TRANSFERS
Marie needs you to place the w/c by her bed first thing in the morning, ensuring to lock the brakes.
What is Independent with Set Up?
Marie is able to reposition herself throughout the night. Every 2 hours, CNAs enter the room to check on her. If she is awake, offer her a drink of water.
What is independent with no setup?
Rose is sitting in the hallway in her w/c. It is about time for supper. As I walk by, I instruct her that it is time to make her way to the MDR for supper. I point down the hall to give her a sense of direction. She begins to self-propel towards the MDR.
What is supervision with no setup help or physical help?
Bill is evaluated by speech therapy and noted to be at risk for aspiration. It is recommended that someone be at his table during meal time. He also has cue cards to be placed in front of him during meals for swallowing strategies. Staff put his plate in front of him and sit down to assist another resident.
What is supervision with no set up?
Jenny is taking a whirlpool bath. I assist her with transferring into the tub chair. Once in the tub, she washes her arms and legs with the wash cloth I hand her. I wash her back for her and it is her day for the beauty shoppe, so I shampoo her hair as well. Once out of the tub, she dries herself off and I offer stand by assist for dressing. How do I code bathing?
What is physical help limited to transfer only?
ADL support provided: dependent upon how you helped with the transfer. Did you watch, did you guide, did you lift??
Joe requires you to set the w/c at the side of the bed. Requires you to assist his legs out of bed. Once in sitting position, Joe uses the slide board to transfer to his chair while you monitor for safety.
What is Supervision with Set Up help?
Remember, we are not talking about bed mobility here, transfers.
Flo has suffered a stroke affecting her left side. Her left arm is flaccid and legs are weak. I am turning her to her left side, she is able to grab the assist bar with her right arm and pull herself over, my hand guides her onto her left side, I then place a pillow behind her back.
What is limited assistance with 1A?
Harry has an electric w/c that he controls and is safe with. Once in w/c, I place his feet on foot pedals and his right arm in position to control After transferring him into the chair, the battery fails and is unable to turn on. The staff must put it in manual mode and push him to supper. I have already documented independent with set up for earlier in my shift. How should I code locomotion off unit now? On unit?
What is dependent with 1 staff assist?
Lu Lu has had a stroke. I am assisting her with her meal. Goal is to promote independence as much as possible with her. She is able to feed herself- BUT IT TAKES FOREVER!! I assist her with her meal by putting the food on her spoon and giving her bites. I also pick up her drinks and hold them to her mouth.
What is total dependence with 1 Assist?
I notice a red area to Mavis' right neck crease while I am bathing her. I ask the nurse to come in to look but for some reason she is unable to at this time. I don't want to forget to tell her about this. What should my next action be?
What is fill out a STOP AND WATCH TOOL!
Irene is capable of moving into a standing position from her chair. I am the CNA in the room and she is moaning and confused on what I am asking her to do. I place her hands on the chair, remind her to push up and hold onto the gait belt for safety. She pushes up from the chair and grabs her walker.
What is limited assistance of 1 assist?
What is total dependence with 2 assist?
Mary Jo ambulates independently in her room with stand by assist for safety after I place her walker in front of her. She does NOT use a w/c. I have documented for locomotion in room: supervision with set up help only. I have documented for walk in room: limited assistance with 1 assist. Which is correct or are they both correct? What situation could both documentation scenarios be correct?
What is supervision with set up help only?
What is if they ambulate in their room but also use a w/c that CNAs assist?
Lu Lu is at lunch, I am assisting her again. I seem to have more patience at this meal and I allow her to feed herself. She struggles at times to get the spoon to her mouth, so I guide her hand the last few inches so the spoon enters her mouth without spilling.
What is limited assistance with 1 assist?
Sally ambulates with FWW and staff assistance. Staff hold onto the gait belt while ambulating to meals. She has a shuffling gait and cues are given to take BIG steps. We make it to the dining room and she sits down at the table for the meal.
What is limited assistance with 1 Assist?
What would make this situation extensive assist?
Don is independent in his room. I see him at all meals and activities throughout the day. I provide no assistance to him at all. How do I code Don's transfers?
What is Independent with No set-up of help from staff?
Don usually is independent with maneuvering himself in and out of bed. Today, however, I am in his room visiting with him before lunch, when I notice his foot is caught on the blanket while trying to sit up, I reach over and assist his foot from being tangled and then he sits up in bed. I have already charted his bed mobility as Independent. What should I do?
What is chart Limited Assistance of 1 person?
Terry ambulates with FWW to all meals. One staff member assists him into standing position and then holds onto the gait belt to help keep Terry standing as he walks to meals. Terry is able to maintain almost all of his weight. A second staff member follows Terry and you with the wheelchair in case he needs to rest.
What is Extensive Assistance of 1 assist?
It is the middle of the night, James puts on his light and requests a drink of water. It is midnight and his glasses are not on. Normally independent with eating/drinking, he asks you to hold the cup and straw for him. He takes a few swigs and says goodnight.
What is total dependence of 1 Assist?
I enter Ethel's room at 6:00 a.m. I assist her in dressing her bottom half while in bed. She is able to roll side to side when directed to pull up her pants. I assist her into a sitting position by lowering her legs and supporting her back, she uses the assist bar to pull herself into sitting position. She dresses her upper half. She puts on her call light and my co-worker and I use the gait belt and transfer her to the w/c in which she stands with <25% weight bearing. Once in the w/c, she is able to locomote in the room independently. By the way, she was incontinent before I got her dressed and I provided pericares while she rolled side to side in bed. I put her brief on for her.
What the heck??
Jack has suffered a stroke and has very little strength and movement on his right side. He is unable to bear weight. How should Jack transfer? How would you code this?
What is 2 assist and the hoyer lift?
What is Total Dependence with 2 Assist?
It is 130 a.m. and Judy would like a sip of water. She is awake and alert lying in bed. I place my hand upon her back and guide her to sit up in a position that she can hold the cup and drink with the straw.
What is limited assistance of 1 person?
I am walking down the hall from the MDR to the nurses station when I meet Barney. Barney is independent with ambulation and uses no assistive devices. Barney tells me he is looking for a restroom. Barney has dementia and it is just easier if I show him to his room and the restroom. I take Barney's hand and we walk down the hall to his room where I show him the bathroom. How do you code both locomotion on/off unit and walk in hall/room? Should they be the same or different?
What is limited assistance of 1 person?
Marvin is independent with cares. He eats all meals in his room per his request. Staff hand him his tray, remove the cover, unwrap his silverware and assist him with salt/pepper on food.
What is independent with set up help only?
John is in a w/c and able to self propel himself to activities and meals. Today, I am in a hurry so I tell him to put his arms on his lap and lift his legs and I give him a ride to supper. How would I code this?
What is Total Dependence of 1 person?
What is WRONG with this scenario????