Clinical Assessment Recognises Subtle Changes

Our eyes see what is familiar and what they expect to see.  Are we good at picking up subtle changes through your assessment processes and acting on them appropriately?  The ability to see the less than obvious is essential when responsible for clinical assessment as you won’t act on those things you haven’t noticed.

On the 5th July I presented a full day seminar on a range of topics to Nurses working in aged care.  During the day I made what should have been an obvious change but I have no doubt it wasn’t noticed by all.  In the morning I wore a dress with a white jacket. In the afternoon I’d changed the dress for one of a different colour and pattern but retained the white jacket.  I made the change during the lunch break.

When I entered the room after the lunch break three people commented straight away.  I saw a small number of puzzled looks but those nurses didn’t say anything.  Others didn’t seem to notice and didn’t make comment.  We had three distinct groups.  Those that notice and comment, those that notice but don’t comment and those that don’t notice and therefore don’t comment!  Which are the nurses you’d feel safest with if it came to performing a clinical assessment on you on an ongoing basis day after day?  Which differences would they notice and which wouldn’t get a second glance. Which changes would be commented on?

We need a mix of ‘detail’ thinkers and ‘big picture’ thinkers to see everything that occurs.  Equally these two groups of people can complement each other.  Working separately they will each only see part of what needs managing.  Some over think and others don’t seem to think or reflect.  Awareness of how the members of your nursing team work and think could be important in supporting you to minimise risk resulting from subtle changes occurring which may not have been addressed.

It may be beneficial to review personality types to see how your team are working separately or collectively to ensure the best outcome for residents in their care. This increased recognition of each others natural thinking styles may also enhance the ability of the team to understand each other and consciously support others differences.  There are a raft of profiling tests however Myers Briggs has been around as a validated tool for a long time and may be a useful one for you and your team.

What subtle changes are occurring with your residents that you haven’t noticed?  Did you see the white dress in the morning change to a black one in the afternoon? If not, what else are you not seeing that could expose someone to risk?  Are any of your team seeing things but not saying anything because they don’t recognise it’s their responsibility or think someone else has commented?

/by

Weight management goals in care planning

When care planning, the goals or objectives developed for each aspect of care need to be measurable.  This ensures you’re able to evaluate progress and determine whether the goal has been met or not.  The concern is making sure an appropriate goal is set.  While we look at this from a clinical perspective, we must always remember the resident as the central focus and director where they are able to provide input into what the care plan relays.  People have choice within their capacity and sometimes as nurses, we may not agree with a choice made by our patients / residents in aged care.

When guiding weight management goals from a clinical perspective, Liz Beaglehole, Registered Dietitian has offered the below guide.

Ideal weight range in the care process: 

Body mass index is still helpful in determining healthy weights for older adults.  A healthy BMI range for adults over 65 actually shifts upwards as compared to adults. So a healthy BMI for older adults has been found to be BMI – 22 – 27kg/m2. A BMI above 32kg/m2 would suggest obesity, a BMI below 20 suggests underweight, and below 18.5 is malnourished.

To work out the BMI: (weight/height²).  Example case:  height = 1.5m and weight = 45kg

  1. We need the height in metres and the weight in Kg.
  2. The height needs to be squared. So a height of 1.5m = 2.25 when squared.
  3. Then the BMI is the weight in Kg divided by the height²

Example:  weight = 45kg divided by 2.25 = BMI of 20kg/m².  This is regarded as the lower end of ideal body weight and suggests the resident is underweight for optimal health.

An ideal body weight for some who is 1.5m tall would be a BMI range of 22 – 27 so a weight range of min 50kg up to around 60kg.  Basically to work out ideal body weight just enter different weights into the BMI calculation until you get to the BMI of at least 22 and then again to a BMI of around 27.

The ideal body weight may differ to the GOAL weight.  The goal weight may be something that is set when the BMI is outside the ideal range but some weight changes are desirable.  The goal weight is more useful and practical as it considers the weight history of the resident and the ability to achieve changes in weight.  For example, a resident may be underweight with a weight of 42kg (BMI= 18.6) but they have been this weight for the past year.  Ideally they would gain weight to 50kg, but this is unrealistic.  The goal weight therefore becomes either weight stabilisation at 42kg or a slight weight gain to 44kg.  This would still mean the resident is underweight but is realistic in what can be achieved.  If the initial goal weight is achieved, a second goal weight may be identified.  This may be to stabilise weight at 44kg or to gain to 45kg.  etc…

This can work for overweight residents too.  Using the same example height of 1.5m.  Someone who weighs 78kg has a BMI of 34.6, and is obese.  However, realistic weight loss to within the ideal body weight range would suggest the resident would need to lose around 18 – 28kg, which is completely unrealistic and would never be suggested for aged care.  A more realistic GOAL weight would be weight stabilisation and then some weight loss.  5% weight loss can improve many health outcomes and this would be a realistic target.  Weight loss of 5% is still around 4kg, which is possible but still difficult.

Article contributed by: Liz Beaglehole (NZ Registered Dietitian), Canterbury Dietitians

/by