Behavioral Controlling Medications



Medication

Administration

Part 2

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Bedsores (pressure ulcers)

Overview

Bedsores — also called pressure ulcers and decubitus ulcers — are injuries to skin and underlying tissue resulting from prolonged pressure on the skin. Bedsores most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips and tailbone.

People most at risk of bedsores are those with a medical condition that limits their ability to change positions or those who spend most of their time in a bed or chair.

Bedsores can develop quickly. Most sores heal with treatment, but some never heal completely. Symptoms

Warning signs of pressure ulcers are:

• Unusual changes in skin color or texture

• Swelling

• Pus-like draining

• An area of skin that feels cooler or warmer to the touch than other areas

• Tender areas

Bedsores fall into one of several stages based on their depth, severity and other characteristics. The degree of skin and tissue damage ranges from red, unbroken skin to a deep injury involving muscle and bone.

Common sites of pressure sores

For people who use a wheelchair, pressure sores often occur on skin over the following sites:

• Tailbone or buttocks

• Shoulder blades and spine

• Backs of arms and legs where they rest against the chair

For people who are confined to a bed, common sites include the following:

• Back or sides of the head

• Shoulder blades

• Hip, lower back or tailbone

• Heels, ankles and skin behind the knees

When to see a doctor

If you notice warning signs of a bedsore, change your position to relieve the pressure on the area. If you don't see improvement in 24 to 48 hours, contact your doctor.

Seek immediate medical care if you show signs of infection, such as a fever, drainage from a sore, a sore that smells bad, or increased redness, warmth or swelling around a sore.

Causes

Bedsores are caused by pressure against the skin that limits blood flow to the skin. Other factors related to limited mobility can make the skin vulnerable to damage and contribute to the development of pressure sores.

Three primary contributing factors for bedsores are:

• Pressure. Constant pressure on any part of your body can lessen the blood flow to tissues. Blood flow is essential to delivering oxygen and other nutrients to tissues. Without these essential nutrients, skin and nearby tissues are damaged and might eventually die.

For people with limited mobility, this kind of pressure tends to happen in areas that aren't well-padded with muscle or fat and that lie over a bone, such as the spine, tailbone, shoulder blades, hips, heels and elbows.

• Friction. Friction occurs when the skin rubs against clothing or bedding. It can make fragile skin more vulnerable to injury, especially if the skin is also moist.

• Shear. Shear occurs when two surfaces move in the opposite direction. For example, when a bed is elevated at the head, you can slide down in bed. As the tailbone moves down, the skin over the bone might stay in place — essentially pulling in the opposite direction.

Risk factors

People are at risk of developing pressure sores if they have difficulty moving and are unable to easily change position while seated or in bed. Risk factors include:

• Immobility. This might be due to poor health, spinal cord injury and other causes.

• Lack of sensory perception. Spinal cord injuries, neurological disorders and other conditions can result in a loss of sensation. An inability to feel pain or discomfort can result in not being aware of warning signs and the need to change position.

• Poor nutrition and hydration. People need enough fluids, calories, protein, vitamins and minerals in their daily diet to maintain healthy skin and prevent the breakdown of tissues.

• Medical conditions affecting blood flow. Health problems that can affect blood flow, such as diabetes and vascular disease, increase the risk of tissue damage.

Complications

Complications of pressure ulcers, some life-threatening, include:

• Cellulitis. Cellulitis is an infection of the skin and connected soft tissues. It can cause warmth, redness and swelling of the affected area. People with nerve damage often do not feel pain in the area affected by cellulitis.

• Bone and joint infections. An infection from a pressure sore can burrow into joints and bones. Joint infections (septic arthritis) can damage cartilage and tissue. Bone infections (osteomyelitis) can reduce the function of joints and limbs.

• Cancer. Long-term, nonhealing wounds (Marjolin's ulcers) can develop into a type of squamous cell carcinoma

• Sepsis. Rarely, a skin ulcer leads to sepsis.

Prevention

You can help prevent bedsores by frequently repositioning yourself to avoid stress on the skin. Other strategies include taking good care of your skin, maintaining good nutrition and fluid intake, quitting smoking, managing stress, and exercising daily.

