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Comprehensive Assessment

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Title: Comprehensive Assessment


1
Comprehensive Assessment
  • The Keys to Unlocking the Mystery of Assessment

2
Objectives
  • Share practices with staff from other facilities
  • Understand what data collection is and what role
    it has in completing comprehensive assessments
  • Complete a comprehensive assessment

3
  • The discussions today are not about how to
    complete an MDS.
  • The discussions will not be all inclusive, nor is
    everything absolutely required.
  • The discussions will be about the process for
    completing a comprehensive assessment.
  • The discussions will be interactive, we will all
    have an opportunity to learn from each other.

4
  • Due to the confidential nature of my position, I
    am not allowed to know what I am doing.

5
Nursing Process
  • Based on nursing theory developed by Jean Orlando
    in the 1950s
  • Nursing care directed at improving outcomes for
    the resident, not nursing goals
  • Essential part of the care planning process

6
  • It takes time to understand the process and many
    fight it every step of the way, until one day a
    light bulb goes on.

7
  • The process provides a framework for planning and
    implementing resident care and helps to solve
    problems.
  • The interdisciplinary team has primary
    responsibility, but all personnel take part in
    the process such as in data collection or
    implementation.

8
The Nursing Process in 5 Steps
  • Assessment
  • Diagnosis
  • Planning
  • Implementation
  • Evaluation

9
  • Diagnosis A complex problem requiring a series
    of intellectual steps to analyze the data
    collected.
  • Planning Involves setting priorities,
    establishing goals or objectives, establishing
    outcome criteria, writing a plan of action and
    developing a resident care plan.

10
  • Implementation Setting the plan in motion and
    delegating responsibility for each step.
    Communication is essential to the process. The
    health care team are responsible to report back
    all significant findings or changes.

11
  • Evaluation The process is an ongoing event.
    Involves not only analyzing the success of the
    goals and interventions, but examining the need
    for adjustments as well. Evaluation leads back to
    assessment and the whole process begins again.

12
Assessment
  • Assessments of nursing home residents should be
    accurate, comprehensive, interdisciplinary, and
    individualized.
  • How are assessments done in your facility?
  • Is there a system to collect data accurately and
    efficiently?
  • Do staff understand the importance of the
    information requested?

13
What is an assessment?
  • An assessment is not filling in a checklist or
    assessment tool.

14
  • Assessments need to be routinely done the
    schedule often driven by resident need.
  • Not all needs and assessments will be addressed
    by the RAI process.

15
Data Collection
  • Objective Data Detected by the observer and can
    be measured by accepted standards
  • Subjective Data Can only be described by the
    resident/family
  • Data can be variable or constant
  • Interview formally and informally with specific
    questions

16
  • Once the data is collected, the members of the
    interdisciplinary team take the data and analyze
    it in order to complete the comprehensive
    assessment.

17
  • Critical thinking is the active, organized
    cognitive process of analyzing the data
    collected.
  • The interdisciplinary team draws on knowledge of
    standards of care, aging process, disease
    process, physical sciences, psychosocial
    knowledge, experience, and other areas to analyze
    the information collected.

18
  • Assessments can be initial assessments, focused
    assessments, and/or time lapsed assessments
  • The KEY to the assessment process is asking the
    question why when you have the answer to why
    your assessment may be complete and interventions
    may be developed

19
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20
Assessment Types
  • The following assessments are required by the RAI
    process or based on resident need, review RAP
    tips
  • The list is NOT all inclusive
  • The assessment types completed with the ID Team
    will be driven by resident need

21
  • The summary of information identified with the
    assessment types are suggestions (triggers) for
    consideration when completing the assessment if
    the suggestion is not an issue, dont include it
    in the assessment
  • The triggers are not required in the assessment
    unless the IDT determines it pertinent to the
    residents assessment

22
Delirium Assessment
  • Six Areas Usually the Underlying Cause of
    Delirium
  • Medications
  • Infectious Process
  • Psychosocial Environment
  • Diagnoses/Conditions
  • Elimination Problems
  • Sensory Losses

23
Medications
  • Review all medications, number of meds
    including PRNs
  • Age 85 or older
  • Drug levels beyond or at the high end of
    therapeutic

