Advanced Aged Care Clinical Skills. Workbook: Preparation Activities, Face-to-Face Workshop Content and Post-Workshop Activities

Advanced Aged Care Clinical Skills Workbook: Preparation Activities, Face-to-Face Workshop Content and Post-Workshop Activities Associate Professor Victoria Traynor & Carolyn Antoniou School of Nursing and Midwifery, University of Wollongong Feb 2014

Contents Acknowledgements... 6 Project team... 7 Project manager... 7 Academic co-ordinator... 7 Workshop programme... 8 Welcome... 9 Welcome to Country or Acknowledgement of Country... 10 How do I gain my CPD points?... 11 Continuing Professional Develop points for the preparation and Post-Workshop Activities... 12 Continuing Professional Develop points for the Workshop activity... 14 Preparation Activities... 15 Part A: Topic specific Preparation Activities... 15 Preparation Activity 1: (i) Recognising and (ii) Escalating and reporting deteriorating health conditions for older people... 15 Preparation Activity 2 Preparation Activity: Advanced care of different types of urinary catheters (female and male)... 21 Preparation Activity 3: Administration and management of sub-cutaneous fluids and medication... 26 Part B: Developing individual learning goals for the Workshop... 30 I thought it was the teacher s job to write learning objectives - not the students!... 30 How do I write my individual learning goals... 32 What s next?... 34 Workshop... 35 1.i - Recognising deteriorating conditions in older people... 36 Activity 1: Learning goals... 36 Activity 2: Q & A about Preparation Activities... 36 Activity 3: How do you know when the health condition of older person has deteriorated?... 37 Pathophysiological changes which are risk factors for older people... 37 Activity 4: How do you know when the health condition of older person has deteriorated?... 38 Recognising when the health condition of a client has deteriorated... 38 Associate Professor V Traynor & C Antoniou Feb 2014 2

Activity 4: How do you know when the health condition of older person has deteriorated?... 39 Assessing the client and identifying the possible cause of the deterioration... 39 Activity 5: Peer review activity: Teaching others about recognising deteriorating health conditions in older people... 44 What else do you want to know about the client?... 45 Activity 6: Q&A about Session, Evaluation and Post-Workshop Activity Preparation... 46 Any questions... 46 Evaluation... 46 Post-Workshop activities... 46 1.ii. Escalating and reporting deteriorating health conditions in older people... 47 Activity 1: Learning outcomes... 47 Activity 2: Q & A about Preparation Activities... 47 Activity 3: Assessment of an older person who is experiencing a deteriorating condition... 48 Activity 4: Observing and practising escalating and reporting the deteriorating health condition... 49 Why do we use a structurerd handover process?... 49 Standard key principles to structured hand-over... 50 Activity 3ii: ISBAR as an structured hand-over process... 51 ISBAR: Framework for communication... 51 Activity 5: Peer teaching: Role playing escalating and reporting the deteriorating health condition of an older person... 52 Activity 6: Q&A about Session, Evaluation and Post-Workshop Activity Preparation... 54 Any questions... 54 Evaluation... 54 Post-Workshop activities... 54 2. Advanced catheter care... 55 Activity 1:Learning outcomes... 55 Activity 2: Q & A about Preparation Activities... 55 Activity 3i: Theory of catheter care: Insertion of catheters... 55 Activity 3ii: Theory of catheter care: Trouble shooting catheter care... 57 Activity 4: Observation and practice of the insertion of catheters... 57 Activity 5: Peer teaching and critical review opportunity... 59 Associate Professor V Traynor & C Antoniou Feb 2014 3

Activity 6: Q&A about session, Evaluation and Post-workshop activity... 59 Any questions... 59 Evaluation... 59 Post-Workshop activities... 59 3. Administration and management of subcutaneous fluids and medication... 60 Activity 1:Learning outcomes... 60 Activity 2: Q & A about Preparation Activities... 60 Activity 3: Theory of administration and management of subcutaneous fluids and medication... 61 Activity 4: Observation and practice of inserting a sub-cutaneous cannula... 62 Activity 5: Peer teaching and critical review opportunity... 65 Activity 6: Q&A about session, Evaluation and Post-Workshop activity... 65 Any questions... 65 Evaluation... 65 Post-Workshop activities... 65 Post-Workshop Activities... 66 Part A: Topic specific Preparation Activities... 66 Post-workshop Activity 1: Escalating and reporting deteriorating health conditions for older people... 66 ISBAR: Framework for communication... 66 Preparation Activity 2 Preparation Activity: Advanced care of different types of urinary catheters (female and male)... 69 Preparation Activity 2 Preparation Activity: Advanced care of different types of urinary catheters (female and male)... Error! Bookmark not defined. Part B: Developing an Action Plan for your future learning... 72 Mind mapping... 73 Learning Action Plan Template... 76 Appendices... 76 Appendix A: List of equipment... 80 All Learning activities... 80 Learning Activity 1(i): Recognising deteriorating health conditions in older people... 80 Learning Activity 1(ii): Hand over of an older person who has been recognised as experiencing a deteriorating health condition... 80 Learning Activity 2: Advanced catheter care... 80 Associate Professor V Traynor & C Antoniou Feb 2014 4

Learning Activity 3: Management of sub-cutaneous fluids and medications... 80 Appendix B: Facilitators... 81 Appendix D: Evaluation Form... 82 Advanced Aged Care Clinical Skills... 83 Evaluation... 83 References and further reading... 86 References... 86 Further reading... 87 Welcome to Country or Acknowledgement of Country... 88 Recognising and escalating the care of an older person experiencing a deteriorating health condition... 88 Developing your Learning Action Plan... 88 Advanced Care Catheter... 88 Associate Professor V Traynor & C Antoniou Feb 2014 5

Acknowledgements This Workshop was made possible with financial and in-kind support from the following organisations: HammondCare; Illawarra Multi-cultural Village; IRT; MediCare Local Illawarra-Shoalhaven; UnitingCare: Ageing; University of Wollongong; Warrigal; and Wollongong Nursing Home. In addition, Clinical Nurse Consultants from the Illawarra and Shoalhaven Local Health District provided content for the clinical scenarios used for the learning activities: Miriam Coyle; Kim Henderson; and Cathy McPhail. Associate Professor V Traynor & C Antoniou Feb 2014 6

Project team Project manager Samantha Karmel, Aged Care Project Officer, MediCare Local Illawarra-Shoalhaven Samantha has over fifteen years of experience working in health promotion and public health. She has worked in the field of alcohol and other drugs, cervical screening, cardiovascular health and women s health at a Commonwealth, State and local level with both Government and non-government organisations. Her health promotion projects have included encouraging women over 50 to engage in physical activity, educating fitness instructors on the importance of safe pelvic floor exercises as well coordinating falls prevention programs. In 2013, she was successful in gaining funding and coordinated Empowering Young Women workshops for more than 600 girls and 200 parents in the Illawarra. Academic co-ordinator Associate Professor Victoria Traynor, PhD, BSc (Nursing Studies) Hons, RGN Victoria co-ordinates the Master of Science and Graduate Certificate courses in Gerontology and Rehabilitation Studies and Dementia Care. Victoria's experience combines research education, and clinical experience in aged and dementia care. The focus of her work is on improving dementia care services using qualitative research and practice development techniques across care settings with multidisciplinary teams. Key achievements have been developing a range of resources for delirium care, including national clinical pathways, nursing and multi-disciplinary dementia care competencies, a one-day interactive workshop implementing person centred care and a Driving and Dementia Decision Aid. Associate Professor V Traynor & C Antoniou Feb 2014 7