Tips for repositioning

Consider the following recommendations related to repositioning in a bed or chair:

• Shift your weight frequently. If you use a wheelchair, try shifting your weight about every 15 minutes. Ask for help with repositioning about once an hour.

• Lift yourself, if possible. If you have enough upper body strength, do wheelchair pushups — raising your body off the seat by pushing on the arms of the chair.

• Look into a specialty wheelchair. Some wheelchairs allow you to tilt them, which can relieve pressure.

• Adjust the elevation of your bed. If your bed can be elevated at the head, raise it no more than 30 degrees. This helps prevent shearing.

Tips for skin care

Consider the following suggestions for skin care:

• Keep skin clean and dry. Wash the skin with a gentle cleanser and pat dry. Do this cleansing routine regularly to limit the skin's exposure to moisture, urine and stool.

• Protect the skin. Use plain talcum powder to protect skin at friction points. Apply lotion to dry skin. Change bedding and clothing frequently if needed. Watch for buttons on the clothing and wrinkles in the bedding that irritate the skin.

• Inspect the skin daily. Look closely at your skin daily for warning signs of a pressure sore.

Behavioral Controlling Medications include:

❑ Medications administered on a PRN basis to promote adaptive behavior

❑ Medications used on an ongoing basis for the maintenance of adaptive behavior

❑ Psychotropic medications used for the treatment of diagnosed mental illness

Psychotropic medication must have a signed consent form from the guardian, which will be updated yearly. This needs to be signed prior to administering the medication.

Common Psychotropic Medications

|  Antipsychotics |Anti-depressants |Anti-obsessive Agents |

|Typical Antipsychotics |Tricyclics |Luvox (fluvoxamine) |

|Haldol (haloperidol) |Asendin (amoxapine) |Paxil (paroxetine) |

|Mellaril (thioridazine) |Tofranil (imipramine) |Prozac (fluoxetine) |

|Thorazine (chlorpromazine)    |Vivactil (protiptyline) |Zoloft (sertraline) |

|Atypical Antipsychotics |SSRIs |Antianxiety Agents |

|Abilify (aripiprazole) |Celexa (citalopram) |Ativan (lorazepam) |

|Clozaril (clozapine) |*Luvox (fluvoxamine) |BuSpar (buspirone) |

|Geodon (ziprasidone) |Paxil (paroxetine) |*Klonopin (clonazepam) |

|Risperdal (risperidone) |Prozac (fluoxetine) |Lexapro (escitalopram) |

|Seroquel (quetiapine) |Zoloft (sertraline) |Valium (diazepam) |

|Zyprexa (olanzapine) |MAO Inhibitors |Xanax (alprazolam)  |

|Mood Stabilizers |Nardil (phenelzine) |Stimulants (for ADHD) |

|Depakote(valproic acid) |Parnate (tranylcypromine)    |Adderall (amphetamine and dextroamphetamine) |

|Lithobid (lithium) |Others |Cylert (pemoline) |

|*Tegretol (carbamazepine) |Effexor (venlafaxine) |Dexedrine (dextroamphetamine) |

|*Topamax (topiramate) |Wellbutrin (bupropion) |Ritalin (methylphenidate) |

Common Side Effects to Watch For

❑ Facial Movements

o Tics-brief muscular contractions of small sections of the face

o Grimaces – brief muscular contractions of large sections of the face or the forehead area (i.e. brow-arching)

❑ Ocular movements

o Blinking – rapid opening and closing of the eyelids increasing the frequency of resulting in “bursts” of blinking.

❑ Oral Movements

o Chewing – circular or up and down jaw movements similar to chewing gum. Do not include jaw tremor; and/or

o Lip Smacking – quick parting of the lips which usually produces a smacking sound

o Puckering – pursing the lips similar to the movements when kissing or pulling a drawstring of a purse; and or

o Sucking – drawing in one or both lips similar to the motion when drinking with a straw and/or

o Thrusting lower lip – extending action of the lower lip similar to a child’s pout.