24
  • New medications correspond with onset?
  • OTC drugs with anticholinergic side effects
  • Medications with contraindications for the
    elderly
  • Keep abreast of medication updates

25
Infectious Process
  • Elevation of baseline temperature
  • History of lower respiratory infection or urinary
    tract infection
  • History of chronic infection

26
Psychosocial Environmental Issues
  • Recent relocation or change in personal space
  • Recent loss of family/friend/room mate
  • Isolation
  • Restraints
  • Increase in sensory stimulation

27
Diagnoses and Conditions
  • Diabetes hypo/hyperglycemia
  • Hypo/Hyperthyroidism
  • Hypoxia-COPD, URI
  • ASHD
  • Cancer
  • Head Trauma - falls
  • Dehydration, Fever
  • Surgical Complications
  • Cardiac Dysrhythmias, CHF

28
Elimination Problems
  • Urinary Problems
  • History of incontinence, retention, catheter
  • Signs/symptoms of dehydration, tenting, elevated
    BUN
  • Decreased urinary output
  • Taking anticholinergic medications
  • Abdominal distention

29
  • Gastrointestinal Problems
  • Decreased number of BMs or constipation
  • Decreased fluid and/or food intake
  • Abdominal distention

30
Sensory Losses
  • Hearing - hearing aid not functioning
  • Vision - glasses lost, misplaced
  • Recent sleep disturbances
  • Environmental changes such as a new room

31
  • Consider pain and pain management as a potential
    contributing factor to delirium re evaluate
    pain status
  • New onset or poorly managed chronic pain

32
Cognitive Assessment
  • Complete a screening test for cognitive deficits
    several available
  • Assess for memory loss vs. slow retrieval of info
  • Rule out delirium

33
  • Screen for depression may be part of the
    dementia or mimic dementia
  • Screen for systemic illness may cause or worsen
    dementia
  • Medications review, any changes
  • History from resident/family/significant other
  • Determine forgetfulness vs. cognitive impairment

34
Quick Tool
  • DEMENTIA
  • D dehydration, depression
  • E endocrine, environmental changes, electrolyte
    abnormalities
  • M medications, metabolic diseases
  • E eye/ear disease

35
  • N nutritional deficiencies
  • T tumor, trauma
  • I infections, impaction, ischemia, insomnia
  • A anemia, anorexia, alcoholism, anesthetics

36
  • Memory test MMSE most common, many available
  • Competency ability to make decisions regarding
    self if unable, are there legal instruments in
    place to legally give decision making authority
    to another, if not, does a process need to be
    initiated what decisions is the resident
    capable of still making

37
Vision Assessment
  • Ocular and medical history
  • Medications
  • History/surgeries
  • Degree of visual acuity/loss

38
  • One/both eyes affected
  • Is further loss expected
  • Most recent eye exam/current Rx
  • Signs of infection, trauma
  • Appropriate use of visual appliances
  • Environmental modifications more light, less
    light, large numbers, bright colors

39
  • Any recent, acute changes
  • Complaints about vision, pain
  • Observe resident compensating for vision, field
    cuts

40
Communication Assessment
  • Assessment may include
  • Understanding
  • Speaking
  • Reading and writing
  • Appropriate use of language

41
  • Review medical history, medications
  • Does the resident have any problems with
    communication hearing, vision, aphasia
  • Any communication devices history, are/were
    they effective, concerns
  • Any limitations in ability to communicate
    dyslexia, dementia

42
  • Consults ST, OT, audiologist, etc any already
    done, any referrals needed
  • Consider cultural, spiritual issues affecting
    language ability
  • Work with family, significant other on
    communication techniques

43
ADL/Rehab Potential Assessment
  • Review medical social history, meds
  • Observe the resident for a period of time, with
    adequate time can the resident complete the
    task independently, with set up, stand by,
    partial or total assist

44
  • Review consults PT, OT consider referral
  • Does the residents ability vary over the course
    of the day any recent change in ability
  • Is the resident able to complete tasks if broken
    into shorter tasks, with step by step
    instructions
  • Does the resident need a device to complete the
    task consider all devices, which would be
    appropriate for use why, why not

45
  • How does culture, mood, behavior effect the
    residents ability to complete ADLs
  • Consider mobility limitations neurological,
    musculoskeletal
  • Can any factors affecting ADLs/mobility be
    modified, improved why, why not

