Comprehensive Assessment

Document Sample
Comprehensive Assessment Powered By Docstoc
					 Comprehensive
  Assessment

The Keys to Unlocking the
  Mystery of Assessment
         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
 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.
 Due to the
 confidential
 nature of my
 position, I am not
 allowed to know
 what I am doing.
       Nursing Process
 Based on nursing theory developed
  by Jean Orlando in the 1950’s
 Nursing care directed at improving
  outcomes for the resident, not
  nursing goals
 Essential part of the care planning
  process
 It takes time to
 understand the
 process and
 many fight it
 every step of
 the way, until
 one day a light
 bulb goes on.
 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.
The Nursing Process in 5 Steps

 Assessment
 Diagnosis
 Planning
 Implementation
 Evaluation
 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.
 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.
 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.
        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?
What is an assessment?




 An assessment is not filling in a
  checklist or “assessment tool”.
 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.
         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
 Once the data is
 collected, the
 members of the
 interdisciplinary
 team take the
 data and analyze
 it in order to
 complete the
 comprehensive
 assessment.
 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.
 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
        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
 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, don’t
  include it in the assessment
 The triggers are not required in the
  assessment unless the IDT determines
  it pertinent to the resident’s assessment
  Delirium Assessment
 Six Areas Usually the Underlying
  Cause of Delirium:
 Medications
 Infectious Process
 Psychosocial Environment
 Diagnoses/Conditions
 Elimination Problems
 Sensory Losses
           Medications

 Review all medications, number of
  meds – including PRN’s
 Age 85 or older
 Drug levels beyond or at the high end
  of therapeutic
 New medications – correspond with
  onset?
 OTC drugs with anticholinergic side
  effects
 Medications with contraindications for
  the elderly
 Keep abreast of medication updates
       Infectious Process


 Elevation of baseline temperature
 History of lower respiratory infection or
  urinary tract infection
 History of chronic infection
Psychosocial Environmental Issues

 Recent relocation or change in
  personal space
 Recent loss of family/friend/room
  mate
 Isolation
 Restraints
 Increase in sensory stimulation
     Diagnoses and Conditions
   Diabetes – hypo/hyperglycemia
   Hypo/Hyperthyroidism
   Hypoxia-COPD, URI
   ASHD
   Cancer
   Head Trauma - falls
   Dehydration, Fever
   Surgical Complications
   Cardiac Dysrhythmias, CHF
      Elimination Problems
 Urinary Problems:

 History of incontinence, retention, catheter
 Signs/symptoms of
  dehydration, tenting, elevated BUN
 Decreased urinary output
 Taking anticholinergic medications
 Abdominal distention
 Gastrointestinal Problems:


 Decreased number of BM’s or
  constipation
 Decreased fluid and/or food intake
 Abdominal distention
           Sensory Losses

 Hearing - hearing aid not functioning
 Vision - glasses lost, misplaced
 Recent sleep disturbances
 Environmental changes such as a new
 room
 Consider pain and
  pain management
  as a potential
  contributing factor
  to delirium – re
  evaluate pain status
 New onset or poorly
  managed chronic
  pain
Cognitive Assessment
           Complete a
            screening test for
            cognitive deficits
            – several
            available
           Assess for
            memory loss vs.
            slow retrieval of
            info
           Rule out delirium
 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
            Quick Tool
 DEMENTIA


 D – dehydration, depression
 E – endocrine, environmental changes,
  electrolyte abnormalities
 M – medications, metabolic diseases
 E – eye/ear disease
 N – nutritional deficiencies
 T – tumor, trauma
 I – infections, impaction, ischemia,
  insomnia
 A – anemia, anorexia, alcoholism,
  anesthetics
 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
Vision Assessment

         Ocular and
          medical history
         Medications
         History/surgeries
         Degree of visual
          acuity/loss
 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
 Any recent, acute
  changes
 Complaints about
  vision, pain
 Observe resident
  – compensating
  for vision, field
  cuts
Communication Assessment
             Assessment may
                  include:

             Understanding
             Speaking
             Reading and
              writing
             Appropriate use
              of language
 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
 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
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
 Review consults – PT, OT – consider
  referral
 Does the resident’s 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
 How does culture,
  mood, behavior
  effect the resident’s
  ability to complete
  ADL’s
 Consider mobility
  limitations –
  neurological,
  musculoskeletal
 Can any factors
  affecting
  ADL’s/mobility be
  modified, improved
  – why, why not
        Urinary
Incontinence/Catheters
     Assessment
 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
 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
 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
 Diagnoses
 Tests or studies indicated to identify the
  type(s) of urinary incontinence – PVR’s,
  UA/UC – or evaluations assessing the
  resident’s readiness for bladder rehab
  programs
 Environmental factors and assistive
  devices that may restrict or facilitate
  the use of the toilet
 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
 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
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
 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
 Psychosocial Assessment
 Wide variety of assessments to
  consider –
  emotional, behavioral, spiritual, psych
  ological, 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
 Social history
 Psychosocial well
  being
 Social interactions
 Spiritual/Legal/
Emotional
 Financial
 Discharge
  potential/
Placement
             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
    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
        Social Interactions