❑ Lingual Movements

o Tongue Thrusts – abrupt (similar to a frog catching a fly) or rhythmic movements of the tongue in and out of the mouth beyond the edge of the lips; and or

o Tongue in Cheek – pressing the tongue against the cheek or lips producing a noticeable bulge similar to a large piece of candy or wad of tobacco.

o Tonic tongue – a hanging tongue extending beyond the edge of the lips somewhat like the hanging tongue of a dog when panting.

o Tongue Tremor – a fine rhythmic or quivering tongue observed with the mouth open and the tongue inside or outside of the mouth

o Antheoid Tremor – worm like rolling and twisting movements of the tongue observed with the mouth open and the tongue inside or outside the mouth; and/or

o Myokymic Tongue – jerking or twitching motion of the tongue observed with the mouth open and the tongue inside or outside the mouth; and/or

o Lateral Tongue – side-to-side movements of the tongue observed with the mouth open and the tongue inside or outside the mouth.

❑ Head/Neck/Trunk Movements

o Rectrocollis – contraction of the neck muscles resulting in snapping or bending the head back, similar to looking up at the ceiling; and/or

o Torticollis – contractions of the neck muscles resulting in snapping or twisting the head to one side

o Should/Hip Torsion – twisting or rolling movements of the shoulders and/or hips involving large sections of the body

❑ Upper Limb Movements

o Anthetoid Finger-Wrist-Arm – worm like, writhing, vermicular, rolling and twisting movements of the fingers, wrists, and/or arms. Do not include tremor which is rhythmic; an/or

o Myokymic Finger-Wrist-Arm – twitching or jerking movements of the fingers, wrists, and/or arms. Do not include tremor, which is rhythmic.

o Pill Rolling – circular movements of the thumb against the fingers, wrists, and or arms. Do not include tremor, which is rhythmic.

❑ Lower Limb Movements

o Ankle Flexion – circular, up and down, and/or back and forth, bending ot twitching movements of the ankle or foot

o Foot Tapping – an alternating contact-non contact taping or striking movement of the hell, toe, and/or entire foot with the floor.

o Toe Movements – bending or jerking movements of the toe(s). Do not include tremor.

It is not likely that you will ever fill out a MOSES scale, but it is important to see the types of side effects that people might have from psychotropic medications.

|MONITORING OF SIDE EFFECTS SCALE (MOSES) |INDIVIDUAL |I.D. |

| |John Hanson | |

| |DATE |RATER SIGNATURE AND TITLE |

| |4-18-05 |Jane Nurse, RN |

| |INSTRUCTIONS: See other side. Bold items are primarily observable. Regular print items are primarily client|

| |verbalization, staff input, and/or chart review. |

|SCORING: See other side for details. |Exam Type (check one; if * specify in comments) |

| |1. Admission ( 4. Drug D/C (*) |

|0 = None 2 = Mild 4 = Severe |2. Baseline ( 5. Drug Initiation |

|1 = Minimal 3 = Moderate NA = Not Assessable |3. Dosage Increase ( 6. Six Month Assessment |

| |( 7. Other (*) |

|EYES/EARS/HEAD |MUSCULOSKELTAL/ |URINARY / GENITAL |

| |NEUROLOGICAL | |

|01. Blink Rate: Decreased (0) 1 2 3 4 NA |28. Arm Swing: Decreased (0) 1 2 3 4 NA |55. Menstruation: absent/irregular |

|02. Eyes: Rapid Vert/ Horiz (0) 1 2 3 4 NA |29. Contortions/Neck or (0) 1 2 3 4 NA |56. Sexual: Continual erection |

|03. Eyes: Rolled Up (0) 1 2 3 4 NA|Back Arching |57. Urinary Retention |

|04. Face: No expression/ (0) 1 2 3 4 NA |30. Gait: Imbalance/Unsteady(0) 1 2 3 4 NA |58. Urination: Decreased WHILE THE SIDE |

|Masked |31. Gait: Shuffling (0) 1 2 3 4 |59. Urination: Increased EFFECTS IN |

|05. Tics/Grimace (0) 1 2 3 4 |NA |(includes nocturnal) THESE TWO |

|NA |32. Limb Jerking/Writing (0) 1 2 3 4 NA |60. Sexual: activity AREAS ARE |

|06. Blurred Double Vision (0) 1 2 3 4 NA |33. Movement: Slowed/ (0) 1 2 3 4 NA |increased OFTEN DIFFICULT |

