Unintentional falls among the elderly in the United States remains one of the most challenging safety problems for healthcare providers across the care continuum. It is the most common cause of injury and accidental death, according to the Agency for Healthcare Research and Quality.1 National Patient Safety Goal #9 for long-term care states, “reduce the risk of resident harm resulting from falls,” using interview strategies and identifying risks and the need for further evaluation could be accomplished by using SPICES.2 SPICES is an acronym for:
Problems with eating and feeding
Evidence of falls
Nurses working with older adults in long-term care could use SPICES as a framework for their assessments, shift reports, and handoffs. SPICES was developed by Dr. Terry Fulmer in 1988 and was used in the Nurses Improving Care for Health System Elders program,3 which helps hospitals assess and implement effective systemic changes to improve care to the older adults.
Geriatric patients are more likely to experience problems with sleeping, eating, feeding, elimination, incontinence, confusion, falls, and skin breakdown. The presence of these conditions alone or in combination, can lead to increased death rates, higher costs, and longer hospitalizations. SPICES is an evidenced-based tool which provides a framework to identify six common geriatric syndromes.
The Fulmer SPICES identified six common conditions that may signal for in-depth assessment. During the assessment of an admission in the long-term care setting, the licensed vocational nurse (LVN) and the registered nurse (RN) work collaboratively to develop a plan of care that can be followed to ensure the patient remains at his or her highest functioning level. While SPICES is not comprehensive and constipation and depression are significant, this mnemonic device reviews the resident's response to the care given and points to the problems that face the elderly. By asking the resident or family member questions related to sleeping patterns, eating-chewing-swallowing difficulties, elimination problems, confusion or changes in behavior, falls, and skin conditions, a plan of care is developed. The use of SPICES also provides evidence that the resident's physical and safety needs are continually being monitored for changes.
Plans of care are monitored by the LVNs and RNs in long-term care to provide continuity of care and provide documentation for payment. The Joint Commission Patient Safety Goals 2010 identify falls and skin care as a priority. Early identification on admission for these problems guides the staff and creates evaluation tools that improve care by identifying the need for further assessment. Determining the resident's fall risk on a daily basis is an excellent preventive measure that is accomplished by using SPICES. Nurses can use SPICES to guide and focus daily assessment of acute and chronic conditions affecting the elderly population, during nursing rounds, shift handoffs, and identifying preventable findings that need further evaluation when collaborating with other healthcare providers.
Here's a clinical example of how to use SPICES: The nurse enters the room of “Mrs. R”, addresses her, and says good morning. The nurse asks her how she slept throughout the night. Mrs. R is alert and oriented, no signs of confusion, and states she slept well, but did get up a couple of times to use the bathroom, which is not unusual for her. The nurse asks Mrs. R if she has any problems eating, swallowing, or chewing, at which time she states “no.” She says she enjoyed her dinner last night and is waiting for her breakfast. The nurse knows that Mrs. R does not have any bladder or bowel incontinence, however this morning notices she has urinated in bed, which is very unusual. The nurse asks if she could sit in the chair until the bed linen is changed. Mrs. R appears to be in pain when trying to stand. The nurse immediately assesses her left hip pain, at which time Mrs. R thinks she might have fallen last night during one of her trips to the bathroom.
This case scenario describes how the nurse might use SPICES to identify the need for further evaluations, such as a comprehensive pain, environment, and fall risk assessment. Data collected from using the SPICES tool might also generate a medication review, followed by gait and balance testing, including how well the resident uses his or her assistive devices.
Kim Hall, RN, MSN, CNL, has more than 16 years of experience in nursing. She is currently a geriatric clinic nurse at the South Texas Veterans Healthcare System, San Antonio. Her areas of nursing practice include intensive care, emergency, psychiatry, medical-surgical, hospice, occupational health, transplant, and outpatient clinics.
Mary E. Mather, RN, MSN, CNL, has worked with the geriatric population in long-term care for five years, dialysis patients in the ICU/CCU setting for two years, five years in long-term geriatric rehabilitation, and the last year in the Geriatric Evaluation and Management Clinic at the South Texas Veterans Healthcare System, San Antonio. She is a member of National Gerontological Nursing Association as well as secretary for the local chapter.
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