Mid Essex Care Home Manual

The Care Home Manual

Supporting care homes in mid Essex

DRAFT FOR
TRIAL USE

The Care Home Manual Welcome

Welcome

We want everyone in mid Essex to Live Well. For us all that means developing and providing
services that support people to lead healthy lives. It also means helping people, when needed, to
get joined-up care with the best outcome.

Navigating the local NHS and care services can sometimes be difficult and confusing. This
information guide has been created by a wide range of professionals from NHS Mid Essex CCG,
Provide CIC and Essex County Council in order to help you, in your role, provide the best care
possible.

Information is current at time of production (August 2017) and will be updated by Mid Essex CCG
as/if protocols or processes change.

The guide has been divided into three main sections for ease of reference and can be used as an

Section One Section Two Section Three Section Four

Assessment – to help Clinical – to provide Emergency – to help Your organisation
you identify when you with information/ you identify quick protocols
residents may need references/checklists
additional care and regarding common action in emergencies
illness and conditions
from which services
that residents may
experience

The Care Home Manual Contents

Contents 1

Abbreviations 5
7
SECTION ONE – ASSESSMENT 8
• Important statements 10
• Resident not feeling/appearing well today 11
• What sort of help do they need? (explaining SBAR)
• SBAR tool 15
• Worried about a resident – who shall I call? 17
19
SECTION TWO – CLINICAL 27
• Depression 33
• Delirium 36
• Dementia 37
• Pain management 41
• Medicines - key points you need to know 55
• Sore throat, cough, colds and flu 62
• COPD 72
• Hydration and nutrition 77
• Suspected UTI and urine samples 80
• Constipation and continence 82
• Diarrhoea and vomiting 85
• Dysphagia
• Choking 88
• Skin problems 89
• Pressure sores 91

SECTION THREE – EMERGENCY 96
• Falls/Collapse
• Stroke
• Sepsis

SECTION FOUR – PROTOCOLS
• Infection prevention

The Care Home Manual Abbreviations / Glossary

Abbreviations / Glossary

AHR Alcohol Hand Rub
AKI Acute Kindney Injury
BP Blood Pressure
BNF British National Formulary
CCG Clinical Commissioning Group
CPA Central Point of Access
Single telephone number that you can call to get information and be
CPPE referred to many of mid Essex’s health and care services from a
CQC Triage Nurse and supporting telephonists. The service is delivered by a
CPR Nurse and support staff.
COPD
CSU See Early Supported Discharge Admissions Avoidance and Resettlement (ESDAAR)
CVA
DH Centre for Post Graduate Pharmacy Education
D&V Care Quality Commission
DOLS Cardio Pulmonary Resuscitation
DN Chronic Obstructive Pulmonary Disease
DNACPR Catheter Specimen of Urine
ECP Cerebro Vascular Accident
Department of Health
Diarrhoea and Vomiting
Deprivation of Liberty Safeguards
District Nurse
Do not attempt cardio-pulmonary resuscitation
Emergency Care Practitioner

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The Care Home Manual Abbreviations / Glossary

EoL End of Life
ENT Ear, Nose and Throat
EU European Union
ESDAAR Early Supported Discharge Admissions Avoidance and Resettlement
The service aims to prevent and avoid admissions to hospital by using
FAST its contacts and networks in the community. It also works closely with
FTU hospitals to enable patients to be safely discharged early from hospital and
GP resettled back home.
LWA&CPT The service runs seven days a week between 8am and 11pm.
MAR
MCA See Central Point of Access (CPA)
MC and S
MDS Face, Arm, Speech, Time to phone 999
MHRA Finger Tip Unit
MRSA General Practitioner
MSU Local Working Agreement and Care Planning Toolkit
MUST Medicines Administration Record
NA Mental Capacity Act
NACC Microscopy, Culture and Sensitivity
NICE Monitored Dosage System
Medicines Healthcare Regulatory Agency
Meticillin Resistant Staphylococcus Aureus
Midstream Specimen of Urine
Malnutrition Universal Scoring Tool
Non Adherent
National Association of Care Catering
National Institute for Care Excellence

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The Care Home Manual Abbreviations / Glossary

NPA National Pharmacy Association
NPSA National Patient Safety Agency
NSAID’s Non-Steroidal Anti Inflammatory Drugs
OOH Out of Hours
PIL(s) Patient Information Leaflet (s)
PEG Percutaneous Enteroscopic Gastrostomy
PPE Personal Protective Equipment
PRN As Required
RCN Royal College of Nursing
RPS Royal Pharmaceutical Society
SLT Speech and Language Therapy
SBAR Situation, Background Assessment and Recommendations
SMART Specific, Measurable, Achievable, Realistic, Timely
TIA Transient Ischaemic Attack
TV Tissue Viability
UTI Urinary Tract Infection
WHO World Health Organisation

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Section One

Assessment

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The Care Home Manual Section One: Assessment

Section One: Assessment

IMPORTANT STATEMENTS

It is intended that this guide will be used by staff who have a good working knowledge and
understanding about Consent; Deprivation of Liberty; Dignity; Mental Capacity and Safeguarding
Adults and that any treatment offered and given is done so with reference to and consideration of
the above. Furthermore, this should be recorded in the individual’s care plan.

Informed Consent – why consent is crucial

1. People have a fundamental legal and ethical right to determine what happens to their own
bodies. Valid consent to treatment is central to all forms of health and social care from
personal care to major surgery. Seeking consent is also a matter of common courtesy between
professionals and those for whom they care.

2. Consent is a person’s agreement for a professional to deliver care and may be indicated non-
verbally (e.g. presenting an arm for the pulse to be taken), orally or in writing. For consent to
be valid a person must be competent to make the particular decision, have received sufficient
information to give it, and not be acting under duress. A person’s mental capacity to consent
should be considered. For more information visit: http://www.nhs.uk/Conditions/Consent-to-
treatment/Pages/Introduction.aspx.

Deprivation of Liberty Safeguarding (DOLS)

Care homes, as bodies that perform public functions, have legal duties and responsibilities to
uphold and protect the human rights of individuals living in the care home. Article 5 of the Human
Rights Act (HRA) relates to Deprivation of Liberty and care homes have specific responsibilities
as a Managing Authority under the Deprivation of Liberty Safeguards (DOLS) to refer relevant
individuals who may be ‘Deprived of Liberty’ to the appropriate Supervisory Authority i.e. Essex
County Council.

There is a test for Deprivation of Liberty for the purpose of Article 5 of the European Convention
on Human Rights (right to liberty and security of the person), for adults who lack capacity to make
decisions about their care and treatment within a number of settings.

Care homes need to consider if the person lacks capacity to consent to care and treatment
arrangements, is not free to leave and is subject to continuous supervision and control. If it
appears that these criteria apply then a referal should be made with advice and support as
required from Essex Social Care Direct – http://www.essexsab.org.uk/en-us/professionals/
mcaanddols.aspx.

Care home staff may be working with people who are already subject to an authorisation under
DOLS and need to be aware of any conditions that are affected to ensure that any care and
support provided to the person is compliant with the law. This may include gaining consent for
the treatment of a minor illness or consideration of the Mental Capacity Act to assess a person’s
capacity to make a decision about treatment and if required make a best interest decision.

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The Care Home Manual Section One: Assessment

Dignity in Care means the kind of care, in any setting, which supports and promotes, and does
not undermine, a person’s self-respect regardless of any difference (Social Care Institute for
Excellence 2007). In other words, treat someone the way you would wish yourself or your family to
be treated.