|07. Ear Ringing (0) 1 2 3 |Lack of |61. Sexual: activity TO DETERMINE, |

|4 NA |34. Pill Rolling (0) 1 2 3 |decreased PLEASE BE |

|08. Headache (0) 1 2 3 4|4 NA |62. Sexual: erection inability AWARE THEY |

|NA |35. Restlessness/Pacing/ (0) 1 2 3 4 NA |63. Sexual: orgasm difficult MAY OCCUR |

|MOUTH |Can’t Sit Still |64. Urination: Difficult/Painful DEPENDING ON |

| |36. Rigidity (0) 1 2 3|--------------------------------------- THE SPECIFIC |

|09. Drooling 0 (1) 2 3|4 NA |65. Agitated DRUG |

|4 NA |37. Tremor/Shakiness (0) 1 2 3 4 NA |PROFILE. |

|10. Dry Mouth (0) 1 2 3 4|38. Fainting/Dizziness upon (0) 1 2 3 4 NA |66. Drowsiness/Lethargy/ BE CERTAIN TO |

|NA |Standing |Sedation INQUIRE ABOUT |

|11. Mouth/ Tongue Movement0 (1) 2 3 4 NA 12. |39. Seizures: Increased 0 1 2 3 4 (NA)|67. Attention Difficulty THESE IF THE |

|Speech: Slurred/Difficult/ (0) 1 2 3 4 NA |40. Complaints of Jitteriness/ (0) 1 2 3 4 NA |68. Confusion CLIENT IS |

|Slow |Jumpiness |(69.) Irritability VERBAL.|

| |41. Tingling/Numbness (0) 1 2 3 4 NA |70. Morning “hangover” |

|NOSE/THROAT/CHEST |SKIN |71. Perceptual: hallucinations/ |

| | |Delusions |

|13. Nasal Congestion (0) 1 2 3 4 NA |42. Acne 0 1 (2) |72. Sleep: excessive IF SEEN: |

|14. Sore Throat/Redness (0) 1 2 3 4 NA |3 4 NA |73. Sleep: insomnia -CIRCLE ITEM |

|15. Breast: Discharge 0 1 2 3 4 (NA) |43. Bruising: Easy/ (0) 1 2 3 4 |74. Withdrawn -ENTER UNDER |

|16. Breast: Swelling 0 1 2 3 4 |NA |75. Feelings of Sadness/ “OTHER” |

|(NA) |Pronounced |Crying -ASSIGN SCORE |

|17. Labored Breathing (0) 1 2 3 4 NA |44. Color: Blue/Coldness (0) 1 2 3 4 NA | |

|18. Swallowing: Difficult (0) 1 2 3 4 NA |45. Color: Pale/Pallor (0) 1 2 3 4 NA |76. Nightmares/Vivid Dreams |

| |46. Color: Yellow (0) 1 2 3 4 |( |

|GASTROINTESTINAL |NA | |

| |47. Dry/Itchy (0) 1 2 3 | |

|19. Vomiting/Nausea (0) 1 2 3 4 NA |4 NA | |

|20. Appetite: Decrease (0) 1 2 3 4 NA |48. Edema (0) 1 2 3 | |

|21. Appetite: Increase 0 (1) 2 3 4 |4 NA | |

|NA |49. Hair: Abnormal Growth (0) 1 2 3 4 NA | |

|22. Constipation (0) 1 2 3 4|50. Hair: Loss (0) 1 2 3 4 | |

|NA |NA | |

|23. Diarrhea (0) 1 2 3 |51. Rash/Hives (0) 1 2 3 4 | |

|4 NA |NA | |

|24. Flatulence (0) 1 2 3 |52. Sunburns/Redness (0) 1 2 3 4 NA | |

|4 NA |53. Sweating: Decreased (0) 1 2 3 4 NA | |

|25. Thirst: Increase (0) 1 2 3 4 |54. Sweating: Increased (0) 1 2 3 4 NA | |

|NA |MEASURES (enter under OTHER) | |

|26. Abdominal Pain (0) 1 2 3 4 |Temperature Pulse Blood Pressure | |

|NA | | |

|27. Taste Abnormally: Metallic (0) 1 2 3 4 NA | | |

|etc. | | |

| | | |

| | |OTHER: |

| | |_______________________________________ |

| | |69: 2_________________________________ |

| | |Blood Pressure: 129/82____________ |

| | |Pulse: 66______________________________ |

| | |Temperature: 99.2 °F___________________ |

| | |_______________________________________ |

| | |_______________________________________ |

| | |_______________________________________ |

| | |_______________________________________ |

| | |_______________________________________ |

| | |_______________________________________ |

| | |_______________________________________ |

| | |_______________________________________ |

Tardive Dyskinesia

• Neurological disorder resulting from long-term and/or high dosage use of antipsychotic medications.

