO)forTexas(contentapplicableinallstates):
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