The Mental Capacity Act (MCA)

The Act provides a legal framework designed to help protect adults aged 16 and over who are
unable to make decisions including consent for themselves. The Act is necessary because some
adults may be unable to make some or all of their own decisions due to a temporary or permanent
disturbance in the way the mind or brain works. This can result from ill health e.g. dementia, stroke
or delirium. Such inability to make decisions is known as ‘lack of mental capacity’ – the decisions
to be made could be about personal welfare, healthcare or money matters.

Care homes are likely to have some residents who lack mental capacity. Homes have a legal duty
to ensure that everything done for, or on behalf of, a resident is in the resident’s best interests
and is the least restrictive option. A mental capacity assessment is time and decision specific.
For instance, someone who lacks capacity for some decisions may be able to make day to day
choices.

For more information about the Mental Capacity Act see ‘Making Decisions. A Guide for People
Who Work in Health and Social Care’ (2007) https://www.gov.uk/government/publications/health-
and-social-care-workers-mental-capacity-act-decisions.

Safeguarding Adults

All adults have the right to live a safe life, free from fear or harm. Organisations that provide
services to vulnerable adults have a professional duty of care; this will be included in the home’s
Code of Conduct. All organisations in mid Essex work to the Safeguarding Adults Procedures for
mid Essex, although your own organisation may have its own policy and procedures which are in
line with this.

For information about Safeguarding Adults visit Essex County Council’s website https://www.
essex.gov.uk/Publications/Documents/Safeguarding_Adults_-_Information_Leaflet.pdf.

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The Care Home Manual Section One: Assessment

Resident not feeling well today?

Before requesting advice/support from any service, the following pages may help you to identify
what symptoms/issues are causing concern so that you can communicate this effectively.
Always make sure you have the following information to hand:

Always make sure you have the following information to hand:

• Resident’s name; date of birth (DOB) or NHS number
• Name of care home and type
• Full postal address of home; telephone/contact number/email address
• GP name and address
• Resident’s medical history including allergies
• GP review/care plan including DNA/CPR information/crisis planning information/use of special

patient note
• MAR sheet
• Any other specialist involved
• Next of kin details and if they are aware/unaware of health changes

The central point of access (CPA) within mid Essex provides clinical triage, advice and navigation
to health care professionals, patients and carers including staff from care homes.

The CPA service will need basic information about the resident so that it can help identify and
provide the most appropriate service for the resident’s needs. This could involve sending a district
nurse to the care home to support the resident or a rapid response ESDAAR nurse who will
assess and initiate urgent treatment for a patient in a crisis (within 2 to 4 hours of making the call).

To access the CPA / ESDAAR service call 0300 1310 111

The CPA/ESDAAR service runs seven days a week, between 8am and 11pm. Outside of these
times please contact NHS 111 for urgent medical help that is not a 999 life-threatning emergency.

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The Care Home Manual Section One: Assessment

What sort of help do you need? (explaining SBAR)

There are many people who may care for a resident throughout each day; some within the care
home and others from outside for example GPs; specialist teams like tissue viability or continence
service. They may be constantly changing due to shift patterns or changes in employment.
The health and needs of residents will also be constantly changing – sometimes gradually and
sometimes suddenly due to periods of acute illness like chest or urine infections, wounds or
injuries from a fall.

The quality of information and continuity in how it is shared is vital. The right information used in
the correct way is central to a resident’s safety, health and wellbeing and dignity.

The SBAR (Situation, Background, Assessment, Recommendation) tool was developed to help
exchange information to maximum effect.

Using SBAR is suggested by the World Health Organisation (WHO) as a change that could be
implemented to make improvements in care.

It helps you to paint a clearer picture of the problem to the person who is being asked to give
advice/support and offers a framework for sharing information confidently. It can used equally by
registered nurses and carers.

It may also be a useful tool to follow at handover time.

Situation – what is happening now?
Background – what has led to this situation?
Assessment – what do I think the problem is?
Recommendation – what action needs to be taken?

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The Care Home Manual Section One: Assessment

Resident Not Feeling / Appearing Well Today?

Before requesting advice / support from any service, use this to help you identify your concerns –
so you can communicate most effectively about your concerns. See SBAR on page 10.

Changes to urine Bowel problems, Off their food,
e.g. output, clarity, constipation changes to appetite

odour etc

Changes in
behaviours

Falling, off balance, Confusion or Changes to fluid intake,
unsteady increased confusion increase or reduction in

Agitated or Depressed/can’t usual amounts taken
more agitated be bothered/low
Restless or more
than usual mood/ weepy restless than usual

Feeling Swollen
nauseous
feet, legs
Weak, listless, or ankles
drowsy
Coughing more than
Breathlessness/ Temperature 1.5C usual, changes to
more breathless above ‘usual/baseline’, colour of sputum

than usual feeling hot to touch, Vomiting and/
clammy or sweating or vomiting and

diarrhoea

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DRAFT VERSION FOR TRIAL (Aug 2017) When phoning health professionals Situation, Background, Assessment, Recommendations (SBAR) The Care Home Manual
for advice about a resident who
is unwell you will always need THE CALLER SHOULD BE WITH THE RESIDENT WHEN MAKING THE CALL Section One: Assessment
the following information at your
fingertips: Situation

• Residents name; date of birth • I am <your name>, a <RMN/RGN/carer>, working at <name and type of home>
(DOB) or NHS no • I am ringing about one of our residents <name, DOB or NHS number>
• I am worried because...
• Name of care home and type
• Full postal address of home; Background

telephone/contact number/email • <name of patient> has a history of…
address • They have …
• GP name and address • <xxxx> condition has changed in the following way/s ............ and I have recorded observations
• Residents medical history
including allergies as follows...
• GP review/care plan including • They were last seen by the GP (or other) on ……………………………………for …. They do/do
DNA/CPR information/crisis
planning information/use of not have a crisis management plan, or End of Life (EoL) in place
special patient note • The GP <has/has not sent> the Special Patient Notice to out of hours
• MAR sheet • They are on the following medications …………………………and I can email the list to you
• Any other specialist involved
• Next of kin details and if they Assessment
are aware/unaware of health
changes • I think the problem might be…
• I am worried that …
• I have done the following <medication given/observations taken etc>
• I am not sure what the problem is but they are getting worse. I am very worried about ...

Recomendations

• I need you to come and see <name of patient> urgently
• Is there anything we should do until you arrive?
• Can I read your instructions back to you?

Thank you.

10

The Care Home Manual Section One: Assessment

Worried about a resident – who shall I call?

Note: Non bed bound patients should always be taken to GP / dental surgery
to access appointments.

CPA / ESDAAR The CPA service should be your first point of contact to provide the most appropriate service for the
resident’s needs.

This could involve deploying a district nurse or a rapid response ESDAAR nurse who will assess
and initiate treatment for a patient in a crisis. The team are skilled to deal with urgent requests and
will respond within 2 to 4 hours. Support can include:

• Resident generally unwell
• General medical concerns – access to COPD, heart failure and diabetes community teams
• Cough
• Abdominal pain
• Skin complaints
• Bites
• Cuts
• Foreign objects
• Falls – no obvious injury
• Catheter management
• PEGs (feeding tubes)
• Syringe drivers
• Ears
• Wound care/management
• Palliative care
• Constipation
• Any other DN enquiry

To access this service call 0300 1310 111

GP Clinical Concern Contact Details

• Community services – all referrals via GP Contact the patient’s usual GP for those
problems listed to the left – or await the usual
• Worsening confusion visiting day if appropriate to do so.