• Dyskinesia– impairment of involuntary movements.

• Tardive– can continue or appear after the drugs are no longer taken.

• Develops after years of taking these medications

• Examples of involuntary movement include grimacing, frequent blinking, puckering, lip smacking, tongue thrusting, twisting or jerky movements of arms, legs and/or trunk

• Report any changes immediately to the nurse

These are the common side effects seen:

|1. Tics……………………………(0) 1 2 3 4 NA |

|2. Grimaces……………………..(0) 1 2 3 4 NA |

|3. Blinking ………………………(0) 1 2 3 4 NA |

|4. Chewing/Lip Smacking…….. 0 (1) 2 3 4 NA |

|5. Puckering/Sucking |

|Thrusting lower lip…………. (0) 1 2 3 4 NA |

|6. Tongue Thrusting/ |

|Tongue in cheek………….... (0) 1 2 3 4 NA |

|7. Tonic Tongue………………. (0) 1 2 3 4 NA |

|8. Tongue Tremor ………….…. (0) 1 2 3 4 NA |

|9. Athetoid/Myokymic/ |

|Lateral Tongue……………. (0) 1 2 3 4 NA |

|10. Rectocollis/Toricollis……….(0) 1 2 3 4 NA |

|11. Shoulder/Hip Torsion ……..(0) 1 2 3 4 NA |

|12. Athetoid/Myokymic |

|Finger-Wrist-Arm…………..(0) 1 2 3 4 NA |

|13. Pill Rolling ………………… (0) 1 2 3 4 NA |

|14. Ankle Flexion/ |

|Foot Tapping……………....(0) 1 2 3 4 NA |

|15. Toe Movement ……………(0) 1 2 3 4 NA |

Behavioral PRN’s

PRN stands for a medication that has been ordered by a physician to be given as needed or upon request. PRN medications may be physician ordered over the counter medications (such as Benadryl) or prescribed medications (such as Trazadone).

Staff must follow the PRN protocol when there is a behavioral episode and the person has an ordered PRN.

Documentation is required when administering a behavioral PRN. Its use must be documented in the following places:

• The communication book,

• Health Progress Notes,

• PRN Administration Sheet

• PRN Use Report

• Individual’s Daily Log Book,

• Individual’s Day Program/School Book,

• Medication Administration Record.

When a behavioral PRN is given, staff must notify their supervisor and the supervising nurse. (Throughout the weekend, the on-call supervisor must be notified.

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Metropolitan Office

9400 Golden Valley Road, Golden Valley, Minnesota 55427

Phone: (763) 450-5010 FAX: (763) 450-5015

Meridian Services, Incorporated

Seizure Protocol

First Aid

Protect From Injury

1. Cushion falls when possible

2. Place on floor, clear all obstacles and residents from immediate area.

3. Help to a side-lying position (to prevent tongue from obstructing airway).

4. Remove eyeglasses / hearing aid when worn.

5. Loosen tight clothing.

6. Place something soft under the head for a pillow.

7. Time the seizure.

8. Remain with the individual. Do not leave to get help, if this can be avoided.

9. Do not try to restrain movement, since attempts to do so can case injury.

10. Do not attempt to pry the mouth open.

11. If partially alert, do not allow any food or drink during a seizure, due to a possibility of choking.

Assist Breathing

1. Promote a side-lying position after the seizure has stopped. This will allow saliva that has accumulated to drain from the mouth and aid the tongue to return to a normal position. Tip the head back to help open the airway.

2. Do not attempt to clear airway. Breathing returns on its own as the seizure passes.

Avoid Premature Activity

1. Do not give food or liquids immediately following a seizure due to the

possibility of choking. Allow enough recovery time before doing so.

2. Do not rush into a standing position or encourage walking while the post seizure confusion remains. Awakening and resuming activity will occur ad lib.