Workshop programme 08:00-08:15 Project team arrive 08:15-08:30 Registration 08:30-08:45 Welcome 08:45-10:15 Learning Activity 1i, 1ii, 2 or 3* 10:15-10:45 Morning tea 10:45-12:15 Learning Activity 1i, 1ii, 2 or 3* 12:15-13:00 Lunch 13:00-13:15 Lessons learnt from morning session 13:15-14:45 Learning Activity 1i, 1ii, 2 or 3* 14:45-15:00 Afternoon tea 15:00-16:30 Learning Activity 1i, 1ii, 2 or 3* 16:30-16:45 Evaluation 16:45 Close and collection of Certificates *: Learning activities will be facilitated in groups in the Clinical Simulation Centre. You will be allocated a group at the start of the day and rotate round the four (4) learning activities during the day. Please note: You are required to arrive on time to ensure OHS documentation can be completed. Remember to wear loose fitting clothing and leather or vinyl closed-in and low heeled shoes to ensure you can participate in the learning activities. Learning Activity 1(i): Recognising deteriorating health conditions in older people. Learning Activity 1(ii): Escalating and reporting deteriorating health conditions in older people Learning Activity 2: Advanced catheter care Learning Activity 3: Administration and management of sub-cutaneous fluids and medication Associate Professor V Traynor & C Antoniou Feb 2014 8

Welcome Welcome to the Advanced Skills for Aged Care Nurses Workshop. We are looking forward to working with you and developing our collaboration to support you in your workplace and for us to develop our learning from you about aged care services to inform our education and research activities here at UOW. This workbook includes administrative details, guidelines for completing the Preparation Activities, an overview of the Workshop content and guidelines for completing the Post-Workshop Activities which make up this Workshop. Associate Professor V Traynor & C Antoniou Feb 2014 9

Welcome to Country or Acknowledgement of Country Delivering the Workshop from the UOW Wollongong Campus We would like Acknowledge the Wodi Wodi people from the Dharawal Country who are the Traditional Custodians of this Land. I would also like to pay respect to the Elders both past and present. I would like to extend that respect to other Aboriginal people and/ or colleagues present today. Adapted from: NSW Teachers Federation Aboriginal Education and Aboriginal Committees (2012) The Dharawal people (also spelt Tarawal or Thuruwal) lived on the coastal areas of Sydney between Broken Bay / Pittwater, west to Berowra Waters, south to Parramatta and Liverpool and extending into the Illawarra and Shoalhaven districts. The traditional language of this tribe was also known as Dharawal. The Wodi Wodi are a sub-group of the Dharawal nation who occupied areas around Lake Illawarra, including Berkeley and Hooka Creek. Other nation groups residing within the Illawarra region include, but are not limited to the Yuin, Wiradjuri, Kamilaroi, Bundjalung, Dunghutti and Gumbayggir nations. Cultural identities are extremely important for the Aboriginal and Torres Strait Islander people. They represent different heritages, languages, cultural practices, spiritual beliefs and geographic areas. Delivering the Workshop from the UOW Nowra Campus Wollongong Council (2011) We would like to Acknowledge the Traditional Custodians of Country the Dharawal people. May their spirits guide us and protect us. We would like to extend our gratitude and thank them for allowing us to work on their Country. I Acknowledge and pay my respect to all Aboriginal Elders, past and present, and to the families of this region. They are the Traditional Custodians and Cultural knowledge holders of this Land. Adapted from: Tharawal Land Aboriginal Land Council (2014a and b) Tharawal or Dharawal as it is referred to in historical records refers to the original peoples of the southern and south western Sydney area from the south side of Botany Bay, around Port Hacking to the north of the Shoalhaven River (Nowra) and extending inland west to Campbelltown and Camden. Tharawal Land Aboriginal Land Council (2014b) Associate Professor V Traynor & C Antoniou Feb 2014 10

How do I gain my CPD points? To start with, we want to remind you about how you can gain your Continuing Professional Development (CPD) points for completing the Preparation Activities, participating in the Workshop and completing the Post-Workshop Activities. A total of eleven (11) CPD points are allocated to this Advanced Aged Care Clinical Skills Workshop, consisting of the Preparation Activities, the ace-to-face Workshop Content and Post-Workshop Activities for the: two (2) CPD points for completing the Preparation Activities; seven (7) CPD points for participating in the Workshop; and two (2) CPD points for completing the Post-Workshop Activities. To re-new your annual registration with the Australian Health Practitioner Registration Agency (AHPRA) you are required to confirm that you in the previous year you completed twenty (20) CPD points. Practitioners are required by APHRA to maintain a portfolio of evidence to record their completion of CPD points and professional development achievements. Some of you will already be maintaining your portfolio. You will be keeping an electronic and/ or paper portfolio of evidence of your professional development activities. For others, the concept of a portfolio will be a new one which you can learn more about during the Workshop. If you do not already have a portfolio you can ask the facilitators on the day of the Workshop for information about how to create and maintain your portfolio. In summary, the content of a portfolio is typically made up items similar to the ones listed below (hard copy print outs, scanned documents and/ or word document versions): workshop certificates of attendance / degree award certificates; and/ or reflective accounts of a clinical incident from your workplace; and/ or review notes from reading a book chapter or journal article; and/ or summaries of key learning from notes taken during from a workshop. Associate Professor V Traynor & C Antoniou Feb 2014 11

Important note Commencing in 2014, AHPRA will randomly select practitioners who will be required to send in their portfolio to provide evidence that they have completed the required professional development activities to achieve twenty (20) CPD points they said they completed when they re-registered. An international standard to calculate CPD points is: One (1) hour of active learning = One (1) continuing professional development (CPD) point We have followed this formula for these Preparation Activities, Workshop and Post- Workshop Activities. Continuing Professional Develop points for the preparation and Post- Workshop Activities Preparation activities To gain the two (2) CPD points allocated for preparation activity we invite you to complete learning activities included below. The Preparation Activities are made of two parts: Part A: topic related learning activities and Part B: Development of your individual learning goals for the Workshop. Associate Professor V Traynor & C Antoniou Feb 2014 12

To ensure we meet the needs of a wide range of learners we have included more than one topic related preparation activity for Part A of the Preparation Activities. Each individual topic related preparation activity in Part A is estimated to take one and a half (1.5) hours to complete and therefore you can gain one and a half (1.5) CPD points for completing one learning activity within Part A. Part B is estimated to take thirty (30) minutes to complete and therefore you can gain half a (0.5) CPD point for completing Part B. Completion of one preparation activity in Part A + Completion of preparation activity in Part B = two (2) hours of active learning = two (2) CPD points If you choose to complete more than one of the Preparation Activities included in Part A you can gain more CPD points. You can gain a further one and a half (1.5) CPD points for each of the Part A Preparation Activities you complete. Thus, within the Preparation Activities for this Workshop there is a potential for you to gain a total of five (5) CPD. Completion of two (2) Preparation Activities in Part A + Completion of preparation activity in Part B = three and a half (3.5) hours of active learning = three and a half (3.5) CPD points Completion of three (3) Preparation Activities in Part A + Completion of preparation activity in Part B = five (5) hours of active learning = five (5) CPD points Associate Professor V Traynor & C Antoniou Feb 2014 13

Post-workshop activities Guidelines for the Post-Workshop Activities will be distributed at the Workshop. The Post-Workshop Activities will be allocated two (2) CPD points and when you have completed the Post-Workshop Activities you can gain the additional two (2) CPD points. Continuing Professional Develop points for the Workshop activity You will be issued with a certificate of attendance as a record of your participation at the Workshop. The certificate of attendance will state that participation at the Workshop is allocated seven (7) CPD points. APHRA will know that this means you participated in seven (7) hours of active learning. Friendly exchange of services required You will issued your Certificate of Attendance after you have completed our evaluation form which will provide us with feedback about what you found useful about in Workshop, your learning and ideas for making amendments to future deliveries of the Workshop. You can add the printed copy of your certificate to your hard copy portfolio folder or scan it and add it to your electronically stored portfolio. Associate Professor V Traynor & C Antoniou Feb 2014 14

