Nursing Home Care - Basic Rules

When is a person sent to a nursing home (NH)?

Generally, when they are not able to perform the ADL independently, and there is nobody to assist them at home.

The ADL/IADL can be remembered by the mnemonic DEATH SHAFT (Dressing, Eating, Ambulation, Toilet, Hygiene; Shopping, Housekeeping, Accounting ~ finances, Food preparation-> who’s cooking?, Transportation -> driving?). The IADL can be performed by a relative but when one or more of the five ADL are lost, then, usually, it is time to think about a NH placement.

What are the NH rules?

Every patient needs a focused history, physical exam and a SOAP note every 2 months. This is usually focused on one or two active problems from the patient's problem list or a new problem, e.g. dementia, rash, etc.

Every patient needs a complete H&P once per year.


How to approach a problem?

When you review the chart of a NH patient, check the following 4 areas:
- Problem list
- Medication list
- Previous progress notes
- Labs

If you write a SOAP note focused on a psychiatric problem (agitation, psychosis), and the medication effect, concentrate on the following questions:
- Indication for the medication?
- Is it helpful?
- Any AE?
- Should you continue the medication?


NH chart

These are the major sections of a NH chart (you can make an info sheet for each patient):
- Date of admission
- Age
- DPOA, DNR-CCA, advanced directive?
- Problem list (usually 10 problems but can be up to 25)
- H&P
- Orders sheet
- Progress notes - physicians, nursing practitioners
- Nurses notes
- Labs


Why is geriatrics different from general medicine?

There are several major differences between geriatrics and general internal medicine. Just review the table of contents of the Merck Manual of Geriatrics, and you will see the main geri topics:
- Dementia
- Delirium
- Incontinence
- Falls
- Decubitus
- End of life care
- Other

NH standing orders


Example of NH standing orders

References:

Merck Manual of Geriatrics
Eight rules to consider when rounding on elderly patients. 2006 Today's Hospitalist.
PBS Documents Bid to Build a Better Nursing Home. Listen to NPR story. 'Almost Home' Site at PBS.org

Related reading:
Falls in the Elderly - AFP 04/00
Advances in the Treatment of Alzheimer's Disease - AFP 11/98
Early Diagnosis of Dementia - AFP 02/01
Diagnostic Approach to the Confused Elderly Patient - AFP 03/98
Diagnostic Evaluation of Urinary Incontinence in Geriatric Patients - AFP 06/98
Depression in Later Life: A Diagnostic and Therapeutic Challenge - AFP 05/04
Constipation in the Elderly - AFP o9/98
Reformers Seek to Reinvent Nursing Homes - NPR 6/05
WJM, Volume 163(3); September 1995. http://www.ncbi.nlm.nih.gov/pmc/issues/124736
Registered Nurse to Masters of Science in Nursing

In the media:

For the very old, a dose of 'slow medicine.' International Herald Tribune, 02/2008.
A Son's Photo Journal of His Aging Father's Decline - Photo Essays - TIME http://goo.gl/RVCt

Published: 3/01/2005
Updated: 8/12/2005

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