• Worsening pain and pain management (NOT Outside of the usual GP opening hours of
chest pain – see 999) 8am - 6.30pm, your call will be transferred to the
Out of Hours Provider for your area. Non bed
• Mental Health concerns – a number of bound patients should always be taken to the GP
services are available (check with EPUT surgery to access appointments.
what current access is to older persons
mental health team)

• Pallative care – GP to work with community
nursing on end of life planning and symptom
management

• Medication reviews

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The Care Home Manual Section Two: Assessment

DENTIST Clinical Concern Contact Details
All non-emergency dental care, referrals Referrals Co-ordinator
should be made to Community Dental Service Community Dental Services
(CDS). For more information visit: https:// Witham Health Centre
communitydentalservices.co.uk/our-services/ 4 Mayland Road
essex-dental-services/frail-elderly-2/. Witham, Essex
CM8 2UX
For emergency dental treatment (9am to
5:30pm) contact Community Dental Services. Tel: 01376 531013
Out of hours contact NHS 111.
Send electronically to
[email protected]
from a secure email address

EMERGENCY Clinical Concern CALL
• Chest pain 999
• Choking
• Fitting
• Severe breathing problems
• Stroke
• Unconscious
• Vomiting blood
• Passing large volumes of blood rectally
• Head injury
• Suspected fracture
• Resident on Warfarin sustaining injury

resulting in profuse bleeding

Voluntary Service Contact Details

Care Home and Volunteering: Care Homes can Braintree CVS: 01376 550507

connect with their local volunteer centre to work

in partnership to explore opportunities for their Chelmsford CVS: 01245 351888

residents.

VOLUNTARY Maldon CVS: 01621 851891

Connect Well is a ‘social prescribing’ project

stretching across the districts of Braintree, To access Connect Well visit

Maldon and the City of Chelmsford. http://connectwellessex.org.uk

You can access Connect Well to link residents to
advice, activities and support including:

• Befriending and social activities
• Support and self help groups
• Community transport

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Section Two

Clinical

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The Care Home Manual Section Two - Clinical

Depression

Most people will feel fed up from time to time; ups and down in life
are common and normal. Depression is more persistent and can
have a significant impact on day-to-day living. Depression is common
in older people and can be managed and treated.

Definition of Depression

Depression can be defined as a lowering of mood and/or a loss of
interest in and enjoyment of everyday activities plus:

• 2-3 symptoms for mild depression
• 4 or more additional symptoms for moderate to severe depression

Symptoms must be present on most days for at least 2 weeks, causing impairments in sociability
or everyday functioning.

Core symptoms of depression

• Low/sad mood
• Loss of interest/pleasure in life
• Low energy

Other symptoms of depression

• Sleep disturbances such as early waking
• Poor appetite/weight loss
• Feeling worse at certain times of the day
• Pessimism/hopelessness about the future
• Dispairing thoughts e.g. I don’t care if I wake up
• Agitation/irritability
• Forgetfulness/poor concentration
• Behaviour changes
• Anxiety
• Unexplained aches and pains
• Self-neglect
• Slowing of movement/speech
• Feelings of guilt or worthlessness
• Suicidal thoughts

The risk of depression increases for people in care homes due to loss of
independence and control; poor health and high levels of dependency; loss of
identity; isolation and inactivity; bereavement.

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The Care Home Manual Section Two - Clinical

How you can help

Be alert

If you know that someone has a history of depression, find out how it affected them
and what helped them to recover. Listen out for changes in conversation, watch out for
symptoms, look for differences in habits and ask the resident how they are feeling.

If you suspect that a resident is depressed, use the SBAR tool in the analysis section to
make a note of the behaviour changes/health changes that are concerning you and contact
their GP.

The GP will be responsible for carrying out an assessment and deciding on next steps of
support – this could be prescribing medication or referring on to a community mental health
team for further assessment and care.

Helping with recovery

Supportive listening – encourage the resident to talk about their fears or feelings without
judging or criticising. Listening can build trust and help you identify together other things that
may help

Goal setting – when change seems overwhelming and motivation may be poor, it may help
to put in place some small steps to encourage the resident and help them achieve change.

Life improvements – find out what matters most to your resident and make a plan on how to
achieve change. This might include re-establishing contact with friends or family, resuming
hobbies, making time for conversation.

References and useful sources of information

NICE guidelines – Depression No90, No91
www.nice.org.uk

Mid and North Essex MIND
http://mnessexmind.org/

Royal College of Psychiatrists – Depression in Older Adults
http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/depressioninolderadults.aspx

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The Care Home Manual Section Two - Clinical

Delirium

Delirium is a state of mental confusion that can happen if someone becomes medically unwell.
Medical problems, surgery and medications can all cause delirium. It often starts suddenly and
usually lifts when the condition causing it gets better. It can fluctuate during the course of the day.

Things that can trigger Delirium:

• Pain
• Bladder catheterisation
• Kidney disease
• Dehydration or malnutrition
• Recent surgery
• Dementia
• Nicotine withdrawal
• Excess alcohol
• Severe illness

Symptoms of Delirium

• Memory loss
• Decreased attention or concentration
• Disorganised thinking
• Frequent changes in mood
• Communication difficulties
• Slowed movement or restlessness
• Signs of medical illness
• Confusion or disorientation
• Changes in sleep patterns

What to do if you suspect Delirium

Observe, at least once daily, for any changes or variations to the resident’s “usual behaviour” (see
pages 7 to 10 for Resident not feeling / appearing well today?)

These may be reported by the resident, a relative or friend, a co-worker or other health/care
professional.

If any of the above changes are present, then record your assessment using SBAR and refer to
page 11 (Who shall I call?) for further support and assessment.

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The Care Home Manual Section Two - Clinical

How can you help

• Develop a plan of care involving GP, district nurse, care team to resolve possible causes

• Provide ongoing education, reassurance and emotional support to the resident and
relatives/friends

• Ensure daily records reflect the changes in behaviour and what care has been delivered
in order to minimise the effects of delirium

• Maintain a comfortable and familiar environment (e.g. provide eyeglasses, hearing aids)
in line with care plans

• Establish a routine to reduce the person’s stress level; encourage family to stay with the
person if this provides reassurance

• Promote sleep at night by controlling noise and disruptions in line with care plan

• Ensure adequate fluid intake to prevent dehydration – see pages 41 to 44 for more
information

References and useful sources of information

NICE
http://www.nice.org.uk/cg103

Royal College of Nursing
https://www.rcn.org.uk/clinical-topics/older-people/delirium

Royal College of Psychiatry
http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/delirium.aspx

Alzheimer’s Society
https://www.alzheimers.org.uk/info/20029/daily_living/370/delirium

Dementia UK
https://www.dementiauk.org/delirium/

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The Care Home Manual Section Two - Clinical

Dementia

The word ‘dementia’ describes a set of symptoms that may include
memory loss and difficulties with thinking, problem-solving or
language. These changes are often small to start with, but for
someone with dementia they have become severe enough to affect
daily life. A person with dementia may also experience changes in
mood or behaviour.

Dementia is caused when the brain is damaged by diseases such as
Alzheimer’s disease or a series of strokes. Alzheimer’s disease is the
most common cause of dementia, but not the only one. The specific symptoms that someone with
dementia experiences will depend on the parts of the brain that are damaged and the disease that
is causing the dementia.