Preparation Activities The purpose of completing the Preparation Activities is for you to have an opportunity to think about your clinical strengths and identify specific areas where you can gain further development in the topics areas focused on in the Workshop. Part A: Topic specific Preparation Activities During the Advanced Aged Care Clinical Skills Workshop you will be provided with learning in the following topic areas: 1. Deteriorating health conditions: Appropriate responses for older people: i. Recognising deteriorating health conditions in older people; and ii. Escalating and reporting deteriorating health conditions in older people. 2. Advanced care of different types of catheters (female and male); and 3. Administration and management of sub-cutaneous fluids and medication. Preparation Activity 1: (i) Recognising and (ii) Escalating and reporting deteriorating health conditions for older people This activity will take approximately 1.5 hours to complete. The causes of deterioration for an older person living independently in the community or with the support of residential accommodation services will, inevitably, vary. What we know in the hospital setting is that patients who are acutely ill have an increased risk of experiencing deterioration in their condition and the signs are often sudden and dramatic. In contrast, older people who experience deterioration in their health condition may only display subtle signs, which can be further disguised by pre-existing comorbidities. Practitioners working with older people need to develop advanced clinical skills which include understanding delirium, to ensure they can recognise common signs of deterioration and initiate appropriate responses. Associate Professor V Traynor & C Antoniou Feb 2014 15

To start with, we invite you to recall from your experience, an older person who you worked with who experienced a deteriorating health condition. Give this person a pseudonym so you can write about him/ her in the first person. 1. List the signs, symptoms, clinical observations and general observations which alerted you to the early stages of the deteriorating condition which this older person was experiencing.......... 2. Begin to reflect on and consider in more detail the situation are recalling from your experience. What happened? Describe how you knew the health condition of the older person had deteriorated. You might want to include the vital sign recording you did or something more intuitive from your general impressions about what was happening to the older person who you were working with. Associate Professor V Traynor & C Antoniou Feb 2014 16

...... What was good and bad about the situation you are recalling from your experience? What actions do you consider had a (i) positive impact on the situation and (ii) negative impact on the situation?... Associate Professor V Traynor & C Antoniou Feb 2014 17

What else could have been done about the situation you are recalling from your experience? When we have time to reflect on a situation we are sometimes able to think about what we or others could have done differently to ensure a different and more positive outcome was achieved. List anything you can think of that would have helped recognise the deterioration earlier or enabled the reporting of the deterioration to be more successful........ Associate Professor V Traynor & C Antoniou Feb 2014 18

References to support your learning We invite you to visit the following website resource as one way of learning more about recognising and escalating reporting of deteriorating health conditions appropriate care for older people. NSW Ministry of Health 2009a, DETECT: Chapter 5: Confused Older Person NSW MoH 1 In particular, page 7 of 10, where the simple scale for assessing a conscious state (Figure 1) is suggested as an alternative to the Glasgow Coma Scale. The Glasgow Coma Scale is not always appropriate for frail older people when their verbal and motor responses are already compromised due to frailty and/ or co-morbidities associated with ageing. Figure 1: AVPU Scale (Adapted from NSW Ministry of Health (2009a)) Would the AVPU Scale be useful and effective in your workplace? Would your colleagues be willing to use this simple case? 1 Please note the front page states that the document not be distributed but is freely available on the following website: NSW Ministry of Health, 2009b, DETECT Sydney, NSW MoH Associate Professor V Traynor & C Antoniou Feb 2014 19

Write down reasons why (i) the scale would work in your workplace....... Write down reasons (ii) barriers to using sale in your workplace..... If you come across a term or word you are not familiar with visit Wikipedia the free online encyclopaedia. Associate Professor V Traynor & C Antoniou Feb 2014 20

Preparation Activity 2 Preparation Activity: Advanced care of different types of urinary catheters (female and male) This activity will take approximately 1.5 hours to complete. Indwelling urinary catheters (IUCs) are used for a range of reasons with older people. The maintenance of IUCs is dependant on the reason for the catheter insertion and the co-morbidities that the client using the IUC is experiencing. Now consider how catheterisation and ongoing catheter care is undertaken in your workplace. As a reminder of best practice you could watch these YouTube film of a demonstration of insertion of a female Foley catheter (2 mins). When you considered how catheterisation is undertaken in your workplace and/ or watched the YouTube clips write down any thoughts that came to you about these practices? Associate Professor V Traynor & C Antoniou Feb 2014 21

Ask yourself these questions: are you satisfied by the way in which catheterisation is undertaken in your workplace? what works well? what could be changed to improve this practice? In hospital, after a catheter is inserted there is a 3-7% daily risk of developing a UTI and by day thirty (30) of catheterisation there is 100% risk of experiencing a UTI (EnvisionInc., 2008). In the USA, catheter associated urinary tract infections (CAUTIs) (during or shortly after the insertion of a catheter) is not a billable item to the USA equivalent MediCare. Now we invite you to find out what your colleagues think about catheterisation catheter care practices in your work place. If there are Registered Nurses or Enrolled Nurses working in your organisation, ask one to four of these colleagues to answer the following questions about the care of UICs and record their responses in the summary table provided. 1. Policies, procedures, protocols and best practice knowledge 1.i. Are you aware of the protocol/ procedure/ policy which we need to adhere to for best practice for indwelling urinary catheter care in the organisation/ place where we work? Individual responses recorded Total Yes No Associate Professor V Traynor & C Antoniou Feb 2014 22

1.ii. Would you show me the location of the protocol/ procedure/ policy? Individual responses recorded Total Yes No 2. Application of practice knowledge 1 2 3 4 2.i. How often would you change a urinary indwelling catheter? 2.ii. When would you change a urinary indwelling catheter sooner than this? 2.iii. When is it appropriate to leave an indwelling catheter in situ longer than this? Mean (average answer) 3. Adherence to protocol/ procedure/ policy 3.i. In your experience do members of your team, in the main, adhere to protocol/ procedure/ policy? Individual responses recorded Total Never Rarely Often Always Associate Professor V Traynor & C Antoniou Feb 2014 23

3.ii. What is the impact of this on the care received by older people who have a urinary indwelling catheter? 1 Free text open ended responses given by your colleagues when you talk to them 2 3 4 Associate Professor V Traynor & C Antoniou Feb 2014 24

3.ii. What is the impact of this on the care received by older people who have a urinary indwelling catheter? Your summary of responses (including responses which were repeated by different RNs and ENs) Associate Professor V Traynor & C Antoniou Feb 2014 25

Preparation Activity 3: Administration and management of sub-cutaneous fluids and medication This activity will take approximately 1.5 hours to complete. Subcutaneous refers to the loose connective tissues just below the dermis and is a common way of delivering both intermittent and continuous fluid and medication. Older people require a sub-cutaneous infusion for a range of reasons. Now consider how sub-cutaneous infusions are inserted and managed in your workplace. When you considered how sub-cutaneous infusions are inserted and managed in your workplace down any thoughts that came to you about these practices? Ask these questions: are you satisfied by the way in which sub-cutaneous fluid and medication administration and management is undertaken in your workplace? what works well? what could be changed to improve this practice? Now we invite you to find out what your colleagues think about sub-cutaneous fluid and medication administration and management practices in your work place. As a reminder of best practice you could watch these YouTube film of a demonstration of inserting a subcutaneous line on a manikin (4.5 mins) or inserting a butterfly cannula subcutaneously (3.5 mins). Associate Professor V Traynor & C Antoniou Feb 2014 26

If there are Registered Nurses and Enrolled Nurses working in your organisation, ask one to four colleagues to answer the following questions about administration and management of sub-cutaneous fluids and medication and record their responses in the summary table provided. 1. Policies, procedures, protocols and best practice knowledge 1.i. Are you aware of the protocol/ procedure/ policy which we need to adhere to for best practice for sub-cutaneous fluid and medication administration and management in the organisation/ place where we work? Individual responses recorded Total Yes No 1.ii. Would you show me the location of the protocol/ procedure/ policy? Individual responses recorded Total Yes No 2. Application of practice knowledge 1 2 3 4 2.i. How often would you change a cannula? 2.ii. When would you change a cannula sooner than this? 2.iii. When is it appropriate to leave an cannula in situ longer than this? Mean (average answer) Associate Professor V Traynor & C Antoniou Feb 2014 27