46
Urinary Incontinence/Catheters Assessment
47
  • Prior history of urinary incontinence onset,
    duration, characteristics, precipitants,
    associated symptoms, previous treatment/management
  • Voiding patterns over several days incontinent,
    voided on toilet, dry with routine toileting
  • Medication review
  • Patterns of fluid intake amounts, times of day

48
  • Use of urinary tract stimulants or irritants
  • Pelvic and rectal exam prolapsed uterus or
    bladder, prostate enlargement, constipation or
    fecal impaction, use of cath, atrophic vaginitis,
    distended bladder, bladder spasms
  • Identification and/or potential of developing
    complications skin irritation, breakdown

49
  • Functional and cognitive capabilities impaired
    cognitive function, dementia, impaired mobility,
    decreased manual dexterity, need for task
    segmentation, decreased upper/lower extremity
    muscle strength, decreased vision, pain with
    movement, behaviors effecting toileting
  • Types of physical assistance necessary to access
    toilet and prompting needed to encourage urination

50
  • Diagnoses
  • Tests or studies indicated to identify the
    type(s) of urinary incontinence PVRs, UA/UC
    or evaluations assessing the residents readiness
    for bladder rehab programs
  • Environmental factors and assistive devices that
    may restrict or facilitate the use of the toilet

51
Assess Type of Incontinence
  • Urge incontinence urgency, frequency, nocturia
  • Stress incontinence loss of small amounts of
    urine with activity
  • Mixed incontinence combination urge and stress
    incontinence

52
  • Overflow incontinence bladder is distended from
    urinary retention
  • Functional incontinence secondary to factors
    other than inherently abnormal urinary tract
    function
  • Transient incontinence temporary or occasional
    incontinence

53
Indwelling Catheter
  • Clinical rationale for use of an indwelling
    catheter and ongoing need
  • Determination of which factors can be modified or
    reversed
  • Alternatives to extended use of an indwelling
    catheter

54
  • Assess the risks vs. benefits of an indwelling
    catheter
  • Potential for removal of the catheter
  • Consideration of complications resulting from the
    use of an indwelling catheter
  • Develop plan for removal of the indwelling
    catheter based on assessment

55
Psychosocial Assessment
  • Wide variety of assessments to consider
    emotional, behavioral, spiritual, psychological,
    gerontological, financial input into physical
  • Significant input from resident, significant
    others
  • Key role in length of stay and appropriate
    planning
  • Key assessment in assisting to develop whole
    person planning

56
  • Social history
  • Psychosocial well being
  • Social interactions
  • Spiritual/Legal/
  • Emotional
  • Financial
  • Discharge potential/
  • Placement

57
Social History
  • Born and raised? Where did they live throughout
    their adult life?
  • Siblings, parents still alive, relationship
  • Education, military
  • Marriage, children, significant others current
    involvement
  • Work history
  • Organizations member of, hobbies, religion
  • Cultural/ethnic background/traditions
  • Pets

58
Psychosocial Well-Being
  • Personality abuse history
  • Speech/communication, hearing, vision any
    impairments, any outside services needed
  • General behavior/mood
  • General cognition
  • General interactions with others
  • Related diagnoses, psych history

59
Social Interactions
  • With family, spouse, significant other, friends
  • Sexual
  • Other residents
  • Staff
  • Others
  • Recent losses/Significant losses family, home,
    pets

60
Spiritual/Emotional/Legal
  • Adjustment issues
  • Spiritual/cultural beliefs related to medical
    care and receipt of treatment
  • Abuse financial, physical, emotional, sexual
    consider restraining orders
  • Advanced directives, living wills, health care
    proxy, POA, financial guardian, guardian of
    person or guardian of both
  • Sale of large items home, business

61
Financial
  • Pay Source
  • Business matters does the resident complete
    their own business or does a family member, POA,
    trustee, guardian, etc.
  • Will the resident need help related to insurance
    issues, qualifying and applying for medical
    assistance, etc.