Dementia is progressive and will get worse over time. The likelihood of developing dementia
increases significantly with age but the condition is not restricted to older age.

For advice and support 24 hours please call the Essex Partnership University Trust (EPUT)
dementia helpline on 01245 515 313 or visit https://eput.nhs.uk/contact-us/in-crisis/.

Download the EPUT specialist dementia and frailty service booklet here: http://midessexccg.nhs.
uk/about-us/the-library/patient-guides/ageing-well/2572-eput-dementia-booklet-mid-essex/file.

How does it affect people?

People with dementia have the same basic needs as everyone else. However, they may be less
able to recognise their needs, know how to meet them, or communicate them.

When a person with dementia behaves differently, this is often mistakenly seen as a direct result of
the dementia or simply as another symptom of the condition. However, this is often not the case.
The behaviour may have many causes, including difficulties relating to dementia (such as memory
loss, language or orientation problems), but also physical and mental health, habits, personality,
interactions with others and the environment.

When supporting a person with dementia who is behaving differently, it is important to see beyond
the behaviour itself and think about what may be causing it. Sometimes behaviour can be a result
of frustration about how others around the person are behaving, a sense of being out of control, or
a feeling of not being listened to or understood.

Behaviour may be an attempt to meet a need (e.g. removing clothing because they are too hot or
walking around because they are bored or feel they need to be somewhere), or to communicate a
need (e.g. shouting out because they need the toilet).

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The Care Home Manual Section Two - Clinical

Causes of Dementia

Alzheimer’s Vasular Dementia with Frontotemporal Rarer
Disease Dementia Lewy bodies
Dementia Causes
Caused by
changes in the Caused by Caused by A range of There are over
structure of
the brain and problems with irregularities conditions 100 different
a shortage
of important the supply of in brain cells including Pick’s causes of
chemicals that
help with the blood to the brain, leading to disease more dementia – some
translation of
messages. commonly caused symptoms similar likely to affect rarer examples of

by a series of to Alzheimer’s younger people these conditions

small strokes or and Parkinson’s and typified by are Creutzfeldt-

other vascular disease. behaviour change Jakob disease

diseases. and language and Korsakoff’s

problems. syndrome.

The Effects of Dementia

Memory Verbal Disorientation Changes in Rarer
Loss Communication Perception Causes

As the short Language A person believes Leads to Recognising
term memory problems often
deteriorates begin with they are in a confusion of familiar faces
a person with forgetting the
dementia uses names of people different time sights, sounds can be a problem
their experiences or everyday
from the past to objects. This or place. This such as shadows, but other things
make sense of can progress to
the present. the extent that can lead to mirrors, patterns can help with
speech becomes
incoherent. them feeling lost on the carpet or recognition ie if

even in familiar noise from TV. someone speaks

surroundings. that may spark

recognition.

Disinhibition Perseveration Sequencing Incontinence Attention

A reduced ability Also known as A person may This could be A person may
to regulate repetition – a struggle to do forgetting where easily become
speech or person may things in the the toilet is or distracted or
behaviour become stuck on right order or having difficulties find it hard to
so a person one word, phrase to complete a with fastening concentrate on
may become or behaviour task even if they through to loss of conversations or
impulsive, and may need can do various bladder control tasks.
doing or saying prompting to elements of it. as dementia
things which are move on to progresses.
unusual or out of something else.
character.

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The Care Home Manual Section Two - Clinical

Types of behaviour and possible unmet needs

The charts that follow may help you to recognise, assess and manage changes in behaviour
associated with Dementia.

Restlessness Shouting and Walking Sleep disturbance
(fidgeting / pacing / screaming and night time
agitation) walking

Pain or discomfort. Pain or discomfort. Some people with Sleep disturbances are

dementia start to walk common for people

Communication Communication about more. Some with dementia, and
problems. problems. reasons why people often lead to carers
may walk include also experiencing

A feeling e.g. anxiety A response to a relieving boredom problems with their

or boredom. hallucination. or anxiety, revisiting sleep. A person with

A medical reason Under-stimulation or a past habit (e.g. dementia may get up

e.g. depression, over-stimulation. collecting the children repeatedly during the

constipation or the side from school or taking night and may become

effects of medication. the dog for a walk) or disorientated when

A basic need e.g. Attempting to confusion. The person they wake. They may
hunger, thirst or communicate a need
needing the toilet, e.g. hunger or thirst. may also feel that they get dressed or try to
being prevented from
getting out of bed. have somewhere to leave the house. This

be. Walking may offer may make the person

the person a chance to tired during the day

The environment – it An expression of be independent, give and they may sleep for
may be too hot or too distress due to
cold, over-stimulating strong feelings such the person something long periods.
or under-stimulating. as embarrassment,
to do and opportunities

for exercise.

frustration.

A feeling e.g. anxiety,

loneliness or boredom.

An unsupportive
environment e.g. it
may be too hot, too
cold or too dark.

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Asessing and Managing Behaviours in Dementia

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Managing behaviours

DO DON’T
Give undivided attention Ignore the emotion behind the message

Allow the person time to finish his/her thoughts Allow your attention to wander
Ask open-ended questions
Finish someone’s sentences or “fill in the
blanks”

Go with the flow Dismiss concerns before exploring them

Be aware of the person’s body language – Give false reassurances
what is it telling you?
Jump to conclusions before you have listened
Be aware of your body language – what is it to the person
telling them?
Make assumptions
Avoid being judgmental
Offer unwanted advice
Use restatement to clarify (“so what I hear you
say is……”) Change the subject

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Behavioural Chart

Behavioural Chart For:
Challenging Behaviour:

Please record any episodes of the above behaviour (day/night)

Date and time What was the person doing just before the
incident?

Where did the incident occur?

Which staff were involved? (initials) What did you see happen? (actual behaviour)

What did the person say at the time of the incident?

Possible reason for behaviour?

How did the person appear at the time of the incident? (may be more than one tick)

Angry Frustrated Other (please state)

Anxious Happy

Bored Irritable

Content Physically unwell

Depressed Restless

Despairing Sad

Frightened Worried

How was the situation resolved?

(Dementia Rapid Response Team) 24

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Providing care to prevent or reduce behaviour that challenges

Understanding the cause of changes in behaviour is essential for developing appropriate
interventions – whether the behaviour concerns issues with everyday tasks, engagement with
personal care, the person’s beliefs or associated expression of emotions such as anger, anxiety or
despair.

The Newcastle Challenging Behaviour Team provides a 5 stage model, detailed below, to
determine the interventions which will help to prevent or reduce behaviour that challenges for an
individual with dementia.

Stage 1 – Background information

Personality: understanding a person’s individuality, lifestyle choices and how they have coped
with difficulties in the past

Biography: as life history affects the way dementia is expressed, knowing about someone’s
experiences is crucial to understanding behaviour. It also provides ideas for appropriate activities,
helps with understanding a person’s needs and knowing how to approach and deliver personal
care

Physical health: past medical history, current health problems, age related illnesses and the
likelihood of pain

Mental health: past and present, being aware that previous problems may re-emerge. Knowledge
about previous treatments and outcomes for physical and mental health issues is also helpful

Medication: side effects and interactions

Cognitive abilities: how is the person affected by their dementia with reference to memory,
language skills, understanding, orientation, perceptions – see page 20.

