The Intoxicated Patient
This week, I was visiting with a client and read a Resumption of Care assessment where the nurse had charted that a patient had, “a strong odor of alcohol, slurred speech and problems with balance”. I thought this was a very appropriate description of a patient who was ‘drunker than Cooter Brown’. Further on in the assessment that I noted very minimal, if any, impairment documented in the functional domain. The patient used a cane but was able to transfer, bathe, and dress independently.
This became a lively debate at the agency that day. The patient who had been on service long before his readmission was capable of living independently in the home. He had not been drinking prior to the hospitalization but had a history of alcohol abuse and liver disease. One nurse said that because alcohol impairment was temporary and he was able to perform these tasks on a regular basis, that the chart should reflect his usual ability more than fifty percent of the time.
Another nurse stated that the patient had a prior history of alcohol abuse that it was unlikely that this was an isolated event and thus the patient wouldn’t be safe the majority of the time in the future.
I just sat in the corner and wondered if ever the day would come when I heard everything. But as I thought more about the issue, it occurs to me that many patients are temporarily impaired on a regular basis, not just the occasional patient who abuses alcohol. This could be the result of pain medications or anesthesia/sedation after an outpatient procedure or varying abilities secondary to a disease process. Therefore, even though we don’t get many intoxicated patients, the answer was very important.
Here is what the OASIS manual, chapter 8 says about scoring the functional domain questions:
The patient’s ability may change as the patient’s condition improves or declines, as medical restrictions are imposed or lifted, or as the environment is modified. The clinician must consider what the patient is able to do on the day of the assessment. If ability varies, choose the response describing the patient’s ability more than 50% of the time.
The time period being assessed is the day of assessment. So if a client is able to perform a task more than 50 percent of the time on the day of assessment, questions would be answered accordingly. A patient who awakens with pain in the mornings might not be safe to bathe or dress independently for an hour or so until pain medication takes effect but assuming the medications do not have side effects, the patient would be able to safely perform the tasks mentioned more than 50 percent of the day of assessment.
Conversely, a patient who is admitted following an outpatient procedure where strong sedatives were used might not be safe to bathe or dress independently for the rest of the day. In this case, the degree of functional impairment should reflect the patient’s ability under the lingering effects of sedation.
Patients taking powerful narcotic pain relievers might also be temporarily impaired. The key to answering the questions in the functional domain is how often the patient requires narcotic pain relief.
In recent clinical work, we have clearly uncovered the need for additional OASIS/PPS training. In the next week, we will be making available web based training for all clients and other interested agencies. Please email us at firstname.lastname@example.org if you have an interest in providing additional training for your clinicians.
As always, your comments, stories and questions are most welcome.