62
Placement/Discharge
  • Adjustment/length of stay
  • Pets who is caring for the pets
  • Services needed after discharge if short term
  • Coordination with family, significant others
    any training/education needed prior to discharge

63
Mood Assessment
  • Evaluated by observation of the resident and
    verbal content
  • Most common, although under treated, mood
    disorder is depression

64
  • Mood can affect cognitive function
  • Depression can create a pseudodementia
  • Anxiety often related to depression, phobias,
    obsessions
  • Delusions common in 40 of residents with
    dementia
  • Many tools available to assist with assessing
    mood disorders
  • What signs/symptoms is resident displaying

65
  • Review diagnoses, medications
  • Utilize tools, as appropriate
  • History of abuse, alcohol or drug use, mood
    disorder

66
  • Is this a short term issue/adjustment reaction
  • Is there a pattern, is it cyclical
  • Has the resident received mental health services
    in the past, would a referral be appropriate
  • Does mood respond to treatment meds,
    psychosocial therapy

67
Behavior Assessment
  • Define the behavior and the scope
  • Determine if there is a pattern to the behavior
  • What, if anything, does the resident behavior
    respond to
  • Rule out delirium

68
  • Listen carefully to what the resident is saying
    during the behaviors
  • Observe the resident for periods of time over the
    course of several days what do they say, what
    do they do before, during, and after the
    behaviors pay particular attention to the
    antecedents of the behavior
  • Review the social history including the cultural
    background

69
  • Is the behavior truly a behavior or is it
    something that is outside the accepted societal
    norms
  • Is the behavior creating a danger to the resident
    or someone else immediacy of the issue,
    effectiveness of interventions, level of
    supervision required

70
Physiological Causes
  • Diagnoses
  • Medications
  • Fatigue how is the resident sleeping
  • Physical discomfort - pain, constipation, gas

71
  • Infectious process
  • Trauma to the head
  • Physical assessment vital signs, O2 sats, bowel
    and lung sounds, blood sugar, palpate for
    pain/distress

72
Environmental Causes
  • Sudden movements
  • Unfamiliar surroundings, people
  • Difficulty adjusting to changes in lighting

73
  • Temperature too hot, too cold
  • Uncomfortable, ill-fitting clothing
  • Disruption in routine
  • Staffing issues

74
Sensory Causes
  • Sensory overload too much noise, clutter,
    activity
  • Hearing does the resident understand what you
    are saying
  • Vision can the resident see what youre doing,
    is the lighting adequate
  • Sudden physical contact, startling noises

75
Other Causes
  • Tasks not broken into manageable steps
  • Activity not age appropriate
  • Change in routine

76
  • Resident feelings belittled, reprimanded,
    scolded
  • Lack of control, feelings of loss
  • Lack of validation
  • Inability to communicate
  • Depression

77
Activity Assessment
  • Review medical history any limitations to
    activity type/level
  • Obtain history of activities level of activity,
    preferences, dislikes, group vs. individual,
    outside groups

78
  • How much assistance does the resident need to
    attend and participate in activities what needs
    to be done to improve independence
  • How does the resident feel about leisure
    activities good idea, waste of time
  • Do the scheduled activities meet the residents
    needs or will something need to be added/changed

79
  • If the residents activity level has declined
    why illness, fatigue, mood, isolation,
    adjustment issues, disinterest in activities
    offered
  • If behaviors/moods are identified, are there
    activities that could be provided to assist with
    improving them

80
Falls Assessment
  • 10-20 of falls cause serious injuries
  • Falls usually occur due to environmental or
    physical reasons
  • For many, goal is to minimize, not eliminate falls

81
The Three Whys
  • Why is the resident on the move?What are they
    trying to do?
  • Why cant the resident stay upright?
  • Why arent the existing interventions effective?
    Are they as effective as they can be?

