This A to Z guide covers a number of issues touched on in "Undercover nurse" which relate to the care of older people on hospital wards.
The guidance has been extracted from a number of "best practice" guides written within the NHS or associated bodies which are listed below with links, where they are available online.
If a patient in hospital is not receiving care according to these standards then it should not be a matter for alarm but it is something which the patient or someone acting on their behalf should feel confident about raising with nurses or doctors on the ward.
It is a stated ambition of the government and department of health to root out age discrimination in the NHS. NHS services should be provided on the basis of clinical need alone.
Patients benefit from care that is centred on the individual. Patients should be enabled to make choices about their care. Their opinions and wishes should be respected. Ward staff should strive for the greatest level of independence possible for individual patients.
See personal hygiene
Each patient should have an individual care plan drawn up by nurses on the ward. Ideally this should be drawn up in consultation with the patient or their carers. It sets out the care that has been planned for the patient, the decisions that have been made regarding that care and the care that has been delivered. It should record physical, psychological and functional needs of the patient (eg; is the patient able to move around or go to the toilet without help?). It should also set objectives, so that care can be evaluated as it is delivered. In addition, it should record objections which the patient has to proposed aspects of their care.
Calling for help
Patients should have buzzers to call for help and should be shown by staff where these are when they are given their bed.
Every area should be cleaned thoroughly at least once a day. There should be no visible blood or body substances, dust, dirt, debris, adhesive tape or spillages. The area should be tidy, ordered and uncluttered with only appropriate, cleanable, well-maintained furniture.
If patients see problems with the cleaning they should feel able to report them to staff, who should be able to contact cleaning staff to remedy the situation.
Patients and carers should experience effective communication, sensitive to their individual needs and preferences. Older people should be listened to and encouraged to express their preferences when there are choices to be made concerning their healthcare.
Nurses should recognise when a patient has particular needs which are impairing communication and should refer these to the appropriate services; eg. Interpreters, speech and language therapists for example.
If a nurse is writing information down for a patient they should check the patient can read their handwriting.
Hearing aids and dentures should be left within a patient's reach and the patient should know they are there.
All patients, their relatives and their carers should have accessible information about the complaints procedure in a hospital. Patients who make complaints should not be discriminated against.
Where a person is suffering from dementia this should be noted and should form part of their care plan. Communication with patients with dementia needs special attention and can be improved with calm and patience, the staff speaking to the patient simply but not speaking 'down' to them, using touch and allowing time.
People's dignity should be maintained throughout their stay in hospital. This includes when they are being helped to eat, dress or bathe.
Planning for discharge should start prior to the hospital stay for planned admissions and as soon as possible during the hospital stay for other admissions. Patients should not be left wondering about what will happen next. They should understand and be contributing to care planning where discussion is ongoing.
Dehydration is more serious in older patients and can lead to organs starting to fail. Fluid intake should be monitored where there are risks and patients should be helped to drink where they require this assistance. Where a decision has been taken to manage fluid in an older patient, fluid should be monitored with the same level of care as drug prescription.
End of life care
Palliative: where a patient is suffering from a disease which cannot be cured, efforts should still be made to control the pain and distress they are experiencing. Drugs should be prescribed to control existing symptoms and to prevent new ones developing. Treatment should be tailored to individual need. Pain should be kept under review, and changes made to the dose where pain management is not working, provided higher doses produce better pain control and not intolerable side effects. The balance between pain control and the side effects should be decided with the patient.
Emotional/ spiritual: patients should also have access to the emotional and spiritual support they require. Ideally a patient should know when death is coming and understand what can be expected. They should retain control of who is present with them at the end and have time to say goodbye.
Patients should be given a choice of food from a daily menu. A patient should make sure that he/she is being shown the full menu if none of the choices he/she is told about appeal to him/her. Food should be prepared safely and provide a balanced diet.
The nutritional, personal and clinical dietary requirements of individual patients should be assessed and provided, including the right to have religious dietary requirements met.
Patients at risk of malnutrition or already suffering from it should be identified. Where this is an area for concern a nutritional plan should be developed, appropriate food provided, food intake monitored and action taken if nutritional needs are not being met.
Patients should receive the care and assistance they require when eating and drinking. This is a nursing responsibility.
Staff should wash their hands between contact with one patient and the next. There should be stations on the ward where either alcohol gel or soap and water is available so that staff, patients and visitors can wash their hands when they need to. Patients should feel free to ask staff to wash their hands, if they think they may not have done so.
Hospital nurses should identify people with incontinence and ensure that treatment is provided and continence needs assessed. A plan should be agreed with the patient to manage incontinence before discharge from hospital.
