Need Help With Rap Summaries For Delirium

[MDSnursing]

Hello There!

Allow me to introduce myself-I am a LPN in Washington State, and I work in the Yelm area, live in Lacey/Olympia area. Just discovered this site, and WOW

what a resource!!! Have a bit if a dilema presently if anyone is available to assist me in a problem I caused during survey.

I am new to my position as a MDS coordinator~about a year now. Had about a month of training however only on MDS', as my predecessor hated care conferences, care planning, as well as Rap summaries. Unfortunately, I need some help here pretty quickly if anyone might be available. We have been through three DON's in the past year. Our newest one used to work here as a Nac, then as a Rn, and left for personal reasons. Fortunately our Administrator convinced her to come back as Don, and she is wonderful as a teacher. She has been a Unit Manager at another facility, and was involved in the care planning process. I have been writing my Rap summaries based on what out QAn nurse had advised me when I asked for assistance about a year ago on references, and just what is it that surveyors are lokking for? She said the same as what another poster said in this thread about care plans. You should be able to read a RAP summary and know exactly who is being discussed without a resident name. And she advised narrative summaries.

Now jump to this years surveys. We got an F-Tag due to my Rap summaries "Being too difficult to follow." OMG. So I have fixed that by starting with an intro to the res, a med list, and diagnosis. Then I follow with seperating Rap summaries by paagraph, instead of essay type. Ok, DON and ADmin are happy with that. But, Another F-Tag is that I did not addres Delirium in my summaries. I over addressed Cognition thinking that it should cover it.

AS part of our Plan Of Correction- Admin is requesting from me an example RAP summary for Delirium, as well as a definition of Delirium, and common triggers/causes of Delirium. (Admin & DON are extremely supportive, and know how much of a perfectionist I am)

Please help!! Does anyone out there have a good example of a RAP summary for Delirium, and can outline for me some common interventions and things important to address?

With Much Appreciation,

Dara

[Talino]

First, identify what item/s triggered the Delirium RAP.

A trigger legend, see RAI p C-3, is a good guide.

Look at the guidelines p C-10 on probable causes.

Say, B6 = 2 caused the the trigger.

So Delirium RAP Summary can be one or a combination of:

"Decline in Cognition related to use of new antipsychotic."

"See related care plans RAPs #2, #11, & #17 addressing potential risks."

"See Psych. consult xx/xx/06 regarding need for antipsychotic"

"See Nurses notes xx/xx/06" sample NN entry--> "Drowsy w/ decreased attention span. 'wll refer to Psych in am for possible dose reduction."

[Nascar nurse, ASN, RN]

This is how I write my RAPS (by the way - social service is responsible for delirium RAP in our facility)

Rap Summary

Mrs. Smith

10/16/06

ADL functional/rehabilitation: Proceed - Mrs. Smith was recently admitted to this facility following hospitalization for an elective knee replacement surgery. As a result of this, she has had a decline in her ADL independence. She is receiving PT/OT as ordered. She has complained of moderate pain less than daily and is receiving effective relief with the use of prescribed PRN pain medications. She is using a w/c as her primary mode of locomotion and is also using a walker with extensive assist. Staff and resident believe she will have an increase w/ her ADL independence upon the completion of therapy and she plans to return to her own home at that time. (Would also include things such as SOB w/ exertion & use of o2, restorative nursing, etc as it applied)

DEHYDRATION: Not proceed - Mrs Smith triggered for risk for dehydration related to having had a UTI within the past 30 days. The infection is resolved at this time and she has not had further symptoms of such. She is consuming most fluids offered w/ meals and medication pass and is able to obtain additional fluids as desired from bedside water pitcher. She is free of clinical indications of dehydration at this time.

(No care plan written based on this RAP).

PRESSURE ULCER: Proceed - Mrs Smith is currently free of pressure ulcers. She is able to make some independant position changes in bed with the use of her upper siderails are desired. She has preventative skin measures in place as ordered. Her surgical wound is monitored for signs of infection daily and a dry dressing is applied as ordered. Her skin will be monitored for concerns daily by the CNA's and a weekly head to toe skin assessment will be completed by a licensed nurse.

END OF EXAMPLE

Sorry I can't be more specific w/ a delirium example as I just don't do that part except on very rare occassion. But, if forced to, I just figure out what triggered the RAP, based on the RAI, then address that in the RAP, explain if it is or isn't a problem at this time and then state what we are going to attempt to do to resolve the issue.

Hope this helps

I'm going to see if I can get a mod to move your post to geriatrics - I think you will get more responses.

P.S. Get your delirium definition for the RAI manual.

[evalesco]

Delirium usually triggers due to decline in mood, and on new admits they usually will have a decline in mood, I just write ...

Rap triggered due to decline in mood, no need to care plan, no s/s of delirium are present, refer to Mood rap and care plan.

That's the case for me anyways.