82
Environmental Risks
  • Poor Lighting
  • Clutter
  • Incorrect bed height
  • Ill functioning safety devices
  • Improperly maintained or fitted wheelchairs
  • Wet floors
  • Staffing issues

83
Physical Risks
  • Weakness
  • Gait disturbance
  • Medications especially psychoactive drugs,
    vascular medications
  • Diagnoses

84
  • Poor foot care ill fitting shoes
  • Inappropriate use of walking aids
  • Infectious process
  • Sensory changes
  • Decreased/change in range of motion

85
Nutritional Status Assessment
  • Medical history diagnoses, meds, pain
  • Weight/Lab data
  • Clinical findings
  • Dietary history

86
  • Weight Data
  • Height, weight usual/norm, desirable
  • Any recent weight changes were changes planned
  • Measurements as appropriate girth, LE, UE
  • Lab data review any pertinent labs high/low,
    dietary needs

87
  • Clinical Findings
  • Physical signs hair, skin, eyes, mouth
  • Daily routines meal times, alcohol use, drug
    use, smoking history, exercise
  • GI function appetite, sense of taste, problems
    chewing/swallowing, sense of smell, digestive
    upset (nausea, vomiting, heartburn, distention,
    cramping)
  • Bowel history

88
  • Dietary History
  • Favorite foods how often do you eat them
  • Food dislikes
  • How do you feel about food
  • Food allergies
  • Special diet history, family history
  • Typical food intake
  • At home who cooked, facilities available,
    shopping availability

89
Assess Data Gathered
  • What are the residents nutrition/hydration needs
  • Consider appropriate diet altered diet, special
    diet, increased protein, increased fiber,
    supplements, etc.

90
  • Consider any additional monitoring, follow up
    needed
  • Consider any meal time assistance needed
  • Consider diet changes to increase independence
    finger foods

91
Feeding Tube Assessment
  • Why is the tube feeding necessary
  • Were alternatives assessed prior to placement
  • Is the resident NPO or is some oral intake
    allowed
  • Is the tube intended to be long or short term

92
  • Review risks and benefits of placement
  • Assess the efficacy of the tube feeding calorie
    and hydration needs, type of formula
  • Assess for complications irritation at site,
    infection, diarrhea, aspiration, displacement,
    pain, distention, cardiac issues
  • Assess for ongoing need

93
Dehydration/Fluid Maintenance Assessment
  • Identifying the resident at risk for dehydration
    and minimizing the risk
  • Identifying dehydration in a resident and
    assessing the cause

94
Risks for Dehydration
  • Fluid loss and increased fluid need diarrhea,
    fever
  • Fluid restrictions related to diagnosis renal
    failure, CHF
  • Functional impairments unable to obtain fluid
    on their own or ask for it
  • Cognitive impairments forget to drink or how to
    drink, behaviors
  • Availability, consistency

95
Assess for Dehydration
  • Diagnoses? Does the resident have a lack of
    sensation of thirst or inability to express
    feelings of thirst?
  • Any changes in medications?
  • Recent infection? Fever?

96
  • Intake and output are they balanced?
  • Current lab tests hematocrit, serum osmolality,
    sodium, urine specific gravity, BUN
  • Physical assessment review for signs of
    dehydration
  • Cognitive assessment does the resident remember
    to drink or know how?
  • Physical limitations is the resident physically
    capable of obtaining their own fluid?

97
Symptoms of Dehydration
  • Irritability and confusion
  • Drowsiness
  • Weakness
  • Extreme Thirst
  • Fever
  • Dry skin and mucous membranes

98
  • Sunken eyeballs
  • Poor skin turgor
  • Decreased urine output
  • Increased heart rate with decreased BP
  • Lack of edema in someone with history of edema
  • Constipation/impaction

99
Dental Care Assessment
100
Non-Oral Considerations
  • Assess cognitive impairment
  • Assess functional impairment
  • Institutionalized residents at very high risk for
    oral disease
  • Medications and radiation used
  • Behaviors/attitudes/culture

101
Oral Related Factors
  • Mouth related conditions, history of oral
    disease, periodontal disease
  • Xerostomia (complaints of dry mouth) and/or SGH
    (salivary gland hypofunction reduced saliva
    flow)
  • Excessive salivation review diagnoses,
    medications

102
Oral Assessment
  • Tools available for screening Brief Oral Health
    Status Examination (BOHSE)
  • Natural teeth, dentures, partials, implants
  • Observe oral cavity condition of tissue, soft
    palate, hard palate, gums
  • Natural teeth broken, caries

103
  • Condition/fit of dentures, partial
  • Saliva over/under production
  • Oral cleanliness review dental habits
  • Any complaints of pain, oral concerns