Assessment and Documentation of Seizure

1. Staff is to fill out a Seizure Report.

2. If an injury has occurred during a seizure, notify a supervisor or nurse.

3. Document in the Health Progress Notes about the seizure and post-seizure status.

Emergency Situations

1. If the seizure has lasted more than five minutes, call 911.

2. Report the seizure to the Person’s Doctor.

Signatures

M.D. Signature: Date:

M.D. Telephone Number:

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Checking Vital Signs

❑ Temperature

o Normal temperature range is 98.6

o Digital temperature can be taken in the mouth or under the arm.

o Temperature taken via ear Tympanically are 1 degree at times higher than oral. Take temperature in other ear, and use the lowest reading.

o Temperature taken via armpit are 1 degree lower than oral a degree needs to be added. Make sure armpit is dry.

o Temporal artery temperature is comparable to a rectal temperature.

o Always use a probe covers on all thermometers

❑ Pulse

o Normal Range is 60 – 80 BPM Take at wrist, carotid artery (bend of elbow) or with a stethescope at the top of the heart. Take for 15 seconds and times it time 4, or 30 seconds and times it time 2, or for a full minute. Pulse should always be taken for 1 minute if it is irregular.

o This can change due to medication, illness, or behavior

❑ Respiration

o Normal Range 10 – 15 per minute- One breath in and out. Take for 15 seconds and times it times 4, or 30 seconds and times it time 2, or for a full minute. Respiration should always be taken for a full minute if irregular.

o Must be monitored without the person knowing. Watch a piece of their clothing rise and fall.

o This can also change due to medication, illness, or behavior

❑ Blood Pressure

o Normal Range 100 – 140 Top Number (Systolic) is the pressure against the artery when the cuff is pumped up.

o Bottom Number (Diastolic) 60 – 80 –is the pressure of the artery when the cuff is deflated.

o This can also change due to medication, illness, or behavior.

o There are protocols at some sites for holding a blood pressure medication if lower then 90 systolically or 60 diastolically.

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Types of Diets Given To Individuals

What They Are & Why They Are Used

|Type of Diet |Description |Common Purpose |

|Normal Regular |Provides all essentials of good nourishment in normal forms |For patients who do not need special diets |

|Clear Liquid (Hospital |Broth, tea, ginger ale, gelatin |Usually for patients who had surgery or the very ill |

|Surgical) | | |

|Full Liquid |Broth, tea, coffee, ginger ale, gelatin, strained fruit juices, |For those unable to chew or swallow solid food |

| |liquids, custard, junket, ice cream, sherbet, soft-cooked eggs | |

|Light or Soft |Foods soft in consistency; no rich or strongly flavored foods that |Final stage for postoperative patient before resuming |

| |could cause distress |regular diet |

|Soft (mechanical) |Same foods as on a normal diet, but chopped or strained |For patients who have difficultly in chewing or |

| | |swallowing |

|Bland |Foods milk in flavor and easy to digest; omits spicy foods |Avoids irritation of the digestive tract, as with ulcer|

| | |and colitis patients |

|Low Calorie |Low in cream, butter, cereals, desserts, and fats |For patients who need to lose weight |

|Diabetic |Precise balance of carbohydrates, protein, and fats, devised |For diabetic patients; matches food intake with the |

| |according to the needs of individual patients |insulin and nutritional requirements |

|High Protein |Meals supplemented with high protein foods, such as meat, fish, |Assists in the growth and repair of tissues wasted by |

| |cheese, milk & eggs |disease |

|Low Fat |Limited amounts of butter, cream, fats, and eggs |For patients who have difficulty digesting fats, as in |

| | |gallbladder, cardiovascular and liver disturbances |

|Low Cholesterol |Low in eggs, whole milk, and meats |Helps regulate the amount of cholesterol in the blood |

|Low Sodium |Limited amount of foods containing sodium, no salt allowed on tray |For patients whose circulation would be impaired by |

| | |fluid retention; patients with certain heart or kidney |

| | |conditions |

|Salt Free |Completely without salt | |

Portion Control

Following the menu is a very important part of you job responsibilities. It is essential that staff ensure that each individual receives a nourishing meal using appropriate portion sizes. Staff will need to measure portions in ounces, tea or tablespoons, ¼ cup, ½ cup, 1 cup, etc.