Social environment: how does someone perceive the environment they are in, what activities do
they engage in and how do they interact with the people around them or during care practice

Stage 2 – Triggers

Identify time of day, context and people involved

Stage 3 – Facts about the behaviour

Behaviour: a clear description of the problem behaviour – what actually happens?

Appearance: how does the person seem to be feeling – anxious, angry, scared or depressed?

Vocalisations: the content and nature of what the person is saying for example, shouting “help” or
groaning, saying something repeatedly – use the behaviour chart on pages 22 to 24.

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Stage 4 – Identifying the person’s needs

Make a reasonable assumption about behaviour based on the information you have – a case
study below:

Background: quiet, sensitive, history of depression with paranoid ideas, used to be a dinner
lady, enjoys reading/sewing and walking her dogs, poor hearing – wears a hearing aid

Appearance: upset, angry, frightened

Behaviour: gets up and walks away from dining table, angry with staff when challenged,
hides biscuits

Vocalisation: “leave me alone” “get away”

Need/thought: to feel secure, quieter environment, time alone, thinks she is there to help,
hungry

Stage 5 – Devising interventions

Practical interventions including changes to the environment and staff interactions.

Again using the case study above the following interventions could be:

• Encourage the person to help out around the home. Involve in food preparation or cooking
• Minimise background noise, good use of non-verbal language
• Provide meals in own room or with small, select group, encourage to use past coping skills
• Take for a walk or support the person to carry out activities they enjoy
• Refer to GP for assessment of mood

Source: James I A (2011) Understanding Behaviour in Dementia that Challenges: A guide to assessment and treatment,
Jessica Kingsley Publishers

References and useful sources of information

NHS Choices
http://www.nhs.uk/Conditions/dementia-guide/Pages/dementia-behaviour.aspx

Alzheimer’s Society
https://www.alzheimers.org.uk/info/20029/daily_living/28/making_decisions_and_managing_
difficult_situations/7

Social Care Institue of Excellence (SCIE)
http://www.scie.org.uk/dementia/after-diagnosis/communication/behaviour.asp

Dementia UK
https://www.dementiauk.org/understanding-dementia/

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Pain Management

Studies on pain in care homes show that up to 80% of residents may
have some degree of pain. The most common pains are in the joints,
limbs and back mainly due to arthritis.

People who have dementia do not receive as much treatment for
pain as those who do not have dementia.

Source: Pain in Older People with Dementia: A Practical Guide, 2007, Dr
W McClean with C Cunningham, Dementia Services Development Centre,
Stirling University.

How does it affect people?

There is a commonly held belief that people who have dementia do not feel pain as much as other
people but the fact is that dementia does not alter the fundamental experience of pain.

Self-reporting is the standard method for identifying pain but the ability to self-report may be
compromised by:

• Speech decline
• Struggling to understand questions
• Forgetting that they have been in pain
• Difficulty interpreting and understanding the feelings they are having

There is a tendency to normalise pain as we age – aching and soreness is seen as a discomfort to
be expected so older people are less inclined to speak about their experience of persistent pain.

Older people may use different words to describe their pain which younger people may be less
familiar with or there may be cultural factors which alter the way a person expresses their pain.
Older people may describe their pain in ways which understate its severity.

Experience of pain may be influenced by:

Sensation: the feeling of pain, its intensity and where it is
Knowledge: beliefs about the cause of pain
Emotion: how we feel about pain is affected by what we know about it. Long term memories of
childhood pain can affect feelings in older age

What changes when someone is in pain? 27

Facial expression: frowning, sad, grimacing
Vocalisation: groaning, crying, shouting
Body language: guarding, rubbing or holding the painful part of the body
Activity: patterns or routines
Interactions: with others
Behaviour: restlessness, fidgeting, pacing, resistive to care, reaction to touch
Mental status: increased confusion, mood changes

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Pain assessment

The feeling of pain is one that is personal and only really known to the individual experiencing it.
Many factors can affect the intensity of pain and a person’s ability to cope with it, for example, the
type and cause of the pain, sleep disruption, individual expectations and various emotions. Fear,
anxiety, depression, anger, and guilt can increase a resident’s perception of pain, therefore it is
important a holistic assessment is undertaken when assessing individual pain management.
Individuals will also differ in how they express their pain; some may find it difficult to describe,
understand and measure. It is perhaps worth remembering that ‘pain is whatever the resident says
it is and exists whenever they say it does’.

Pain scales

Pain scales are tools that may help diagnose and measure pain intensity and help to evaluate the
effectiveness of an intervention. There are many different pain scales available – one size does
not fit all. What may be suitable for one resident to use may not be suitable for another and the
assessment of pain can be particularly challenging in the presence of dementia, communication
difficulties, language and cultural differences.

Important factors to consider when choosing an appropriate pain assessment tool for an individual
resident are:

• Can the resident and/or all the care staff involved understand and know how to use the
selected tool?

• Is the selected tool appropriate for the resident taking into account any communication issues
they may have?

• The same pain assessment tool should be used for sequential assessments (including
assessment of any pain on movement to give an accurate account of the resident’s pain)
and be evaluated regularly to review with the resident, prescriber and relevant others if the
intervention is achieving an effective and desired outcome.

A record should be made of which pain assessment scale has been chosen and why, along with
any explanation given to the resident, their level of understanding and how this scale will be used
to measure the pain.

The next few pages contain examples of pain assessment tools that you may find helpful.

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Visual scales

Each face shows how a person in pain is feeling. The patient can point to the face that best
describes their pain

Wong-Baker Faces Pain Rating Scale

Verbal scales

a) This scale can be used to describe the degree of discomfort by choosing one of the vertical
lines that most corresponds to the intensity of pain.

b) Verbal descriptor rating scale (5 points) 29
None
Mild
Moderate
Servere
Very severe

c) Verbal numerical rating scale
“On a scale of 0 to 10, please tell me how severe your pain is today’

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The Abbey Pain Scale

The Abbey Pain scale is best used as part of an overall pain management plan. It is designed to
help assess pain in residents who are unable to clearly articulate their needs.

Ongoing assessment

The scale does not differentiate between distress and pain, so measuring the effectiveness of
pain-relieving intervention is essential

Recent work by the Australian Pain Society recommends that the Abbey Pain Scale be used as a
movement-based assessment. The staff recording the scale should therefore observe the resident
while they are being moved, e.g. during pressure area care, while showering etc.

Complete the scale immediately following the procedure and record the results in the resident’s
notes. Include the time of completion of the scale, the score, staff member’s signature and action
(if any) taken in response to results of the assessment, e.g. pain medication or other therapies.

A second evaluation should be conducted one hour after any intervention taken in response to the
first assessment, to determine the effectiveness of any pain-relieving intervention.

If, at this assessment, the score on the pain scale is the same, or worse, consider further
intervention and act as appropriate. Complete the pain scale hourly until the resident appears
comfortable, then four-hourly for 24 hours, treating pain if it recurs. Record all the pain-relieving
interventions undertaken. If pain/distress persists, undertake a comprehensive assessment
of all aspects of resident’s care and monitor closely over a 24-hour period, including any
further interventions undertaken. If there is no improvement during that time, notify the medical
practitioner of the pain scores and the action/s taken.