104
Pressure Ulcer Assessment
105
  • A resident at risk can develop a pressure ulcer
    in 2 to 6 hours
  • Identify which risk factors can be removed or
    modified
  • Should address the factors that have been
    identified as having an impact on the
    development, treatment and/or healing of pressure
    ulcers

106
  • Research has shown that a significant number of
    PUs develop within the first four weeks after
    admission to a LTC facility
  • Many clinicians recommend using a standardized
    pressure ulcer risk assessment tool to assess
    pressure ulcer risk upon admission, weekly for
    the first four weeks after admission, then
    quarterly and as needed with change in cognition
    or functional ability

107
  • An overall risk score indicating the resident is
    not at high risk of developing pressure ulcers
    does not mean that existing risk factors or
    causes should be considered less important or
    addressed less vigorously

108
  • Risk Factors
  • Pressure Points
  • Under Nutrition and Hydration Deficits
  • Moisture and its Impact on Skin

109
Risk Factors
  • Impaired/decreased mobility and decreased
    functional ability
  • Co-morbid conditions end stage renal disease,
    thyroid disease, diabetes
  • Drugs that may effect wound healing - steroids

110
  • Impaired diffuse or localized blood flow
    generalized atherosclerosis, lower extremity
    arterial insufficiency
  • Resident refusal of some aspects of care and
    treatment what behaviors and how do they impact
    the development of PUs
  • Cognitive impairment

111
  • Exposure of skin to urinary and fecal
    incontinence
  • Under nutrition, malnutrition, hydration deficits
  • A healed ulcer history of a healed pressure
    ulcer and its stage

112
Pressure Points/Tissue Tolerance
  • Include an evaluation of the skin integrity and
    tissue tolerance after pressure to that area has
    been reduced or redistributed

113
  • Pressure ulcers are usually located over a bony
    prominence but may develop at other sites where
    pressure has impaired the circulation to the
    tissue
  • Regularly assess the skin of residents identified
    at risk for PUs

114
  • If the resident is dependent for positioning and
    spends time up in a chair and in bed, it may be
    appropriate to review the tissue tolerance both
    lying and sitting
  • When reviewing tissue tolerance, identify if the
    resident was sitting or lying, any pressure
    reducing/relieving devices utilized, the amount
    of time sitting/lying before the tissue was
    observed

115
Under-Nutrition and Hydration Deficits
  • Severity of nutritional compromise
  • Severity of risk for dehydration
  • Rate of weight loss or appetite decline
  • Probable causes
  • The residents prognosis and projected clinical
    course
  • Residents wishes and goals

116
Moisture and Its Impact
  • Differentiate between dermatitis and partial
    thickness skin loss (pressure ulcer)
  • Does the resident have urinary incontinence,
    bowel incontinence, sweating
  • Is the resident impacted by moisture if so, how
    does the moisture impact the resident

117
Psychotropic Assessment
118
  • What psychotropic(s) is the resident on
  • Why is the resident on the medication(s)
  • How does the medication maintain or improve the
    residents functional status
  • When was the medication(s) started at what
    dose(s)

119
  • What is the history of psychotropic use for the
    resident medications, dosages, response to the
    med/dose
  • Medical history including diagnoses,
    hospitalizations
  • Based on the review of the medication(s)-
  • What are the specific behaviors being targeted

120
  • Has the behavior(s) being targeted
    improved/declined what is the frequency and
    severity how are you monitoring/tracking
  • What are the non-pharmaceutical interventions in
    place and what is the effectiveness
  • Are there any side effects from the medication(s)
  • Is a reduction appropriate/required ensure
    minimal effective dose

121
Physical Restraint Assessment
  • Why is the restraint being used
  • What are the least restrictive options for
    restraint use
  • When does the resident need to be restrained
    when doesnt the resident need to be restrained

122
  • Unless an emergent situation is identified,
    complete a comprehensive assessment before
    applying the restraint
  • What is the benefit of restraint use for the
    resident
  • Compare the identified risks to the identified
    benefits
  • Use the assessment process to avoid or minimize
    the use of restraints

123
  • If a diagnosis is driving the use of the
    restraint, individualize that diagnosis to the
    resident what does it mean for that resident to
    have that diagnosis
  • If a behavior is driving the use of the
    restraint, individualize that behavior to the
    resident what does it mean for that resident to
    have that behavior