3. Adherence to protocol/ procedure/ policy 3.i. In your experience do members of your team, in the main, adhere to protocol/ procedure/ policy for sub-cutaneous fluid and medication administration and management in the organisation/ place where we work? Individual responses recorded Total Never Rarely Often Always 3.ii. What is the impact of this on the care received by older people who are receiving fluids or medication through a sub-cutaneous cannula in the organisation/ place where we work? 1 Free text open ended responses given by your colleagues when you talk to them 2 Associate Professor V Traynor & C Antoniou Feb 2014 28

3.ii. What is the impact of this on the care received by older people who are receiving fluids or medication through a sub-cutaneous cannula in the organisation/ place where we work? 3 4 Your summary of responses (including responses which were repeated by different RNs and ENs) Associate Professor V Traynor & C Antoniou Feb 2014 29

Part B: Developing individual learning goals for the Workshop First of all, well done on completing one or more of the topic-specific Preparation Activities for the Workshop. You have gained at least one and a half (1.5) CPD points. If you completed other preparations activities you have gained more CPD points: three (3) if you completed two (2) of the topic specific Preparation Activities and four and a half (4.5) CPD points if you completed three (3) of the topic specific Preparation Activities. To gain another half (0.5) CPD point we invite you to complete a preparation activity which will enable you to develop your individual learning goals for the Workshop activity. This activity will take approximately 30 minutes to complete. I thought it was the teacher s job to write learning objectives - not the students! We know that in your workplace there is an emphasis on using person centred terminology, such as older people and working with clients. Another important innovation in our contemporary aged care industry is the recognition of the importance of working in partnership with older people and their families. No longer is it good enough to do tasks to older people and exclude family members from decision making or care delivery. In a similar way, in education it is no longer good enough for presenters to talk to PowerPoint slides with very limited opportunities for sharing experiences about current practices. Finding a common ground for aged care practitioners and educational colleagues? Associate Professor V Traynor & C Antoniou Feb 2014 30

Have you noticed that in this workbook we refer to ourselves as facilitators and not teachers and yourselves as learners and participants rather than students? That is because we aim for our educational activities to be and feel person centred. We want you to be an active participant in your learning in the same that you would like the clients and families you work with to be active partners in the carer-client relationship you create in your workplace. One way of achieving partnership working, both in an educational and client-carer relationship is for the consumer of the service being delivered to develop individual goals, whether these be learning goals in an educational environment or health and well-being goals within an aged care service environment. What s the outcome for me after I develop my individual learning goals? Developing individual learning goals will enable you to identify your learning needs. As an experienced clinician in your field of specialist practice, you are likely to have some clear ideas of areas of your practice that you would like to develop. Writing these down and referring to them during the Workshop will help you to identify that the Workshop and your own efforts are focussed on these areas giving you the best opportunity for a positive and useful learning experience. Associate Professor V Traynor & C Antoniou Feb 2014 31

We know that the motivation and efficiency of learners who set their own learning goals achieve more than those who have their learning goals set by the teacher. Students who set their own learning goals have more confidence to take on more challenging tasks, regardless of their previous experience. Their motivation to improve and master a task is improved and their self-esteem remains strong, even when they find the learning activity difficult tasks to complete. How do I write my individual learning goals We invite you to re-visit the contributions and notes you made for Part A of the Preparation Activities. These Preparation Activities provided you with an opportunity to identify areas of good practice and aspects of care you consider need improving. You can use these thoughts and feelings to generate your individual learning goals for the Workshop. To develop your own learning goals you need to consider questions such as: are there any particular aspects of the topics that we are covering during this Workshop in which you hope to deepen your understanding? are there areas of your clinical practice which you want to explore further or update? and/ or what impact do you hope the Workshop will have on your confidence for managing complex changes in the well-being of a client? My learning goals for the Workshop are: Learning activity 1(i): Recognising deteriorating health conditions in older people Associate Professor V Traynor & C Antoniou Feb 2014 32

Learning activity 1(ii): Escalating and reporting deteriorating health conditions in older people Learning activity 2: Advanced catheter care Learning activity 3: Administration of sub-cutaneous fluid and medication Associate Professor V Traynor & C Antoniou Feb 2014 33

What s next? During the Workshop, you will have the opportunity to develop advanced skills on the specific topics selected for this Workshop, including the relevant theory underlining the clinical skills being advanced, hands-on practice of the selected clinical skills. After you have completed the Preparation Activities and Workshop you will have advanced to your knowledge and skills as specialists practitioners working with older people and their families. By engaging in the Preparation Activities, you will maximise your learning for the Workshop and see the benefits during your participation at the Workshop. We look forward to working with you at the Workshop. At the end of the Workshop, you will be provided with Post-Workshop Activities. Completing the Post-Workshop Activities will enable you to gain two (2) more CPD points. Associate Professor V Traynor & C Antoniou Feb 2014 34

Workshop The workshop sessions will consist of the following topic areas: Learning Activity 1(i): Recognising deteriorating health conditions in older people; Learning Activity 1(ii): Escalating and reporting deteriorating health conditions in older people; Learning Activity 2: Advanced catheter care; and Learning Activity 3: Administration and management of sub-cutaneous fluids and medication. Each session will be a total of one and a half (1.5) hours and include the following: 1. Learning outcomes for session (2 mins) 2. Q&A about Preparation Activities (7 mins) 3. Theory for session (10 mins) 4. Demonstration and practice of clinical skill (45 mins) 5. Peer teaching: Two practitioners volunteer to teach skill to group (10 mins) 6. Q&A about session, Evaluation and Post-workshop activity (10 mins) Associate Professor V Traynor & C Antoniou Feb 2014 35

1.i - Recognising deteriorating conditions in older people Activity 1: Learning goals This activity will take approximately 2 minutes to complete. By the end of the session, participants will have developed an understanding about how to recognise deteriorating health conditions in an older person; developed an understanding about the potential problems experienced when the health of an older person deteriorates; developed an understanding about the appropriate interventions when an older person experiences a deteriorating health condition; and applied advanced assessment skills in a role play in the clinical simulation setting to identify deteriorating health conditions in an older person. Activity 2: Q & A about Preparation Activities This activity will take approximately 7 minutes to complete. To begin this session, we invite you to re-consider the examples from your previous experience that you reflected on when completing the Preparation Activities for this Workshop. From these reflections, what aspects of your role and the work you do with older people and their families did you hope to benefit from reviewing or developing as part of this learning activity in the Workshop today? Associate Professor V Traynor & C Antoniou Feb 2014 36

Activity 3: How do you know when the health condition of older person has deteriorated? This activity will take approximately 10 minutes to complete. Pathophysiological changes which are risk factors for older people Figure 2: Risk factors for a delirium: Age-related pathophysiological changes (Adapted from Traynor (2014)) Associate Professor V Traynor & C Antoniou Feb 2014 37

Scenario Mrs Vargo is a client who is well known to you. You begin to attend to her care needs and notice she does not seem her usual self. Other team members tell you that her family have also noticed some changes in Mrs Vargo over the previous few days. Mrs Vargo s family described her struggling with some of her daily activities which she has not previously done. Mrs Vargo tells you that she slept well but when you speak to her she appears confused and worried. FACILITATOR NOTES Mrs Vargo has an anaemia. The cause is unknown however recent dark stool suggests it may have a GIT source. The anaemia has an insidious onset and Mrs Vargo has been asymptomatic for a long time. A recent small GIT bleed has caused a slight exacerbation of her symptoms which is manifesting in her disorientated state. Activity 4: How do you know when the health condition of older person has deteriorated? This activity will take approximately 45 minutes to complete. Recognising when the health condition of a client has deteriorated What would make you suspect that Mrs Vargo s health condition has changed? Questions you might ask yourself are: in what way does this client seem different, even if it is only a vague idea? how does the client seem generally? Associate Professor V Traynor & C Antoniou Feb 2014 38