Breakfast:

½ cup cereal

½ cup skim milk

1 slice wheat toast

1 teaspoon butter

1 small orange

8 ounces water

Water

Water is an essential fluid that should be offered to each individual at meals, during snacks, after exercise, and throughout the day. The recommended minimum intake of water is 64 ounces per day.

Water helps with digestion with food and medication. It helps the skin, hair, urinary tract and defication.

Proper Etiquette with Meal Assistance

Before serving a meal to an individual, staff must wash their hands and the individual’s hands. They should provide a clothing protector or napkin.

Staff must be aware of each individual’s:

o Eating Abilities and Supervision

o Type of Diet and Portion Control

❑ Examples: Diabetic, Renal, Low Sodium, Low Fat, etc.

o Meal Preparation

❑ Examples: Cutting up food into smaller pieces, pouring milk, needing to serve an apple without the core, individual preferences, etc

o Allowing Time to Process Food (before giving liquids between each bite)

o Only using teaspoons for individuals that are assisted with eating

When individuals are eating, staff should concentrate their attention on that person at all times.

Menu Documentation

When the items on the menu change (due to unavailability or individual preference), it must be noted on the back of the menu each time a substitute is made. It also needs to be documented when individuals eat out of the home.

Food Safety

Clean: Wash hands and surfaces often

Illness-causing bacteria can survive in many places around your kitchen, including your hands, utensils, and cutting boards. Unless you wash your hands, utensils, and surfaces the right way, you could spread bacteria to your food, and to others.

• Wash hands the right way—for 20 seconds with plain soap and running water. Be sure to scrub the backs of your hands, between your fingers, and under your nails.

• Wash surfaces and utensils after each use. Bacteria can be spread throughout the kitchen and get onto cutting boards, utensils, and counter tops. Rinsing utensils, countertops, and cutting boards with water won’t do enough to stop bacteria from spreading. Clean utensils and small cutting boards with hot, soapy water. Clean surfaces and cutting boards with a bleach solution.

 

• Wash fruits and veggies—but not meat, poultry, or eggs! Even if you plan to peel fruits and veggies—it’s important to wash them first because bacteria can spread from the outside to the inside as you cut or peel them.

Separate: Don’t cross-contaminate

Even after you’ve cleaned your hands and surfaces thoroughly, raw meat, poultry, seafood, and eggs can still spread illness-causing bacteria to ready-to-eat foods—unless you keep them separate.

• Use separate cutting boards and plates for produce and for meat, poultry, seafood, and eggs.

• Placing ready-to-eat food on a surface that held raw meat, poultry, seafood, or eggs can spread bacteria and make you sick.

• Keep meat, poultry, seafood, and eggs separate from all other foods in the fridge. Bacteria can spread inside your fridge if the juices of raw meat, poultry, seafood, and eggs drip onto ready-to-eat foods. 

Cook to the right temperature

Bacteria that cause food poisoning multiply quickest in the “Danger Zone” between 40˚ and 140˚ Fahrenheit. While many people think they can tell when food is “done” simply by checking its color and texture, there’s no way to be sure it’s safe without following a few important but simple steps

Use a food thermometer. Cooked food is safe only after it’s been heated to a high enough temperature to kill harmful bacteria. Color and texture alone won’t tell you whether your food is done. Instead, use a food thermometer to be sure.

 

Keep food hot after cooking (at 140 ˚F or above). The possibility of bacterial growth actually increases as food cools after cooking because the drop in temperature allows bacteria to thrive. But you can keep your food above the safe temperature of 140˚F by using a heat source like a chafing dish, warming tray, or slow cooker.

Chill: Refrigerate promptly

Illness-causing bacteria can grow in perishable foods within two hours unless you refrigerate them. (And if the temperature is 90 ˚F or higher during the summer, cut that time down to one hour!)

• Refrigerate foods that spoil more quickly (like fruits and vegetables, milk, eggs, and meats) within two hours. Warm foods will chill faster if they are divided into several clean, shallow containers.

• Thaw or marinate foods in the refrigerator-- never thaw or marinate foods on the counter. Since bacteria can multiply rapidly at room temperature, thawing or marinating foods on the counter is one of the riskiest things you can do when preparing food for your family.

• Know when to throw food out. You can’t tell just by looking or smelling whether harmful bacteria has started growing in your leftovers or refrigerated foods.

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