124
  • If a cognitive issue is driving the use of the
    restraint, individualize that issue to the
    resident what does it mean for that resident to
    have that issue

125
  • Once the reason for the restraint has been
    determined, assess the least restrictive options
    available
  • Determine what interventions, in conjunction with
    restraint use, could be utilized to minimize
    restraint use
  • Determine any times the resident may be without
    restraint meal times, activities, toileting
    how much supervision is required when not
    restrained

126
Pain Assessment
  • A comprehensive assessment is essential to
    adequate pain relief
  • Pain is a subjective experience its as real as
    the resident communicates it is
  • Start the assessment process with the resident

127
Resident Interview
  • Describe the pain location, onset, intensity,
    pattern
  • Quality constant vs. intermittent, dull vs.
    sharp, burning vs. pressure
  • Aggravating/relieving factors

128
Physiological Indicators
  • Abnormal vital signs
  • Change in level of consciousness
  • Functional status
  • Head to toe assessment focus on musculoskeletal
    and neurological
  • Observe the pain response in relation to activity

129
Behavioral Indicators
  • Muscle tensing, rigid posturing
  • Facial grimaces/wincing, furrowed brow, narrowed
    eyes, clenched teeth, tightened lips
  • Pallor/flushing
  • Agitation, restlessness
  • Crying, moaning, grunts, gasps, sighs
  • Resisting cares, combative

130
Other Factors to Consider
  • History of pain experience and past management
  • Sleep patterns increased fatigue may decrease
    the ability to tolerate pain
  • Environment moist, cold, hot
  • Religious beliefs
  • Cultural beliefs, social issues/attitudes
  • Interview staff what is their knowledge of the
    residents pain

131
Reassessment of Pain
  • Its essential to an effective pain management
    program to have systems ensuring ongoing
    assessments of pain management interventions
  • With changes in interventions, ensure the
    assessment is completed for a period of time long
    enough to determine the effectiveness of the
    implemented intervention

132
Assessing Pain in Cognitively Impaired Residents
  • Interview family/significant others
  • Any functional changes in activity
  • Complete a physical assessment and assess
    physiologic and behavioral indicators as well as
    other factors
  • If pain is suspected, consider a time limited
    trial of an analgesic and closely monitor and
    continually reassess

133
Bowel Assessment
  • Its important to assess bowel habits with a 3 to
    5 day history of patterns some resources
    recommend a longer period of time to establish a
    reliable pattern

134
Characteristics of the Bowel Incontinence
  • Onset, duration, frequency
  • Stool consistency and amount
  • Timing night, day or both, relationship to
    meals
  • Associated symptoms urgency, straining, blood
    in stools
  • Normal bowel pattern
  • History of laxative use stimulants, bulk
    laxatives, suppositories

135
Relevant Past Medical History
  • Past surgeries anorectal, intestinal,
    laminectomy
  • Past childbirth number of children, traumatic
    deliveries
  • History of pelvic radiation
  • Gastrointestinal disorders bowel infection,
    irritable bowel syndrome, diverticulitis,
    ulcerative colitis, Crohns disease
  • Metabolic disorders
  • History of constipation and/or fecal impaction

136
Medication Use
  • Diuretics
  • Antibiotics
  • Antihistamines
  • Antispasmodics
  • Tricylic Antidepressants
  • Narcotics

137
Level of Activity/Functional Status
  • Able to toilet self
  • Ambulatory/Non-ambulatory
  • Bedfast
  • Independent with transfers
  • Assistance with transfers mechanical or 1-2
    person assist

138
Cognitive Status
  • Memory loss short or long term
  • Resident can/can not identify the need to have a
    BM
  • Resident is able/unable to ask for help to get to
    the bathroom
  • Resident can recognize the toilet and know its use

139
Diet History
  • Hydration status ability to obtain fluid on
    their own
  • Caffeine use
  • Amount of bulk in diet
  • Eating pattern consistently eats 3 meals a day
    or only eats breakfast

140
Environmental Characteristics
  • Accessible bathroom
  • Bedside commode
  • Restrictive clothing
  • Availability of caregivers
  • Adaptive devices to toilet

141
Physical Examination
  • Abdominal examination presence of masses,
    distention, bowel sounds
  • Neurological examination evidence of peripheral
    neuropathy