Activity 4: How do you know when the health condition of older person has deteriorated? This activity will take approximately 40 minutes to complete. Assessing the client and identifying the possible cause of the deterioration Using the ABCDEFG Algorithm you can make an assessment of the health condition of the client you are caring for and prioritise their care needs. While this basic algorithm is often considered for emergency situations it is an excellent tool which can be also adapted for use within aged care situations. Using the ABCDEFG Algorithm headings as a guide, discuss the assessments and interventions you consider appropriate for Mrs Vargo. Using your own experience and expertise in this area, consider other aspects of assessment you will need to incorporate into this algorithm. A: Airway FACILITATOR NOTES Assess the airway of Mrs Vargo by talking to her and listening for stridors or wheezes. Airway is clear B: Breathing FACILITATOR NOTES Assess the breathing of Mrs Vargo by talking to her. You will need to ensure she is in a sitting position so that you can assess this more accurately. Breathing assessment needs to include rate and quality of breathing, visualisation of the chest to assess symmetry, assessment of work of breathing and auscultation. Assess for cerebral signs of hypoxia, such as agitation. Respirations are 32 breaths/minute Equal chest movements No abnormal lung sounds SpO2 92% (if available) Associate Professor V Traynor & C Antoniou Feb 2014 39

C: Circulation FACILITATOR NOTES Assess circulation of Mrs Vargo by taking her pulse noting rate, rhythm and quality. Check BP and cap refill. Check for signs of cyanosis or peripheral pitting oedema. Pulse is 92, regular but thready or faint BP is 94/50 CR >3secs No cyanosis however she is generally pale No peripheral pitting oedema D: Disability FACILITATOR NOTES Assess the current state of consciousness of Mrs Vargo. Is there any drowsiness or confusion which is not normal for her? You will be familiar with AVPU (Figure 1, p. 19) from the Preparation Activities rather than the full GCS. Assess the level of confusion of Mrs Vargo by using the Confusion Assessment Method (CAM) (Figure 3). Pain Assessment Next, a pain assessment should be carried out. You might be familiar with several methods of pain assessment but the Abbey Pain Scale is well suited to individuals living with a dementia (Figure 4). Consciousness level When all the assessments are completed, Mrs Vargo s clinical outcome indicators are reported as follows: her level of consciousness is fluctuating between A (alert) and V (verbal); her GCS score is 13. Her pupils are equal and reacting to light. She is orientated to person but not to time or place where previously she was also orientated also to time and place; her CAM score is 3 ; and her Abbey Pain Scale score is 2. Associate Professor V Traynor & C Antoniou Feb 2014 40

Figure 3: Confusion Assessment Method (CAM) Adopted from Waszynski (2001) Associate Professor V Traynor & C Antoniou Feb 2014 41

Figure 4: Abbey Pain Scale adopted from Abbey et al. (2004) Associate Professor V Traynor & C Antoniou Feb 2014 42

F: Fluids FACILITATOR NOTES Assess the hydration status of Mrs Vargo. Skin turgor is diminished in older people so assessing the tongue and mucosal membrane of the mouth can give a better indication of the current state of health of clients. If possible, obtain an idea of her input and output over the last 24-48 hours. Is there an indication that Mrs Vargo is drinking less or visiting the toilet less frequently? Has her urine been noted to be more concentrated or does it have an offensive odour? Is it possible to obtain a urine sample for dipstick and/or an MSU? Did Mrs Vargo open her bowels recently? Have the carers of Mrs Vargo noticed any recent changes in her bowel habits? Has there been a change in the colour or consistency of her bowel motions? Mrs Vargo s tongue is dry and coated Mrs Vargo s other carers have not noticed any changes in her toileting frequency however they reported that she had a small bowel movement the day before which was dark in colour. E: Exposure FACILITATOR NOTES In this scenario, it will be useful to assess Mrs Vargo s temperature noting hyper or hypothermia as well as her skin temperature. Temperature is 35.3 0 Celsius Mrs Vargo s skin is cool to touch. She tells you that she feels cold. G: Glucose FACILITATOR NOTES Whenever there is a change in the condition of a client it is important to rule out hypo or hyper glycaemia as this one of the most potentially dangerous yet easily reversible causes of a deteriorating condition. Mrs Vargo s BGL is 4.8mmol/l. Associate Professor V Traynor & C Antoniou Feb 2014 43

Activity 5: Peer review activity: Teaching others about recognising deteriorating health conditions in older people This activity will take approximately 10 minutes to complete. Pause for a few minutes to consider the following questions How do these findings compare to her normal status and has this status changed over a recent period? What is the highest priority of care for the client right now? What resources are available to me at the moment? Am I able to care for this client safely in this environment? Are there any interventions which I could commence which will improve the outcome for my client? FACILITATOR NOTES Points of discussion Mrs Vargo needs higher level care discuss why. The highest priorities of care for Mrs Vargo are to address her tachypnoea and hypotension. O2 may be available in some situations w..will help in the short term if she will tolerate it. Although her SpO2 is only slightly low her tachypnoea suggests that she is compensating so needs to be acted upon. Her hypotension is not drastic however it should be noted if she takes morning anti-hypertensive medication and if these have not yet been given that they may need to be withheld until medical advice is received. If her BP is normally low would this reading be discounted or are there other aspects to her symptom picture which will make you consider withholding i.e.: tachycardia and tachypnoea suggests compensatory mechanisms have kicked in so would a further decrease in her BP exacerbate her condition? Safety is also a consideration if the hypotension is orthostatic or if she is symptomatic and wants to mobilise. Her dehydration may be adding to her general deterioration and she will need some encouragement to be taking small and very frequent amounts of water or beverage of her choice so as to prevent her dehydration worsening. Obtain recent lab results Hb 8.6 Associate Professor V Traynor & C Antoniou Feb 2014 44

What else do you want to know about the client? As the clients carer, you may already have a good deal information regarding their medical history however to gain an accurate picture it is important that you ensure you have access to all the information. Questions you may seek the answers for are: Is there any known condition which may be contributing to this deterioration? Has there been any change in medication which may be contributing to this condition? Has the client recently had any tests or procedures performed and do I have access to these results? Have there been any recent incidents/falls/emotional or family issues of which I need to be aware? Has the client had any similar episodes or symptom profiles in the past and if so what was the diagnosis or outcome? Mrs Vargo has a history of gastric reflux which has not required investigation. She is on Warfarin for her AF. Her last INR check was four (4) weeks ago and was 3.1 Her medication dosage was decreased slightly however she has not been tested since then. There have been no other incidents reported by her carers. Her last Hb was taken as part of a general check-up and was reported as 9.8 Associate Professor V Traynor & C Antoniou Feb 2014 45

Activity 6: Q&A about Session, Evaluation and Post- Workshop Activity Preparation This activity will take approximately 10 minutes to complete. Any questions Facilitator invites participants to ask any questions. Evaluation Taking into consideration your complete assessment, what steps would you recommend for her immediate care? How does this assessment compare to previous experiences you have had with clients who have had a deteriorating episode? Post-Workshop activities We now invite you to go to the Post-Workshop Activity section of the Workbook and take a few minutes to review what is expected of you for these activities. We invite questions about completing these activities. Associate Professor V Traynor & C Antoniou Feb 2014 46

1.ii. Escalating and reporting deteriorating health conditions in older people Activity 1: Learning outcomes This activity will take approximately 2 minutes to complete. By the end of the session, participants will have: developed an understanding about the information required for an effective handover of assessment to another member of the healthcare team about an older person who is experiencing a deteriorating health condition; developed an understanding about how the ISBAR structured tool can be used to hand over assessment information about the deteriorating health condition of an older person to another member of the health care team; and applied the ISBAR tool using a role play scenario in the clinical simulation setting to handover over assessment information about the deteriorating health condition of an older person to another member of the healthcare team. Activity 2: Q & A about Preparation Activities This activity will take approximately 7 minutes to complete. The facilitator will lead a brief discussion where the participants will have the opportunity to discuss their findings from the Preparation Activities and their previous experiences with handing over a client in their care to a higher level of care. Associate Professor V Traynor & C Antoniou Feb 2014 47

