Bed Mobility, Transfer, Walking
Mr. Adams is not feeling well this evening. Today he ate too much pudding and rare roast beef. Two nurse aides have to reposition him in bed to his right side this evening. The aides support his head and legs during repositioning, and he is able to hold on to the side rail and assist.
How would you document this episode of bed mobility?
Extensive assist of two.
Weight-bearing support provided, but resident did participate
Frank always wears a hat, but he recently injured his arm and the nurse aide 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
Full staff support was provided; the resident did not participate.
Jack is recovering from sunburn on his fingers and thumbs. Due to the bandages on his hands, he is unable to brush his teeth or comb his hair. The nurse aide completes these tasks for him
How would you document personal hygiene?
Total dependence
Full staff support was provided; the resident did not participate
Hudson is a quiet man and prefers to be in his room alone most of the time. This afternoon, during Bingo, he hits the activity director, takes the box of prizes, and yells, “These prizes are all mine!”
What behaviors would you document for Mr. Hudson?
Physical behavioral symptom directed toward others (hitting the activity director)
and
Other behavioral symptoms not directed toward others (yelling in the activity room)
Lyle is usually continent of bowel and bladder. Today, however, right after lunch, Lyle walks down the hallway in a big hurry, and the nurse aide finds bowel just outside the bathroom door. She cleans up the floor and checks on Lyle. 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 today?
Both continent and Incontinent
While some bowels were incontinent, he was able to finish in the bathroom
Randy had an unfortunate accident and broke both his hind legs. Today, two nurse aides 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 with assistance of two
Randy was not able to participate in any part of the activity and required two staff members to transfer with the full-body mechanical lift, which supported all of his weight
Buddy is able to dress himself in his usual shirt and blue jeans. But the nurse aide holds his leg and foot to put on his socks and shoes
How would you document dressing for Buddy today?
Extensive one assist
Buddy was able to assist with part of the dressing, but the nurse aide provided weight-bearing assist to put on socks and shoes
Mrs. Jensen is needing a shower. The nurse aide assists her to get cleaned up. Mrs. Jensen is able to transfer onto the shower chair and complete most of the bathing without assistance, but the nurse aide provides oversight and helps wash her hair and back
How would you document bathing for Mrs. Claus?
Supervision
The nurse aide provided oversight during the entire bathing activity, and the assistance with washing the hair and back is excluded
Keith often feels like he is all alone and is paranoid that two staff members are out to get him. At random times throughout the day and night he will place both hands on his head and scream as loud as he can
How would you document this behavior?
Screaming or disruptive sounds would be documented
This falls under the category of Other behavioral symptoms not directed toward others
Mr. Bushel is very upset that the kitchen staff was unable to get him a pop as he requested. 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 mood symptoms would you document for Mr. Bushel today?
Little interest or pleasure in doing things (did not want to go to Bingo)
and
Poor appetite (refused to eat lunch today)
While on leave from the nursing home, Mrs. Hanson developed a bone spur on her heel from walking so far. She now has difficulty walking in her room. She requires staff 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 staff member.
How would you code this Walk in Room episode?
Extensive assistance
The staff member was bearing weight while helping her walk to the closet and back.
Mr. Warner 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 nurse aide has to help him guide his wheelchair away from the wall several times during the shift. Today he even bumps into the flower vase, knocking it over and breaking it into pieces.
How would you document locomotion on unit?
Limited assist
The nurse aide had to guide his wheelchair away from the wall, but provided no weight-bearing assist
Lincoln puts on his call light and requests assistance to the bathroom. He cannot unfasten the buttons on his pants. The nurse aide assists with buttons and adjusting clothes before he uses the bathroom. When he is finished, the nurse aide again helps to adjust clothes and fasten the buttons
How would you document this toileting activity?
Limited assist
The nurse aide provided non-weight-bearing support to complete the activity
A retired man with dementia is found outside. He says that he is looking for his car and that he needs to get to work or they will fire him. The nurse aide tries to reassure the man that he is retired and does not need to worry about work, but he insists on staying outside looking for his car. This man 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 is on a very special diet of only fish, milk, and eggs. For breakfast, her meal is scrambled eggs and a tall glass of milk. She eats all of the scrambled eggs.
How would you document the percentage of intake for this meal?
75-100%
She was able to eat 100% of the solid food
Phil had to have back surgery because of all the falls he had. He is recovering, but the nurse aide must provide verbal cues while he walks in the hallway. The nurse aide reminds him to walk slowly and to stand close to the handrails.
How would you document this Walking in the Corridor episode?
Supervision
The staff member was not touching him, but giving him verbal cues and reminders while he walked in the hall
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. Today he became very tired after his walk, and the nurse aide propels him in a wheelchair back to his room, as he requested.
How would you document locomotion on unit 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
Holly just returned from an activity outing, where she became too involved and over-exerted herself. Experiencing weakness and fatigue, she requires a nurse aide to help lift and steady her as she transfers to the commode
How would you document this toileting activity?
Extensive assist
The nurse aide provided lifting or weight-bearing assist to the commode
Aaron celebrates his birthday 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?
The screaming would be coded as verbal behaviors directed toward others
and
smearing of food would be coded as other behavior not directed toward others
Little Cindy is scared that someone is going to steal her shirt again. She tells staff that she cannot fall asleep even though she is very tired
What mood symptoms would be documented for Cindy?
Trouble falling asleep and feeling tired
Chris is still recovering from being run over by an ATV. She has required two nurse aides to help her stand and pivot from the edge of the bed to the wheelchair. The nurse aides bear some of her weight using a gait belt
How would transfer be documented for Chris?
Extensive assist of two
The nurse aides provided weight-bearing support
Mrs. Jones is excited that her daughter brought her a cake to celebrate her birthdays. Usually staff provide cueing and guided maneuvering to assist Mrs. Jones with eating at meals. However, for lunch today, she eats in her room and her daughter assists her with eating.
How would you document eating assist for lunch today?
Did not occur
Only document assistance provided by facility staff. Since Mrs. Jones's daughter provided all of the assistance during lunch, the activity would be coded as did not occur for this meal
Jimmy is recovering from a recent accident. He is on strict bed rest for a week and has a urinary catheter in place. The nurse aide empties the catheter bag and provides peri-care. Jimmy is unable to assist with any part of this activity
How would you document this toileting activity?
Total dependence
The nurse aide provided 100% of the cleansing during peri-care; the resident did not participate.
Do not include emptying of the catheter when coding this activity
Lucas needs a shower. In the shower room, Lucas begins swearing and calling the nurse aide all sorts of names. He threatens the aide that if the water is too hot, he will melt and she will get in big trouble. He does this every time the staff try to give him a shower and they are used to it
It happens every time, so would you code this as a
behavior? If so, how would you document it?
Even though it happens every time he takes a shower, it would still be coded, as the behavior did occur and it must be tracked
It would be documented as verbal behavior symptoms directed toward others
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 document continence for this episode?
Continence would not be rated
Document the use of the indwelling catheter only