142
  • Rectal exam
  • -Condition of perineum excoriation
  • -Anorectal conditions fissures, hemorrhoids,
    transient, deformity
  • -External anal sphincter tone
  • -Fecal mass or impaction
  • -Prostatic enlargement

143
Laboratory and Other Tests
  • Stool cultures
  • Abdominal x-ray
  • Barium enema
  • Ova and Parasite

144
Self Administration of Medication (SAM) Assessment
  • Does the resident wish to SAM
  • Review medical history including medications
  • Any history of concerns related to administering
    own medications

145
Review Cognitive Ability
  • Are there any cognitive deficits would they
    affect the residents ability to SAM how
  • Is the resident able to verbalize the
    medication(s) they will SAM including what its
    for, how to administer, side effects
  • Does the resident remember to store the
    medications securely after SAM

146
Review Physical Ability
  • Is the resident able to obtain the medication
    get to where it is stored, open the storage area,
    open the medication, administer the med
  • What modifications could be made to enable
    resident to become physically capable of SAM

147
  • Can the resident administer some meds but not
    others
  • Can the resident SAM with set up
  • What monitoring should the resident receive for
    the SAM process

148
Safety Assessment
  • Assess any threats to resident safety
  • Does resident have any behaviors/habits that put
    them at risk of injury from themselves or others
  • Assess the identified risk factors

149
Review Smoking Risk
  • Is resident cognitively aware of safety needs
    when smoking
  • Is resident physically capable of managing
    smoking materials
  • Review resident smoking history and any previous
    safety concerns

150
  • Is the resident capable of extinguishing a lit
    cigarette/ash that has fallen on
    themselves/others
  • Is the resident able to call for help if needed
  • Past history of poor safety judgment
  • If using O2, does resident understand oxygen use
    as it relates to smoking safety

151
  • Does resident understand smoking policy
  • Does the resident need adaptive equipment to
    assist with smoking safety and/or independence

152
Review Elopement Risk
  • Any history of elopement
  • Psychosocial concerns adjustment issues, recent
    loss
  • If eloping destination, purpose

153
  • Previous lifestyle, occupation
  • Assess the type of wandering
  • Tactile wandering explore environment with hands

154
  • Environmentally cued wandering appear calm and
    led by the environment, sees window looks out,
    chair sits, door exits
  • Reminiscent wandering wandering stems from a
    delusion or fantasy from the past going to the
    market, work announce leaving
  • Recreational wandering wandering based on
    previous active lifestyle

155
  • If resident identified as an elopement risk,
    assess environmental risks
  • Are all doors alarmed and/or wanderguarded
  • Where is the residents room in relation to exits
    and the nursing station
  • Is the resident capable of exiting through a
    window can the windows be exited through

156
  • Are the grounds easily visible from the facility,
    are they well lit
  • Is the facility on or near a busy street
  • Are there hills, woods, water on the grounds
  • Is public transportation available near the
    facility

157
Review Injury Risk
  • Does resident receive frequent bruises, skin
    tears, etc.
  • Does the resident exhibit behaviors that place
    them at risk for abuse from others
  • Are there objects in the environment which place
    the resident at risk for injury sharps,
    chemicals, stairwells

158
Acute Assessments
  • When an acute change occurs assess for possible
    causes
  • Review for any recent changes in treatments/meds
  • Review medical history

159
  • Interview resident as able any changes,
    concerns
  • Interview staff for any identified changes
  • Conduct physical assessment as determined
    appropriate vitals, neuros, auscultate lungs,
    abdomen, palpate area(s) of concern, recent labs,
    last BM, last void anything unusual with stool
    or urine
  • Conduct brief cognitive assessment

160
REMEMBER
  • Not all identified risk factors need to be
    addressed in the comprehensive assessment only
    those the ID Team determines to be pertinent to
    the resident
  • When addressing a risk factor in the assessment,
    indicate how it does impact the resident, not how
    it could

161
  • When completing the comprehensive assessment,
    keep asking WHY
  • Incomplete or inaccurate data is not helpful in
    completing a comprehensive assessment and should
    not be used

162
  • The comprehensive assessment is the key to
    developing effective, individualized resident care
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