Activity 3: Assessment of an older person who is experiencing a deteriorating condition This activity will take approximately 10 minutes to complete. Scenario Mr Rossi is a client in your care. You are told by other members of the healthcare team that there has been an increase in his disorientation and that he does not seem well however no further actions were taken. Mr Rossi appears disorientated and agitated. Using the ABCDEFG algorithm you carry out a thorough assessment and report the following clinical outcomes for Mr Rossi: respirations: 26 Breathing is shallow but not laboured. No audible wheeze/stridor. No audible abnormalities on auscultation; SpO2 (when available): 92% Peripheries are cool; pulse: 90 Irregular/weak. No cyanosis present; BP: 85/50 Taken manually. No obvious oedema; GCS: 15 Client is awake (A)VPU; Confusion Assessment Method C9 (CAM): 3 ; Abbey Pain Scale score of 7 ; and temperature: 33 0 C. Following your assessment you refer back to the documentation records and undertake a urinalysis. Associate Professor V Traynor & C Antoniou Feb 2014 48

You identify the following: urinalysis: PH 7.5, SG 1020, ++ve leukocytes, +ve protein, small amount of nonhaemolysed blood; GP check-up: three (3) week ago and no changes in the health of Mr Rossi were reported. Mr Rossi took his medication as charted last night however this morning his carer was not able to administer any medication due to his increased disorientation and agitation; Mr Rossi refused breakfast which is unusual for him; Mr Rossi has had some increased urinary incontinence over the last 24 hours which was attributed to his increased disorientation and agitation; Mr Rossi last opened his bowels two (2) days ago; Co-mordities include: Mild cognitive impairment, Ischaemic Heart Disease, AF, Type 2 diabetes (medication controlled) and benign prostatitis; Mr Rossi s medical history: a) Bowel resection for cancer ten (10) years ago, cholecystectomy >10years ago, #LNOF repair fourteen (14) months ago with subsequent decreased mobility, osteoarthritis, mild emphysema. Smoker 40/day quit 1987, non-drinker; Social history: He is married with four (4) children. His wife lives independently however she does not drive and is only able to visit three times a week when community transport can be arranged. He has one son who still lives nearby and steps in to help when needed; and Medications: a) Amiodorone, Frusemide, Metformin, Simvastatin, Paracetamol and Warfarin. He also takes a fish oil supplement and a multivitamin. Activity 4: Observing and practising escalating and reporting the deteriorating health condition This activity will take approximately 10 minutes to complete. Why do we use a structured handover process? A handover process will generate a script and cues for how clinical handover which occurs each and every time providing a framework for standardisation which ensures through and safe communication. Associate Professor V Traynor & C Antoniou Feb 2014 49

The standardised protocol will: clearly identify the client who you will be caring for, you and your role; state the immediate clinical situation of the client you care caring for; list the most important and recent observations; provide relevant background/history to the clinical situation of a client; identify assessments and actions that need to occur; identify timeframes and requirements for transition of care; promote the use of the client record to cross-check information; ensure documentation of all important findings or changes of condition; and ensure comprehension, acknowledgement and acceptance of responsibility for the client you are caring for by the practitioner who you are handing over to. (Australian Resource Centre for Health Innovation, 2010) Standard key principles to structured hand-over 1. Leadership Designed for one on one communication. The team member of the healthcare team handing over takes control as the leader. 2. Valuing handover ISBAR has been adopted as an area-wide initiative for clinical handover and adopted from the top down. (A suite of supporting tools have been developed and training is provided to all clinicians, managers, administrators and support services. Training program included as part of orientation and mandatory requirements.) 3. Handover participants The initiator and recipient of handover in all clinical situations. 4. Handover time ISBAR is the designated framework for all verbal and written communication. ISBAR is used in all situations of clinical communication throughout the day. 5. Handover place Applicable to all locations. 6. Handover process please see summary below. Associate Professor V Traynor & C Antoniou Feb 2014 50

Activity 3ii: ISBAR as an structured hand-over process This activity will take approximately 30 minutes to complete. Using the following tool and its prompt questions, you can record the aspects of Mr Rossi s care which will form the basis of your handover to the higher level care of your choice. ISBAR: Framework for communication Many excellent models of clinical handover exist in the NSW Health system. ISBAR is one current model that maps to the Standard Key Principles for clinical handover (Figure 5). Before making a call to escalate and report the deteriorating condition of the older client who you are caring from complete the following steps: 1. assess the client; 2. read most documentation notes; 3. ensure the vital signs of the client are printed out and sitting in front of you or be viewing the computer screen displaying them; and 4. know what you are going to say and what needs to happen. Associate Professor V Traynor & C Antoniou Feb 2014 51

I INTRODUCTION Identify yourself (your name, role and location) and give a reason for calling. I am calling because... S SITUATION Provide the age and gender of the client? What is current status of the client? a) Stable (but in danger of deterioration) b) Unstable B BACKGROUND A ASSESSMENT R RECOMMENDATION Give the relevant details such as presenting problems and clinical problems. Put it all together (their current condition, risks and needs). What is their assessment? Be clear about what you are requesting. e.g. transfer/review/treatment? When should it happen? Figure 5: ISBAR (Adapted from Hunter New England Local Health District (2013)) Activity 5: Peer teaching: Role playing escalating and reporting the deteriorating health condition of an older person This activity will take approximately 30 minutes to complete. Now that you have assessed the client you are caring for, and mapped out what you are going to say, you are ready to give handover. In this activity you will be given the opportunity to role play a handover taken from the notes you have made in the ISBAR tool. Use the following chart to help you to organise the information you need to convey to the client receiving handover. Associate Professor V Traynor & C Antoniou Feb 2014 52

I INTRODUCTION S SITUATION B BACKGROUND A ASSESSMENT R RECOMMENDATION Associate Professor V Traynor & C Antoniou Feb 2014 53

Activity 6: Q&A about Session, Evaluation and Post- Workshop Activity Preparation This activity will take approximately 10 minutes to complete. Any questions Facilitator invites participants to ask any questions. Evaluation What will be the (i) benefits and (ii) challenges of using the structured format of the ISBAR when escalating the care of a client with a deteriorating condition to other colleagues? How do you think you will be able to incorporate the ISBAR into your work in the future? Post-Workshop activities We now invite you to go to the Post-Workshop Activity section of the Workbook and take a few minutes to review what is expected of you for these activities. We invite questions about completing these activities. Associate Professor V Traynor & C Antoniou Feb 2014 54

2. Advanced catheter care Activity 1:Learning outcomes This activity will take approximately 2 minutes to complete. By the end of the session, participants will have: developed an understanding about the insertion of an indwelling catheter (IDC) into an older woman; developed an understanding about advanced catheter care and troubleshooting interventions associated with indwelling catheters (IDCs) in older people (male and female); applied best practice and practised in the clinical simulation setting the insertion of a female indwelling catheter (IDC); and demonstrated to one other practitioner the application of best practice in the clinical simulation setting the insertion of a female indwelling catheter (IDC). Activity 2: Q & A about Preparation Activities This activity will take approximately 7 minutes to complete. The facilitator will lead a brief discussion where the participants will have the opportunity to discuss their findings from the Preparation Activities. Activity 3i: Theory of catheter care: Insertion of catheters This activity will take approximately 5 minutes to complete. Indications for Indwelling Catheter Consider the risks associated with long term urinary catheterisation and ensure that the client is going to benefit from the procedure. Associate Professor V Traynor & C Antoniou Feb 2014 55

Gauge size Indwelling Catheter Generally the smaller the catheter the less trauma and the more easily a urinary catheter is tolerated, in an adult female this is usually 12-14 FG, however a client with sedimentation or blood in their urine will require a larger bore. Choice of urinary catheter bag Catheter bags must be sterile and chosen for the purpose required by the client i.e. large overnight bag or leg bag for during the day. Considerations For a confused client it will be necessary to have at least one team member to assist you to insure the client remains calm and does not become fearful. Check with the client and their documentation for known allergies before inserting a latex catheter. Pre insertion balloon check While it has been practice in the past to test the balloon prior to insertion this is no longer a recommended practice for two main reasons: The quality of catheters has improved and balloon malfunction is extremely rare The previously inflated balloon does not deflate entirely leaving the balloon stretched and disrupting the smooth surface of the catheter. Dwell time of an indwelling catheter What did your policy reveal? Associate Professor V Traynor & C Antoniou Feb 2014 56

