Bed Mobility, Transfer, Walk in Room
Mr. Grinch needed help positioning in bed. Mr. Grinch was able to hold onto a side rail while the IP rolled him to his side. Mr. Grinch's son supported his head and legs during repositioning.
How would you document this episode of bed mobility?
Extensive Assistance / Two-person physical assist
Weight-bearing support provided, but client did participate.
Partially Met
Frosty the Snowman always wears his top hat and scarf, but he recently injured his arm branch and the caregiver has to provide all of his dressing tasks this morning. He is not able to participate at all.
How would you document this dressing activity?
Total Dependence / 1-person physical assist
Full CG support was provided; the client did not participate.
Jack Frost is recovering from frostbite on his fingers and thumbs. Due to the bandages on his hands, he is unable to brush his teeth or comb his white hair. The CG completes these tasks for him.
How would you document personal hygiene?
Total dependence
The client did not participate.
Ebenezer Scrooge is a quiet man and prefers to be in his room alone most of the time. This afternoon, during Bingo, he hits his IP, takes the box of prizes, and yells “This treasure is all mine!”
What behaviors would you document for Mr. Scrooge?
Assaultive (not during personal care): (The individual was physically abusive/ combative toward others)
and
Yelling/Screaming: (Episodes of loud vocalizations (not directed at others) that are disruptive to the environment)
Prancer, the reindeer, is usually continent of bowel and bladder (in a bathroom made specially for reindeer). Today, however, right after lunch, Prancer gallops down the hallway in a big hurry, and his IP finds several droppings just outside the bathroom door. She cleans up the floor and checks on Prancer. He says he couldn’t make it there in time, but was able to finish in the bathroom
How would you document bowel continence for Prancer?
Incontinent less than weekly: Bowel incontinent episodes occur less than once a week
While some droppings were incontinent, he was able to finish in the bathroom
Rudolph the Red-Nosed Reindeer had an unfortunate flying accident, and his hind legs are now paralyzed. Today, two caregivers transfer him into his wheelchair using a full-body mechanical lift. He is not able to assist with any part of the transfer.
How would you document this transfer activity?
Total Dependence / two person physical Assist
Rudolph was not able to participate in any part of the activity and required two caregivers to transfer with the full-body mechanical lift, which supported all of his weight.
Buddy the elf, is able to dress himself in his usual green-and-red jumpsuit. But the caregiver holds his leg and foot to put on his candy-cane socks and pointed elf shoes.
How would you document dressing for Buddy today?
Extensive assistance / 1-person physical assist
Buddy was able to assist with part of the dressing, but the caregiver provided weight-bearing/full caregiver assistance to put on socks and shoes.
Mrs. Claus and her caregiver baked cookies for the neighborhood kids. After a mishap with the mixer, she is covered from head to toe with flour. The caregiver assists her with a shower to get cleaned up. Mrs. Claus is able to transfer onto the shower chair and complete most of the bathing without assistance, but the CG provides oversight and helps wash her hair and back.
How would you document bathing for Mrs. Claus?
Physical part of bathing
CG washed her hair and back, but client was able to do all other bathing tasks.
Kevin McCallister often feels like he is all alone and is paranoid that two bandits are out to get him. At random times throughout the day and night he will place both hands on his cheeks and scream as loud as he can
How would you document this behavior?
Yelling/screaming: (Episodes of loud vocalizations (not directed at others) that are disruptive to the environment.)
and
Unrealistic fears and suspicions: (expresses fear of being abandoned, left alone, being with others. There is no basis for this fear or belief.)
and
Delusions (paranoid/persecutory delusions): (a false belief of being attacked, harassed, cheated, persecuted, poisoned or conspired against.)
Mr. Polar Bear is very upset that his CG was unable to get him an ice-cold Coca-Cola in a glass bottle, as he requested. The town seems to be completely sold out! Today at lunch he refuses to eat, stating that nothing tastes the same without the beverage. He also refuses to come to Bingo, which is one of his favorite activities
What could the CG do in this situation?
Options could include:
ask for client's preferences/choices for eating/drinking,
Mrs. Griswold injured her knee while out with family to find the perfect Christmas tree. She now has difficulty walking in her room. She requires daily assistance to help support her when she selects clothing from her closet. She is able to walk in her room with weight-bearing assistance from one caregiver.
How would you code this Walk in Room episode?
Extensive assistance / 1-person physical assist
The staff member was bearing weight while helping her walk to the closet and back.
Ralphie Parker is wheelchair bound and can only see out of one eye as a result of a BB gun accident as a child. While he is able to propel his wheelchair himself, he often bumps into walls in the hallway. The caregiver has to help him guide his wheelchair away from the wall several times.
How would you document locomotion in room?
Limited assistance / 1 person physical assistance
The CG had to guide his wheelchair away from the wall, but provided no weight-bearing assist.