Adapted from Jenny Abbey (2007)

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Pain management strategies – things to consider

• Analgesic medication
• Positioning/repositioning
• Supporting a limb
• Ensure basic comfort needs are met
• Moderate physical or leisure activity – things to take mind off pain

Principles of pain management

• Ensure resident has access to prescribed analgesia and that this is given as intended by the
prescriber

• Ongoing assessment and review to ensure maximum benefit and minimum side effects
• Accurate and up to date documentation – for example MARs/care plans/daily entries
• Good, effective communication with prescriber
• If you are unsure about any aspect of pain management seek advice from a prescriber or

practice pharmacist

References and useful sources of information

Pain in Older People with Dementia: A Practical Guide, 2007, Dr W McClean with C Cunningham,
Dementia Services Development Centre

Pain in Dementia – factsheet, 2005, Dr Elizabeth Sampson and Ginette Kitchen, North West
Dementia Centre

Pain in older people, 2008, Arun Kumar and Dr Nick Allcock, Help the Aged, University of
Nottingham

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Medicines – the key points you
need to know

Your care home should have a medicines policy. This policy should
include written processes for:

• sharing information about a resident's medicines, including when
they transfer between care settings

• ensuring that records are accurate and up to date
• identifying, reporting and reviewing medicines-related problems
• keeping residents safe (safeguarding)
• accurately listing a resident's medicines (medicines reconciliation)
• reviewing medicines (medication review)
• ordering medicines
• receiving, storing and disposing of medicines
• helping residents to look after and take their medicines themselves (self-administration)
• staff administering medicines to residents, including staff training and competence

requirements
• staff giving medicines to residents without their knowledge (covert administration)
• staff giving non-prescription and over-the-counter products to residents (homely remedies), if

appropriate

Ordering medicines

• Staff should have protected time to order medicines and check medicines delivered to the
home

• Staff who have had the training required should retain responsibility for ordering medicines
from the GP practice and should not delegate this to the supplying pharmacy

Storing and disposing of medicines

Care homes must comply with the Misuse of Drugs Act 1971 and associated regulations when
storing controlled drugs. Care home providers should include the following information in their
process for storing medicines safely:

• how and where medicines are stored, including medicines supplied in monitored dosage
systems, medicines to be taken and looked after by residents themselves (see help residents
to take their medicines for themselves in this pathway) controlled drugs, medicines to be stored
in the refrigerator, skin creams, oral nutritional supplements and appliances

• secure storage with only authorised staff having access

• the temperatures for storing medicines and how the storage conditions should be monitored.

Care homes should assess each resident's needs for storing their medicines and should provide
storage that meets the resident's needs, choices, risk assessment and type of medicines system
they are using.

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Before disposing of a medicine that is still being prescribed for a resident, staff (registered nurses
and social care practitioners working in care homes) should find out if it is still within its expiry date
and if it is still within its shelf-life if it has been opened.
When disposing of medicines and removing medicines classed as clinical waste, care home
providers should have a process for the prompt disposal of:

• medicines that exceed requirements

Medicines Administration

A MAR chart (which stands for medicines administration record) is often used to record when
medicines have been administered to residents.

The MAR chart is not a legal prescription but is a record of administration and may contain
different sections for medicines administration, for example the regular medicines needed every
day by the resident, and medicines that can be given if the resident requires them (e.g. painkillers).

It is important to make sure the resident is not overdosing on a medicine that is documented in
both sections (regular use and when needed). Some medicines are not required to be taken every
day and should be taken once every week, e.g. alendronate or risedronate. It is important to cross
through the days the medicine is not needed on the MAR chart.

There are medicines that require special instructions for handling if the resident is not self
administering. These include medicines such as methotrexate. Details of medicines with specific
handling requirements should be included within the care home medicine policy.

If a resident is away from the care home e.g. visiting relatives or going to hospital, the resident
should go with the medicines they need. Details of the medicines taken should be recorded in the
residents care plan.

There are ‘five rights’ of medication administration. By following the ‘five rights’, the risk of
medication errors and therefore harm is reduced. Before administering medicines always check
that it is:

• The right resident
• The right medicine
• The right dose
• The right route
• The right time

Be aware that if some medicines are delayed in administering it may be harmful to the resident,
e.g. medicines for epilepsy, medicines for diabetes, medicines for Parkinsons disease, anti-
rejection medicines following transplant, antibiotics, anticoagulants such as warfarin.

Despite medicines being used to cure, treat or prevent disease, no medicine is completely safe
and all have the potential to cause harm, especially if they are not taken or used as prescribed.

Individuals respond to medicines differently and so the risks of side effects (or adverse reactions)

also differ. Side effects may result in a hospital admission. Some side effects may be expected e.g.

feeling drowsy after taking sleeping tablet; whilst others may be unpredictable e.g. allergic reaction
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to a new medicine. Side effects can be responsible for a change in a resident’s condition and so
questions to ask when a resident has a problem or change in condition include: Has the resident
recently been started on a new medication? Had a change in medication? Reduced or increased a
dose? Stopped a medication?

Side effects tend to increase with age (due to decline in function of kidneys and liver, which can
increase the active concentration of medicine in the body). The number of medicines taken also
increases with age. Some common side effects seen in older people are:

• Drowsiness and dizziness – which may contribute and /or lead to a resident falling
• Stomach disturbances (e.g. diarrhoea, constipation, vomiting)

Certain drugs may be more frequently associated with side effects in older people, e.g.
anticoagulants (such as warfarin), NSAIDs (such as ibuprofen), diuretics (such as furosemide),
and antibiotics.

Tips for keeping residents safe with their medicines

Maintain accurate and up to date resident records (for example MAR charts, care plans, resident’s
daily entries) including a resident’s allergy status.

If a resident’s condition changes, a new problem develops or any concerns are noticed, care home
staff should report these to the prescriber (and pharmacist) as soon as possible.

Ensure you have access to up to date information regarding medications and know where to
access this information. Patient Information Leaflets (PILs) that come with a resident’s medicine
are a good first line resource that can help you to understand what a medication is for, how it
should be given and be stored. PILs can also help explain some of the potential side effects which
may be experienced.

Some examples of available medication resources:

Patient Information Leaflets – these can be obtained from the Electronic Medicines Compendium
(EMC) website www.medicines.org.uk

Mid Essex CCG Care Home Prescribing guides. http://midessexccg.nhs.uk/your-health-services/
medicines-optimisation/general-prescribing-guidance

BNF – available in paper format published every 6 months and online www.bnf.org

Register with the MHRA (Medicines Healthcare Regulatory Agency – www.mhra.gov.uk) for drug
safety and medical devices alerts and information.

NHS Choices www.nhs.uk

Clinical Knowledge Summaries https://cks.nice.org.uk/

References and useful sources of information

NICE Managing Medicines in Care Homes Guidance March 2014 35

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Sore Throat, Cough, Colds and
Flu-Like Symptoms

These illnesses can be common in care homes. The flow diagram
below may help you in knowing who to contact and when.

Please note: a resident has a fever if their temperature is measured
above 37.9C or 1.5C more than their usual/baseline at least twice in
24 hours.

Coughing associated with eating/drinking could indicate a swallowing problem. For advice contact
the community speech and language therapy (SLT) team on 0300 131 0111.

Does the resident Check the patient information leaflets (PILs) for Yes
have a sore throat, all medication the patient is on to see if symptoms
cough, cold or flu are a known side effect of the medication.
like symptoms?