Activity 3ii: Theory of catheter care: Trouble shooting catheter care This activity will take approximately 5 minutes to complete. In your role at work you may have had some experience with trouble shooting problems with IDCs. What is the significance of the following factors on IDC infection control, patency and client well-being? Hand hygiene No flush Positioning Tubing length Medication Diet/Fluids Constipation Discharge around meatus Hx of recent urethral trauma Activity 4: Observation and practice of the insertion of catheters This activity will take approximately 45 minutes to complete. You will now be given the opportunity to observe and practice standard IDC insertion procedure. You may use the table below to guide and prompt you along the way. You will use the OSCE sheet to ensure you complete all steps in this procedure (OSCE 1). Associate Professor V Traynor & C Antoniou Feb 2014 57

OSCE 1: Insertion of an Indwelling Catheter INSERTION OF INDWELLING CATHETER Tick when completed 1. Identify and confirm indication for procedure 2. Provide client with a clear and appropriate explanation of the procedure 3. Gather equipment Gloves, clean and sterile Light source Catheter tray Solutions per local guidelines Absorbent pad or waterproof sheet Appropriate size catheter 4. Wash hands 5. Provide privacy, raise bed, position client and obtain assistance if needed 6. Expose and wash perineal area 7. Adjusts light to visualise the perineum 8. Establish sterile field, don sterile gloves, prepares equipment 9. Cleans urinary meatus 10. Inserts urinary catheter 11. Inflates balloon if catheter is indwelling 12. Attaches and secures drainage collection bag and secures catheter 13. Clean perineal area and reposition client for comfort 14. Cleans, replaces and disposes of equipment appropriately 15. Document relevant information Adapted from: Tollefson (2007) Associate Professor V Traynor & C Antoniou Feb 2014 58

Activity 5: Peer teaching and critical review opportunity This activity will take approximately 10 minutes to complete. As part of our professional practice it is required that each of participates in ongoing support of our colleagues by participating in education. If you feel comfortable, you will now be invited to work the other learners and role model the facilitation of another colleague s learning to insert an IDC. You can use the OSCE Sheet as your prompt and guidance (OSCE 1). Activity 6: Q&A about session, Evaluation and Postworkshop activity This activity will take approximately 10 minutes to complete. Any questions Facilitator invites participants to ask any questions. Evaluation Reflecting on the learning from this session, what have you learnt about IDC management for clients? Post-Workshop activities We now invite you to go to the Post-Workshop Activity section of the Workbook and take a few minutes to review what is expected of you for these activities. We invite questions about completing these activities. Associate Professor V Traynor & C Antoniou Feb 2014 59

3. Administration and management of subcutaneous fluids and medication Activity 1:Learning outcomes This activity will take approximately 2 minutes to complete. By the end of the session, participants will have: developed an understanding about how the insertion of a subcutaneous cannula for an older person; developed an understanding about care of a subcutaneous cannula and troubleshooting interventions associated with a subcutaneous cannula inserted into an older person; applied best practice and practised in the clinical simulation setting the insertion of a subcutaneous cannula; and demonstrated to one other practitioner the application of best practice in the clinical simulation setting by inserting a subcutaneous cannula. Activity 2: Q & A about Preparation Activities This activity will take approximately 7 minutes to complete. The facilitator will lead a brief discussion where the participants will have the opportunity to discuss their findings from the Preparation Activities. Associate Professor V Traynor & C Antoniou Feb 2014 60

Activity 3: Theory of administration and management of subcutaneous fluids and medication This activity will take approximately 10 minutes to complete. Gauge size of SC cannula 24 gauge is the recommended size for sub cut cannula for administration of medications and fluids. Site choice Site selection is dependent upon the skin turgor of the client you are caring from and their comfort. Consider the mobility, skin condition, ease of access and mental well-being of the client. Inadequate or poorly selected site selection can lead to poor medication absorption and ineffective therapeutic effect. Sites to avoid Any area that restricts body and limb movement (i.e. skin folds, joints). Breast tissue. Areas of obvious bruising, swelling, infection, redness, limbs at risk of lymphoedema, oedema and/ or hardened, broken skin. Irradiated skin areas. Areas where there is minimal subcutaneous tissue (i.e. thin outer arms/ subclavicular area of the client you are caring for). Considerations For a client who is disorientated confused consider a position for the site that is out of the reach of the client (i.e. scapula, upper back). For a client with lung disease avoid the sub-clavicular area to prevent pneumothorax. If a client is being turned at regular intervals avoid the anterior upper arm. When resiting a subcutaneous cannula ensure adequate site rotation. If it is necessary to re-site in the same area, the new site should be at least 5 cm from the old insertion site. If a client requires a continuous infusion with break-through doses consider using two cannulae. Check with the client for known allergies prior to application. Associate Professor V Traynor & C Antoniou Feb 2014 61

Pain relief/ needle phobia Although a rare occurrence in the acute care settings a client might require local anaesthesia prior to subcutaneous needle insertion, whether it is for psychological or physical pain relief. In this scenario it is recommended that a Lignocaine and Prilocaine 5% (EMLA) patch be applied 60 minutes prior to insertion and these must be charted by a medical officer. Pre insertion priming There is 0.1mL of 'dead space within some subcutaneous cannulas. Best practise evidence is that sub cut cannula is to be primed using water for injection prior to insertion. Rationale includes: a) less air being injected into the subcutaneous tissue of the client; and b) checking of the cannula for faults or leaks prior to insertion. Site preparation As the subcutaneous cannula will normally be left in situ for seven (7) days it is imperative that the selected site be adequately cleaned prior to insertion. The site must be cleaned using friction to rub the skin until the wipe comes away clean (at least 3 wipes). If required clip the hair prior to insertion. Clipping is the preferred method as shaving can cause micro abrasion that can predispose the site to infection. Dwell time of sub cut cannula The BD Saf-T intima can remain in situ for up to. Dressings Dressing should be large enough to cover the site and waterproof. Activity 4: Observation and practice of inserting a subcutaneous cannula This activity will take approximately 45 minutes to complete. You will now be invited to observe and practice subcutaneous cannula insertion (Figure 6). You will use the OSCE sheet to ensure you complete all steps in this procedure (OSCE 2). Associate Professor V Traynor & C Antoniou Feb 2014 62

Figure 6: Procedure Inserting a Sub-Cutaneous Cannula (Adapted from SESLHN (2011)) Associate Professor V Traynor & C Antoniou Feb 2014 63

OSCE 2: Insertion of Subcutaneous Cannula INSERTION OF A SUBCUTANEOUS CANNULA Tick when completed 1. Identify and confirm indication for procedure 2. Provide client with a clear and appropriate explanation of the procedure 3. Gather equipment Non sterile kidney dish 10mL Luer lock syringe Appropriately sized winged infusion set 2 caps (i.e. Interlink bung) 10mL water for injection Occlusive dressing Minimum volume infusion line if required. 4. Wash hands 5. Provide privacy, raise bed, position client and obtain assistance if needed 6. Identify appropriate insertion site 7. Don non-sterile gloves 8. Swab area using until the swab comes away clean. 9. Remove clear plastic needle cover and lift a fold of skin between finger and thumb. This is to create of smooth surface in which to pierce the skin. Insert the needle at a 30 o to 45 o angle into the subcutaneous tissue. 10. Gently retract the metal introducer. Grip the Y connection and continue to remove the remainder of the introducer. 11. Dispose of introducer into the appropriate sharps container 12. Place second Interlink cap onto the end of the tubing. 13. Flatten the wings onto the surface of the skin and place the port horizontal to the client. Cover the cannula and wings under the occlusive dressing. 14. Label the dressing with the date and time of insertion. 15. Clean, replace and dispose of equipment appropriately 16. Document relevant information Adapted from: SESLH (2011) and Tollefson (2007) Associate Professor V Traynor & C Antoniou Feb 2014 64

