Observations, Reporting and Team Work
All nursing shifts should make frequent observations on a new resident, especially for the first 72 hours. This information is the basis for the development of a good careplan (CP). As the resident settles in and becomes acquainted with other residents and staff, you will often see a personality change. He or she sleeps better, is more relaxed and becomes involved in the routine of the facility. The charge nurse should meet with all shift direct care personnel to identify patterns for the Activities of Daily Living (ADLs), sleeping, eating, going to the toilet and any expressed concerns (such as pain), should also be identified and investigated. Awareness of the resident’s religious affiliations should also identified as he or she may wish to attend religious services provided by the facility.
The other care disciplines involved in the resident’s care should also communicate their particular findings. That is the best way to begin the interdisciplinary care plan (IDC). All new interventions, involving the resident must be entered in the CP and updated or changed as necessary.
It has been my experience, that involving the Power of Attorney (POA) or family as much as possible is always a positive factor. The resident must also be allowed to participate in the CP if he is adequately cognizant.
The other disciplines who are involved in a resident’s care, as needs are identified, are Dietary, Activities, Social Service and the Therapy Department, including Physical, Occupational and Speech. Also Rehabilitation/Restorative therapy may be included in the IDC. As the assessments are completed and care needs identified, the IDC will be established. As these various disciplines interact with the resident, sometimes on a daily basis, please be aware that Nursing interventions are 24/7.
It is imperative in care of the residents to have a good team approach. An acronym for team which is well known is
T--- Together
E----Each
A----Achieve
M----More
I have received many useful reports on observations made by maintenance, housekeeping and dietary staff but then I always encouraged the input and showed my appreciation for the information.
In some facilities, I have seen the INTERACT tools in use. (http://interact2.net/index.aspx) One of these tools which I have found very useful is the Early Warning Tool “Stop and Watch”. It can be used by the direct care staff or any department personnel, to provide input to the nurse.
Written statements concerning resident care are more beneficial than verbal ones, especially if the nurse is busy with the medication pass or on the phone with the physician or family. A verbal statement may be misinterpreted or easily forgotten. All staff should share information that enables timely decision making by the direct resident care team. Feedback between staff should be delivered in a way that promotes positive interactions. All staff should understand their roles and responsibilities and should be held accountable for their actions.
