Medical Care, Nursing, and

Rehabilitation

Attending Physician

• A generalist or family practitioner in the community

• Patient has the right to choose his or her attending physician

• But, the physician must agree to deliver care and to comply with regulatory standards and the facility’s policies

Unique Aspects of Medical Practice• Physician visits are infrequent, but must comply

with regulatory standards• Nurses render most of the care in accordance with

physicians’ orders• Shared communication and collaboration between

physicians and nurses• Physician is involved in multidisciplinary

teamwork• Referral to specialized services when needed

Medical Director

• Every facility must have one

• A part-time position (2 to 4 hours per week in an average size facility)

• Reports to the administrator

• Key personal traits

• Knowledge of geriatrics

Areas of Special Focus in Geriatrics - 1

• Comorbidities• Complications resulting from chronic diseases• Negative drug interactions• Response to treatment may vary from that in

younger patients• Separating treatable symptoms from changes that

commonly accompany aging

Areas of Special Focus in Geriatrics - 2

• Hydration and nutrition

• Possible impaired metabolism

• Loss of skin turgor

• Psychological disorders

• Palliative care

Separation of Functions

The consulting role of the medical director must be separate from his or her practice as the attending physician even though the latter provides important insights into patient care

Anti-kickback Legislation

• Prohibits gifts or favors in exchange for patient referrals (see p. 143)

• Particularly when the medical director attends to a large number of patients in the facility, patient referrals by the facility may be construed as a favor in exchange for consultancy fees

Medical Director Roles

• Oversight

• Advisory

• Teaching

• Representative

Organization of the Nursing Department

Administrator

Resident Assessment Coordinator

Medical Director

DON

ADONMedical Records

In-Service Director

Charge Nurses

CNAs Staff Nurses

Main Responsibilities of the DON

• Staffing

• Training

• Patient care

• Policy

• Administration

Ensuring Consistent Quality

• Develop policies, procedures, and practice guidelines

• Use them for reference and training

• Review and revise these protocols

Resident Assessment• First step in the delivery of patient care• Serves two main purposes:

– Evaluate each individual patient’s strengths and needs

– Track important changes in the patient’s condition

• Multidisciplinary• To be completed or coordinated by an RN

RAI

Resident Assessment Instrument (RAI)– Minimum Data Set (MDS)– Resident Assessment Protocols (RAPs)– Utilization Guidelines

MDS

• Focuses on a core set of screening, clinical, and functional status elements

• Triggers = risk factors

Revealed during the assessment process

• Triggers call for additional review and assessment using RAPs

Care Delivery Sequence

Assessment

Plan of care

Delivery of care

Evaluation of outcomes

Plan of Care

• Driven by assessment

• Incorporates approaches for addressing problems and needs:– what the resident can do – potential for improvement– action and interventions from staff

• Progress goals

Infection Control

Goals:

• To protect residents, staff, and visitors from contracting infections

• Prevent the transmission of infection

Components of an Infection Control Program

• Policies and procedures

• Screening

• Infection control practices

• Surveillance

• Education

• Control of infectious outbreaks

Falls: Contributing Factors• Intrinsic (medical)

– Effects of drugs

– Cognitive impairment

– Visual impairment

– Frailty

• Extrinsic (environmental)– Poor lighting or glare

– Wet floors

– Loose objects

Fall Prevention• Evaluate risk factors• Teach new residents how to safely navigate within

the room• Strength training and transfer skills• Nursing supervision and monitoring• Drug management• Environmental safety• Focus on chronic fallers

Pressure Ulcers: Main Causes

• Sitting or lying in one position

• Friction against the skin

• Prolonged exposure to moisture, such as from urine or feces

• Poor caloric and protein intake

Pressure Ulcers: Predisposing Factors

• Neurological disease

• Cardiovascular disease

Pressure Ulcer Prevention• Proper nutrition and hydration• Proper bed-making• Proper patient positioning and repositioning at

least every two hours• Pressure relief• Keep the patient clean and dry• Skin inspection and care• Mobility

Legal Use of Restraints

• To be used only when medically necessary

• Use must be temporary

• Under physician orders

• Close supervision by nursing staff

Managing Urinary Incontinence• Focus should be on transient (reversible) causes

such as UTI, delirium, pharmaceuticals, etc., and more serious conditions such as bladder cancer

• Treatment of underlying causes• Voiding schedules, staff assistance, exercises• Catheters to be used only when other measures

have failed

Pharmaceutical Management• Consultation from a licensed pharmacist• State law governs dispensing and labeling• Locked storage• Among other oversight functions, monthly review

of each patient’s drug regimen• Negative drug responses• Emergency medication kit• Safeguarding of controlled substances

Reduction of Psychotropic Drug Use

• Use is governed by law (OBRA-87)• Specific conditions indicating use must be

documented• Gradual dose reduction whenever appropriate• Evaluation of underlying causes for behavioral

problems• Nonpharmacologic approaches must be tried first

Rehabilitation

Main goals:

1. Restore or improve function

2. Maintain residual function and prevent further decline

3. Enable adaptation to functional deficits