Activity 5: Peer teaching and critical review opportunity This activity will take approximately 10 minutes to complete. As part of our professional practice it is required that each of participates in ongoing support of our colleagues by participating in education. If you feel comfortable, you will now be invited to work the other learners and role model the facilitation of another colleague s learning to insert a sub-cutaneous cannula. You can use the OSCE Sheet as your prompt and guidance (OSCE 2). Activity 6: Q&A about session, Evaluation and Post- Workshop activity This activity will take approximately 10 minutes to complete. Any questions Facilitator invites participants to ask any questions. Evaluation We now invite you to reflect on the learning from this session and answer the following questions: What have you learnt about subcutaneous fluid and medication administration? What will be different about your clinical practice when you return to work? Post-Workshop activities We now invite you to go to the Post-Workshop Activity section of the Workbook and take a few minutes to review what is expected of you for these activities. We invite questions about completing these activities. Associate Professor V Traynor & C Antoniou Feb 2014 65

Post-Workshop Activities Welcome back to this Advanced Aged Care Clinical Skills Workshop. You have successfully completed the Preparation Activities and participated in the face-toface Workshop day. To gain your remaining CPD points for this Workshop you are required to complete two (2) of the Post-Workshop activities. Similar the Preparation Activities, you can choose which of these activities to complete to gain your remaining CPD points. Part A: Topic specific Preparation Activities Post-workshop Activity 1: (i) Escalating and (ii) Reporting deteriorating health conditions for older people This activity will take approximately 1 hour to complete. ISBAR: Framework for communication ISBAR is the model of clinical handover which was focused on during the Workshop. ISBAR maps the Standard Key Principles for clinical handover and is therefore considered an example of a best practice approach to improving clinical handover for clients and practitioners. This Post-Workshop activity involves critically reviewing a case study and explaining how the outcomes for the client and practitioner are improved through the use of ISBAR. Case Study One YouTube resource by the Australian Commission on Patient Safety and Quality on HealthCare (ACSQHC) demonstrating case studies of handover. View Case Study 2: Mr Baxter with a suspected pneumonia who is admitted to an acute care hospital. Handover from the week-end Medical Registrar to the Medical Consultant Associate Professor V Traynor & C Antoniou Feb 2014 66

The case study is a 62 year old gentleman presenting with what the practitioner describes as a pneumonia although the gentleman had no history of fevers or rigours. Online Medical Dictionary First of all, list any medical terminology you do not know the meaning of and look it up to discover what it means. At the end of the case study, the medical consultant, Dr Mathews, praises the Weekend Medical Registrar, Emily Yu, Good story. Well done. List the reasons why Dr Mathews is impressed by the hand-over by the Emily Yu.......... Associate Professor V Traynor & C Antoniou Feb 2014 67

Case Study Two YouTube resource by the South Australia Health demonstrating case studies of handover. View Scenario 2: Mrs Murray with a fractured neck of femur. Handover from the GP to the Orthopaedic Registrar The case study is Mrs Murray who is 80 years. What are the lessons from this case study about creating positive outcomes for clients and practitioners when a practitioner from one discipline in a healthcare team contacts a practitioner from another discipline in the healthcare team and a different care setting?......... Associate Professor V Traynor & C Antoniou Feb 2014 68

Post-Workshop Activity 2: Advanced care of different types of urinary catheters (female and male) and Activity 3: Inserting an sub-cutaneous cannula This activity will take approximately 1 hour to complete (if you complete Activity 2 and Activity 3 it will take approximately 2 hours to complete). The aim of this activity is to provide you with the opportunity to review the way in which you teach colleagues clinical skills and provide feedback following the observation of colleagues undertaking a clinical skill: Activity 2: Inserting an indwelling catheter and Activity 3: Inserting a sub-cutaneous cannula. First, you will need to print out the OSCE sheet for inserting an indwelling catheter (OSCE 1, p. 58) and/ or inserting an sub-cutaneous cannula (OSCE 2, p. 64). You can use the OSCE sheets as guidelines for teaching your colleague all the required steps to successfully inserting an indwelling catheter and/ or inserting a subcutaneous cannula. Next, you can ask the colleague if you can observe them inserting an indwelling catheter and/ or inserting a sub-cutaneous cannula using the OSCE sheet to critically review the colleague undertaking this task. Some of you might consider inserting an indwelling catheter and/ or inserting a sub-cutaneous a straight forward clinical skill to do and therefore it might feel like a simple task to teach. What you need to focus on during this activity is not the simplicity of the clinical skill but the complexity of the teaching task and the skills required to provide meaningful and sensitive feedback to colleague after observing them undertaking a clinical skill. Online Medical Dictionary First of all, list any medical terminology you do not know the meaning of and look it up to discover what it means. Associate Professor V Traynor & C Antoniou Feb 2014 69

The reflective part of this activity involves two tasks. 1. Ask your colleague to provide you with feedback your teaching approach and identify three (3) aspects of your teaching which were positive and three (3) aspects of your teaching approach which they suggest you review and amend for your future teaching sessions. A critical review of your teaching approach Positive aspects your teaching approach 1. 2. 3. Suggestions for amendments to your teaching approach for future sessions 1. 2. 3. Associate Professor V Traynor & C Antoniou Feb 2014 70

2. Reflect on the process of providing feedback to a colleague after observing him/ her undertaking a clinical skill. A critical review of providing feedback to a colleague Positive aspects about the way in which I provided feedback 1. 2. 3. Aspects which require amending about my approach to providing feedback 1. 2. 3. Associate Professor V Traynor & C Antoniou Feb 2014 71

Part B: Developing an Action Plan for your future professional development activities This activity will take approximately 1 hour to complete. Now that you have completed the Preparation Activities, participated in the Workshop and completed the Post-Workshop Activities Part A you can now develop a Learning Action Plan for your future learning (). When you develop an Action Plan, of any kind, there several tasks which are required completion before writing your Action Plan. The aim of this Post- Workshop Activity is to provide you with guidance to complete an Action Plan for you Future Learning to develop more advanced aged care skills useful for undertaking your specialist role as a Registered Nurse working with older people. The first tasks we suggest are required for you to complete before writing your Action Plan (p. 76) for future learning are identifying: a competency (skills, knowledge and attitudes relevant to your work role) you want to achieve as one way to improve your contribution to the care of older people and the way in which the aged care organisation you work for delivers services to older people; specific learning goals which will contribute to you achieving the competency you decide to work towards in your role as a Registered Nurse working with older people; a mentor who can provide you with guidance about how to achieve the competency you choose to work towards in your action plan; resources (personnel, organisational or educational) you will need to achieve the competency you choose to work towards in your action plan; and a timeline and review dates to achieve the competency, consisting of immediate, short-term and long-term deadlines. Associate Professor V Traynor & C Antoniou Feb 2014 72

Mind mapping One way of choosing the competency you want to work towards in your action plan and identify your learning goals, mentor, resources and timeline and review dates is to undertake a mind map. You can use the mind map technique to generate ideas about what you need to do to achieve your learning goals and you can record these ideas in your Action Plan. We will provide guidance on how to undertake a mind map. What is a mind map? [g]raphical technique for visualising connections between several ideas or pieces of information. Each idea or fact is written down and then linked by line or curves to its major or minor (or following or previous) idea or fact, thus creating a web of relationships. Developed by the UK researcher Tony Buzan in his 1972 book 'Use Your Head,' mind mapping is used in note taking, brainstorming, problem solving, and project planning. Like other mapping techniques its purpose is to focus attention, and to capture and frame knowledge to facilitate sharing of ideas and concepts. BusinessDictionary, N.D. Associate Professor V Traynor & C Antoniou Feb 2014 73