The Gingerbread Man requested his caregiver assist him to the bathroom. Since he has no fingers, only a round gingerbread arm, he cannot unfasten his gumdrop buttons. The caregiver assists with buttons and adjusting clothes before he uses the bathroom. When he finished, the caregiver again helps to adjust clothes and fasten the gumdrop buttons.
How would you document this toileting activity?
Extensive Assistance / 1-person physical assist
Client is able to transfer on and off the toilet and cleanse himself independently, but needs help with clothing adjustments when using the bathroom.
A retired reindeer with dementia is found outside. He says that he is looking for Santa's sleigh and that he needs to get to work or Santa will fire him. His IP/daughter tries to reassure the reindeer that he is retired and does not need to worry about work, but he insists on staying outside looking for the sleigh. This reindeer is experiencing a sign of possible psychosis
What do you call the expression of a false belief that does not change even in the face of evidence to the contrary?
Delusion
A delusion is expression of a false belief that does not change even in the face of evidence to the contrary
Greta the penguin is on a very special diet of only fish, milk, and eggnog. For breakfast, her meal is scrambled fish fillets and a tall glass of milk. She eats all of the scrambled fish, but takes only one sip of the milk. CG had to encourage Greta to finish eating her meal.
How would you code this for eating?
Supervision because CG had to cue client to finish eating.
Phil, had to have back surgery because of all the falls he had while trying to teach Kevin McCallister a lesson for his home-security pranks. He is recovering, but the caregiver must provide verbal cues while he walks in the hallway. The caregiver reminds him to walk slowly and to stand close to the handrails or use his walker.
How would you document this Walking in the Corridor episode?
Supervision / no set-up help
The staff member was not touching him, but giving him verbal cues and reminders while he walked in the hall.
The little drummer boy, now an elderly man, still likes to practice his marching band skills. He is able to walk all the way to the activity room as he pretends to keep the beat on his imaginary drums. He becomes very tired after his walk, and the caregiver pushes him in a wheelchair back to his room, at his request.
How would you document locomotion in room for this episode?
Extensive assist
He was able to ambulate independently one way, but required full staff assist for locomotion back to his room. Since he required weight-bearing assist but participated in part of the activity, it is documented as extensive assist.
Jolly the elf just returned from an activity outing to the toy factory, where he over-exerted himself. Experiencing weakness and fatigue, his caregiver needed to help lift and steady him as he transferred to the elf-sized commode
How would you document this toileting activity?
Extensive assist
The nurse aide provided lifting or weight-bearing assist to he commode.
Aaron celebrates Hanukkah with his family and one of his gifts is gelts (chocolate coins wrapped in gold foil). When Aaron sees his roommate eating one, he becomes furious and screams at him. He unwraps the rest of the coins and smears them on his wall
What behaviors would you document for this episode?
Yelling/ screaming: (Episodes of loud vocalizations (not directed at others) that are disruptive to the environment.)
Little Cindy Lou Who is scared that someone is going to steal Christmas again. She tells staff that she cannot fall asleep even though she is very tired
What behavior would you add to the assessment?
Unrealistic fears and suspicions
Grandma is still recovering from being run over by a reindeer. She has required two caregivers to help her stand and pivot from the edge of the bed to the wheelchair. The caregivers bear some of her weight using a gait belt.
How would transfer be documented for Grandma?
Extensive assistance / 2-person physical assist
The caregivers provided weight-bearing support
Mrs. Jones is excited that her daughter brought her a fruit cake to celebrate the holidays. Usually caregivers provide cueing and guided maneuvering to assist Mrs. Jones with eating at meals. However, a few times a week her daughter assists her with eating.
What is the highest level of assistance Mrs. Jones requires when eating?
Extensive assistance / 1-person assist
Partially met
Olaf the quirky snowman is paralyzed from a downhill skiing accident. He is bed/chair fast and has a urinary catheter in place. The caregiver empties the catheter bag and provides peri-care. Olaf is unable to assist with any part of this activity
How would you document this toileting activity?
Total dependence
The caregiver provided 100% of the cleansing during peri-care; the client did not participate.
Do not include emptying of the catheter when coding this activity
The elder Frosty the Snowman has been outside, where he got coal dust from his eyes and buttons all over himself. He needs a shower. In the bathroom, Frosty begins swearing and calling his CG all sorts of names. He threatens his CG that if the water is too hot, he will melt and she will get in big trouble. He does this every time his CG's try to give him a shower and they are used to it
What behavior(s) would you enter into the assessment?
Uses offensive language: (The individual uses foul, racist, sexist, etc. language offensive to others.)
and
Verbally abusive: (threatens, demeans, curses at caregivers, family or others)
Tiny Tim has an indwelling Foley catheter. He uses a leg bag during the day so that he can still ambulate using his crutches. His crutch bumps into his leg bag this afternoon, causing it to leak onto his pants and the floor
How would you code Tiny Tim's bladder incontinence on the bladder/bowel screen?
Incontinent once a week or less: Bladder, incontinent episodes occur once a week or less