Yes Check Long Term Condition care plans for more Contact GP/OOH
detail for plan of care if known side effect of
medication urgently (or as
advised as per PILs

or care plans) for

advice, advising

Undertake each of the following steps of symptoms and
• Discuss with ESDAAR Nurse medications
• Record temperature and monitor 4 hourly No Check Long Term
Condition care
for changes plans for more detail
• Give Paracetamol (if prescribed and for plan of care if
known side effect of
suitable). If Paracetamol is given expect medications.
to see a reduction in temperature after 2
hours

• Encourage deep breathing

• Keep the resident comfortable and rested,

either sitting up or lying on their side If the following apply to the resident:
• Monitor pressure areas and give care

appropriately • No improvement in condition after 3 or 4
days or
• Encourage increased fluid intake (unless
• Has flu like symptoms see link below
usually restricted on medical advice), see
pages 41 to 44 • Coughs up blood or green sputum or
• Try to minimise contact with other
• Is suffering from sore throat and pain or
residents, observe for similar signs and

symptoms developing in others • Resident has a long term medical

condition such as diabetes, heart

disease, COPD, kidney disease,

weakened immune system

If the resident experiences breathing • Temperature not falling/keeps rising
difficulties or chest pain.
Contact ESDARR Nurse as a matter
Call 999 of urgency – see page 11.

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Chronic Obstructive Pulmonary Disease –
(COPD)

What is COPD?

COPD is caused mainly by smoking and is often referred to as chronic bronchitis or emphysema.
Chronic means that the problem won’t go away but can usually be controlled. There is no cure for
COPD but medicines will help to control the symptoms.

A patient with COPD will have narrowed and damaged airways and find it harder to breathe. Their
airways will also become inflamed, which causes coughing and excess phlegm.

Without realising it many people cut back on what they do due to breathlessness. This makes
simple activities feel harder as breathlessness increases.

People with COPD may have worsening symptoms from time to time, called acute exacerbations.
It is important to recognise the signs of an ‘exacerbation’ (flare up) and step up the treatment. It
makes it easier to manage the condition and hopefully prevent hospital admissions.

Preventing Deterioration

It is important to recognise the signs of an ‘exacerbation’ (flare up) and step up the treatment. It
makes it easier to manage the condition and hopefully prevent hospital admissions.

The treatment plan, on pages 38 to 40, is one way of managing COPD. It will help to recognise
what is normal and what to do when it’s not. The patient’s clinician will talk it through and fill in the
treatment plan that should be followed. The doctor will advise if pre-emptive treatment is required
in case of an exacerbation.

Please check routinely that the patient’s inhaler technique is adequate, their inhaler device and
spacer are clean and there are doses still in the inhaler.

Emergency – Severe Symptoms

• Very short of breath at rest
• Chest pains
• High fever
• Reduced level of consciousness or confusion

DIAL 999 – FOR AN AMBULANCE

Offer extra reliever inhaler/nebuliser whilst waiting for
ambulance to arrive.

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COPD Plan

Guidance for managing a COPD exacerbation in a care home setting

This guidance has been produced to help care home staff manage an exacerbation of COPD - to
consider treatment and prevent an avoidable hospital admission.

Good Practice for the Care Home

This guidance is intended to be used as a framework for care home managers to adapt when writ-
ing their own process for managing a COPD exacerbation.

Consider a member of staff to be “respiratory champion” for the care home. This member of staff
will have some knowledge about COPD and how the pre-emptive process will be managed in the
care home.

A designated storage facility will be required to store the Rescue Pack and Separate MAR chart
until required for use.

Good practice 1 – setting up rescue packs

• Agree with clinician that pre-emptive COPD medication is considered an option for the service
user. Clinician to complete the appropriate sections on the treatment plan

• Check the clinician completes all fields on the treatment plan
• All appropriate care home staff will be informed about the pre-emptive COPD process and how

the service user may present when having a COPD exacerbation, the non pharmacological
interventions and the prescribed Rescue Pack for the individual service user
• The treatment plan for managing COPD exacerbation is documented in the care plan for the
service user
• Check and log date of review of the pre-emptive prescription to ensure this is up to date

Good Practice 2 – requesting and receiving the Rescue Pack for COPD exacerbation

• Receive active prescription for Rescue Pack from the clinician – decide whether to hold this
prescription until medication is required for use, or have the prescription dispensed straight
away.

Note. If not dispensed ensure plan includes access to pharmacy out of hours.

Factors to consider

Not dispensed prescriptions are valid for 6 months from date prescribed

Liquid antibiotics that have to be reconstituted have a limited life span

Medicines dispensed in MDS have a two month expiry date therefore should be supplied
using original packs

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If dispensed straight away:

• Ensure pharmacy is aware that this treatment is for pre-emptive treatment prior to dispensing –
check the prescription states ‘pre-emptive

• Check treatment is correct on arrival in care home
• Ensure the separate MAR chart is endorsed with ‘pre-emptive COPD exacerbation treat-

ment’, highlighting it is only to be used when it is agreed the service user is having COPD
exacerbation. The MAR chart is held in designated storage area alongside the medication until
required
• Ensure treatment is stored with this MAR chart in a locked facility away from regular medicines
and staff are aware where this storage is
• Ensure there are routine checks, if applicable, on the:

• Expiry date of the prescription
• Expiry date of the dispensed treatment

Good practice 3 – administering medication for COPD exacerbation

• Identify if it is appropriate to dial 999 – see box page 37
• Gain agreement by contacting the Community Respiratory Team that medication for COPD

exacerbation can now commence
• Access medication and check that it is still ‘in date’
• If patient regularly uses a spacer device, use spacer device to assist patient to inhale treatment

effectively
• Administer medication as prescribed
• Record administration on the MAR chart ensuring that the start date is included
• Inform Community Respiratory Team that treatment has commenced
• Record effect of treatment
• Contact Community Respiratory Team to request review

Ensure clear robust documentation in the care plan highlighting relevant communication with
Community Respiratory Team.

References and useful sources of information

COPD information pack – NICE CG101 COPD
http://guidance.nice.org.uk/CG101

Treatment Plan – Managing a COPD Flare Up – see pages 38 to 40.

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Treatment Plan – Managing a COPD Flare Up

CCG guidance describing management of COPD exacerbations can be accessed at the following
website address:

http://midessexccg.nhs.uk/your-health-services/medicines-optimisation/clinical-pathways-and-
medication-guidelines/chapter-3-respiratory-system-2

Worsening symptoms What to do
Contact and confirm with Community
• More breathless and wheezy than normal Respiratory Team whether to start rescue
• Need to use reliever inhaler, nebuliser more medicines as per treatment plan

than normal Useful Advice
• Fever (a temperature of 38°C (100.4°F) or
• Enable more time for rest
above is usually considered to be • Encourage relaxation techniques
• significant) • Encourage clearance of sputum with
• Change in amount and/or colour of sputum
huff and cough techniques – see COPD
(green or blood stained) information Pack
• Cough – new or increased • Offer small amounts of food to be eaten
• Loss of appetite regularly rather than a large meal
• Increasing tiredness and/or poor sleep • Offer plenty of fluids and keep a fluid chart
• Reduced energy for daily activities • Encourage sitting up
• New or worsening confusion

If symptoms become too severe – dial 999

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Hydration and Nutrition

Water and fluids are essential to health and make a valuable
contribution to the quality of health in the older person.

Unfortunately, it is well known that many older people, including care
home residents, do not drink sufficient amounts of fluid. This may be
for a variety of reasons which can be complex (see page 42 for more
information). However, this puts residents at risk of dehydration which
can be dangerous.