Systems should be in place to ensure that the risk of health care acquired infection is reduced, with particular emphasis on high standards of hygiene and cleanliness.
Ideally, meals should not be interrupted by doctor's rounds. Hospitals are now being encouraged to set time aside on each ward so that all the patients on the ward can eat food without interruption. If a meal is missed, then patients should be offered a replacement.
Patients who are getting better should be encouraged and helped to move around. Older people should be encouraged to maintain and where possible improve on their optimum levels of independence. Aids to mobility should be supplied to enable patients to be as independent as possible.
This is the practice whereby each patient has a named, qualified nurse, midwife or health visitor responsible for their care. Either this name should be given to the patient, or where the patient is not well enough to comprehend, it should be given to their chosen representative (a relative or friend). There should be a substitute name for a nurse, when the named nurse is not on duty. This practice is not universally applied across nhs hospitals though it has been recommended in the past and is still accepted as best practice by many nurses.
Where pain relief drugs are prescribed they should be delivered regularly and on time. If the pain is not controlled, then the dose should be increased in reference to the previous dosage, provided this will produce better pain control and not intolerable side effects. There should be frequent and regular reassessment by a medical team until the pain is controlled. No patient should have to endure pain over a very long period whether or not it is possible to cure them. Patient's preferences must be respected between pain relief and side effects. The individual should define their own levels of tolerance of pain and distress - ways should be found to help people communicate this. Treatment should be recorded and reviews of its efficacy should be documented.
See end of life care
Personal hygiene and appearance, including dress, should be maintained according to the older person's wishes. Bathing patients is a nursing responsibility and should not be delegated to healthcare assistants without supervision. Principles of dignity, privacy and respect should be applied.
The condition of patients skin should be maintained or improved in hospital. Pressure sores can develop if a patient is left in one position too long and is unable to adjust their position. Being moved may be an unpleasant experience for an older person, when they require the help of two people but it is better if patients are encouraged to move when they have been sitting in one place for too long.
In the NHS plan, there was a commitment from the government that 'nightingale' wards, where elderly people had been nursed in mixed sex 'dormitory' accommodation would be replaced by wards which allowed for more privacy. Bays should be used to separate patients of different sexes. Curtains should be drawn if a patient requests privacy while they are being attended to by a nurse or healthcare assistant. A patient should not be helped to a commode in public view.
Nurses should ensure that medication when delivered is placed within easy reach of the older person and that they have explained that it is there. If a patient needs help to take their medication because they are blind or suffer dementia then they should be helped.
Records and record keeping
There should be up to date records for every patient on a ward and ideally these should be written with the involvement of the patient and in terms they can understand. Where a doctor has ordered a chart to be filled in, recording how much fluid or food a patient is getting should be regularly filled in. Record keeping is not an optional extra to be fitted in if circumstances allow but an integral part of nursing practice. Records should be clear and notes should be made as and when things happen so that they read as a list of consecutive events. If alterations and additions are made, they should be dated, timed and signed.
Specialist services to help rehabilitate older people should be available and should be involved early on in patients' care. Hospitals should have space for rehabilitation equipment.
Respect, which embraces compassion and empathy, is a principle that a nurse should apply to all patients, including those who may be unable to ensure their rights are being recognised because they are suffering from dementia or cognitive impairment. It also includes respecting the cultural and spiritual needs of patients, (which can be of particular importance to many older people) and recognising diversity in religious belief.
There are no set guidelines as to the number of nursing staff who should be on a ward at any one time. It is a matter of professional judgement and local protocol. Elderly patients on acute wards should be seen by a consultant within 24 hours of admission.
People who have had a stroke should have access to specialist stroke services early on in their treatment who will engage in their rehabilitation and in secondary prevention. Rehabilitation will be individual to each patient's needs but might include speech and language therapy for those patients with communication or swallowing difficulties.
Nurses should be active in meeting requests for toilet help and should respond to a request from a patient who needs to use the toilet within five minutes. People should be treated with sensitivity. The patient's privacy should be respected, which means drawing curtains if they cannot move from the ward.
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The Royal College of Nursing
The following documents are all available from the Department of Health website
National service framework for older people, 2001
NHS plan, 2000
Essence of care: patient focussed benchmarks for clinical governance. 2001
Standards for better health, 2004
Health advisory service "not because they are old: an independent inquiry into the care of older people on acute wards in general hospitals" 1998 - not available online.
2001 Good medical practice, General Medical Council
2004, Good medical practice for physicians
National council for palliative care