It is important to know that:

• All residents are at risk of dehydration – see page 42 to help you identify residents who are at
greatest risk

• During times of ill health and periods of hot weather, or in a very warm care home environment,
residents are likely to need increased fluids, unless restricted on medical advice

Recommended fluid intake

‘There must be provision to ensure patients (residents) are able to access a minimum of 1.5 litres
of fluid per day.

Provide a minimum of seven to eight drinks throughout the day (number depends on volume)’

Source: The British Dietetic Association ‘The Nutrition and Hydration Digest: Improving Outcomes through
Food and Beverage Services’ 2012, Appendix 2, page 123

Please note: the fluid content of food should not be included in the general 1.5 litres of fluid per
day.

Ways to achieve a minimum of 1.5 litres of fluid per day

Suggested drinks for residents during the day include:

• Pre breakfast: tea/coffee/milk (200ml)
• Breakfast: fruit juice (100mls) + tea/coffee (200ml)
• Mid-morning: tea/coffee/glass of milk/fruit smoothie (200ml)
• Lunchtime: squash (200ml)
• Mid afternoon: tea/coffee/squash/milk (200ml)
• Tea time meal: water/squash/ tea/coffee (200ml)
• Supper: hot milk drink e.g.Horlicks/Ovaltine/ cocoa (200ml)

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The Care Home Manual Section Two - Clinical

Dehydration screening tool

Things which can increase the Yes No Signs and symptoms that Yes No
risk of a resident becoming a resident is/has become
Dehydrated Dehydrated
Dementia Irritability (out of character)

Dysphagia (swallowing Changes in behaviour or ‘usual
difficulties), residents on texture behaviours’ e.g. confusion
modified fluids/diet
Reduced urine output (Oliguria)
Leaving or refusing drinks
Concentrated urine i.e. dark not
Dependency pale straw like colour

Poor dexterity Urinary tract infection (UTI)
(hand to mouth co- ordination)
Constipation
Communication difficulties/unable
to make needs known Sudden (acute) changes in body
weight
Impaired vision
Muscle weakness – loss of
Prescribed medications which strength
cause dry mouth
History of unintentional weight
Mouth breathing loss

Acute disease/infection (fever, Fatigue
chest infection, vomiting)
Drowsiness
Pressure sore/wounds
Sunken eyes
Raised temperature
Cold hands and feet
Fluid restricted on medical advice
eg. Heart Failure Dry, less elastic skin

Intentional restricting of fluid (due Unpleasant taste in mouth
to fear of incontinence)
Urinary tract infection (UTI)
Prescribed diuretics
Dry mouth, cracked lips
Urinary tract infection (UTI)
Low blood pressure
Incontinent – Urine
Headaches
Episode of diarrhoea and / or
vomiting Pressure sores/wounds

Loose stools – diarrhoea A resident with any number of the above
signs and symptoms should be discussed
End of Life (EoL)- in the last few with a GP. Check GP crisis management
days of life your resident may
start to reduce fluid intake, seek plan, EoL plan.
medical advice to rule out other
causes

When you have identified the risks you need 42
to describe how you will manage them in the

relevant care plan/s – see example page
53. For more information about writing care
plans see Local Working Agreement & Care

Planning Toolkit (LWA&CPT).

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The Care Home Manual Section Two - Clinical

Important information about using fluid intake and output charts

The amount of fluids residents take IN and pass OUT are very important to their overall
care and wellbeing

If intake and output is recorded it must be done accurately and the totals discussed with
other members of the care team. In care homes, it is the responsibility of the nurses to
ensure this is undertaken accurately if delegated to other staff members

The reason for charting fluids IN and OUT should be stated in the resident’s care plan

Only the actual amount of fluids drunk are classed as ‘intake’. In addition some charts also
ask for the amount ‘offered’ to be recorded

Only the actual amount taken at the end of the 24-hour period should be included in the
total ‘IN’ column

Fluids not consumed by this time should be carried forward and entered on the next days
chart

Never chart fluids taken unless you know they have been taken

Never fill in charts at the end of the morning, afternoon or shift as this results in inaccuracy
– do as you go along

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An example of a fluid intake & ouput record

Name: ALBERT JOHN PICKERING DoB: 12/04/1933 NHS Number: 123456789101234

Target fluid intake: 1,500mls fluid in 24hrs Fluid restricted on medical advice? Y / N

Time Type of oral fluid Amount of Running Feeding Urine Urine via Other -
Wet pad catheter Vomit,
and amount offered fluid taken total tube Diarrhoea,
n/a Specify
taken

B/F Tea 100mls 100mls 100mls n/a
200mls
08:00 Milk 100mls
09:00 (Cereal) 300mls
100mls 350mls
10:00 Tea 150mls 50mls
Water for tablets
100mls

200mls

11:00 Tea 150mls 100mls 450mls

12:00 Soup 150mls 150mls 600mls
13:00 Water for tablets 50mls 650mls

Tea 150mls 100mls

14:00 Sleeping refused Wet pad
500mls
15:00 Tea 150mls 100mls 850mls
1050mls wet pad
16:00

17:00 Water 200mls 200mls

18:00

19:00

20:00

21:00

22:00 Hot chocolate 200mls 1250mls
23:00 200 mls

24:00

01:00

02:00 Wet pad

03:00 Sips of water 50mls 1300mls

04:00

05:00

06:00 Cup of tea 200ms

07:00

Total 700mls and 44
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The Care Home Manual Section Two - Clinical

Acute Kidney Injury

‘Acute’ is a term used to describe something that has occurred over hours or days.

‘Kidney injury’ describes evidence of damage to the kidneys usually with a change in the kidney
function.

The best way to assess kidney function in the short term is to measure a waste product in the
blood called creatinine and also to assess urine output.

AKI is common, serious and harmful. The NHS is the first health system in the world to tackle AKI.
It is recognised as a patient safety priority by NHS England. The Think Kidneys programme aim is
to raise awareness of AKI among health and care professionals so that care for people with AKI is
transformed and rates of AKI are reduced.

Causes and risks

The causes of AKI are many and varied and occur most often in people living with long term
conditions, although it can affect anyone. It can occur as a result of an infection causing stress
on the kidneys, dehydration reducing the flow of blood to the kidneys or the altered effect of
medication caused by illness, surgical or radiological procedures.

The most common underlying risk factors for AKI include:

• pre-existing chronic kidney disease
• age – people aged 75 years or over
• heart failure
• vascular disease
• diabetes
• liver disease

AKI may then be triggered by:

• infection (sepsis)
• dehydration, bleeding (hypovolaemia)
• low blood pressure (hypotension) – for example after a serious heart attack
• certain medications or drugs – this includes prescribed and over the counter medicines

AKI is a challenge for us all. It is a cause of harm and death, yet in many instances we can stop it
happening or improve outcomes by detecting it early.

Care Homes and AKI

The Think Kidneys learning guide has been created for people who work in care homes (both
nursing and residential homes) and it consists of activities to help you understand what acute
kidney injury is, and what you can do to help prevent it. The guide has been designed for nurses
and care home managers to learn more about acute kidney injury (AKI), and to enable you to
share this learning with care home support workers, care home residents and their families. This
guide can be used to support your hydration policy.

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The guide can be found here https://www.thinkkidneys.nhs.uk/aki/wp-content/uploads/
sites/2/2016/02/Care-Homes-AKI-guide-FINAL-160217.pdf.

Wherever you work and whatever your role in health and/or care you should be aware of AKI. This
guide will enable you to understand how to reduce the risk of AKI for residents in your home.

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