 With family, spouse, significant other,
  friends
 Sexual
 Other residents
 Staff
 Others
 Recent losses/Significant losses –
  family, home, pets
   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
               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.
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
   Mood Assessment
 Evaluated by
  observation of the
  resident and
  verbal content
 Most
  common, althoug
  h under
  treated, mood
  disorder is
  depression
 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
 Review
  diagnoses, medicati
  ons
 Utilize tools, as
  appropriate
 History of
  abuse, alcohol or
  drug use, mood
  disorder
 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
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
 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
 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
       Physiological Causes

 Diagnoses
 Medications
 Fatigue – how is the resident sleeping
 Physical discomfort - pain, constipation,
 gas
 Infectious process
 Trauma to the head
 Physical assessment – vital signs, O2
 sats, bowel and lung sounds, blood
 sugar, palpate for pain/distress
    Environmental Causes


 Sudden movements
 Unfamiliar surroundings, people
 Difficulty adjusting to changes in
 lighting
 Temperature – too hot, too cold
 Uncomfortable, ill-fitting clothing
 Disruption in routine
 Staffing issues
        Sensory Causes
 Sensory overload – too much
  noise, clutter, activity
 Hearing – does the resident
  understand what you are saying
 Vision – can the resident see what
  you’re doing, is the lighting adequate
 Sudden physical contact, startling
  noises
            Other Causes

 Tasks not broken
  into manageable
  steps
 Activity not age
  appropriate
 Change in routine
 Resident feelings –
  belittled, reprimanded, scolded
 Lack of control, feelings of loss
 Lack of validation
 Inability to communicate
 Depression
      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
 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
  resident’s needs or will something need
  to be added/changed
 If the resident’s
  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
       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
       The Three Why’s

 Why is the resident on the
  move?What are they trying to do?
 Why can’t the resident stay upright?
 Why aren’t the existing interventions
  effective? Are they as effective as
  they can be?
Environmental Risks
          Poor Lighting
          Clutter
          Incorrect bed height
          Ill functioning safety
           devices
          Improperly
           maintained or fitted
           wheelchairs
          Wet floors
          Staffing issues
           Physical Risks

 Weakness
 Gait disturbance
 Medications – especially psychoactive
  drugs, vascular medications
 Diagnoses
 Poor foot care – ill fitting shoes
 Inappropriate use of walking aids
 Infectious process
 Sensory changes
 Decreased/change in range of motion
Nutritional Status Assessment

 Medical history –
  diagnoses, meds,
  pain
 Weight/Lab data
 Clinical findings
 Dietary history
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
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
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
      Assess Data Gathered

 What are the resident’s
  nutrition/hydration needs
 Consider appropriate diet – altered diet,
  special diet, increased protein,
  increased fiber, supplements, etc.
 Consider any additional monitoring,
  follow up needed
 Consider any meal time assistance
  needed
 Consider diet changes to increase
  independence – finger foods
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
 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
Dehydration/Fluid Maintenance
         Assessment
               Identifying the
                resident at risk for
                dehydration and
                minimizing the risk

               Identifying
                dehydration in a
                resident and
                assessing the cause
       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
      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?
 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?
  Symptoms of Dehydration

 Irritability and confusion
 Drowsiness
 Weakness
 Extreme Thirst
 Fever
 Dry skin and mucous membranes
 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
Dental Care Assessment
   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
       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
         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
 Condition/fit of
  dentures, partial
 Saliva –
  over/under
  production
 Oral cleanliness
  – review dental
  habits
 Any complaints
  of pain, oral
  concerns
Pressure Ulcer Assessment
 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
 Research has shown that a significant
  number of PU’s 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
 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
 Risk Factors
 Pressure Points
 Under Nutrition
  and Hydration
  Deficits
 Moisture and its
  Impact on Skin
            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
 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 PU’s
 Cognitive impairment
 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
    Pressure Points/Tissue
          Tolerance
 Include an
 evaluation of the
 skin integrity and
 tissue tolerance
 after pressure to
 that area has
 been reduced or
 redistributed
 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 PU’s
 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
Under-Nutrition and Hydration
           Deficits
 Severity of nutritional compromise
 Severity of risk for dehydration
 Rate of weight loss or appetite decline
 Probable causes
 The resident’s prognosis and projected
  clinical course
 Resident’s wishes and goals
    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
Psychotropic Assessment
 What psychotropic(s) is the resident on
 Why is the resident on the
  medication(s)
 How does the medication maintain or
  improve the resident’s functional status
 When was the medication(s) started –
  at what dose(s)
 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
 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
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
           doesn’t the resident
           need to be
           restrained
 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
 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
 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
 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
Pain Assessment
          A comprehensive
           assessment is
           essential to
           adequate pain relief
          Pain is a subjective
           experience – it’s as
           real as the resident
           communicates it is
          Start the
           assessment process
           with the resident
 Resident Interview

 Describe the pain –
  location, onset,
  intensity, pattern
 Quality – constant
  vs. intermittent, dull
  vs. sharp, burning
  vs. pressure
 Aggravating/relieving
  factors
    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
      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
   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
      Reassessment of Pain
 It’s 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
 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
      Bowel Assessment
 It’s 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
    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
 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, Crohn’s disease
 Metabolic disorders
 History of constipation and/or fecal impaction
          Medication Use

 Diuretics
 Antibiotics
 Antihistamines
 Antispasmodics
 Tricylic Antidepressants
 Narcotics
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
        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
            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
Environmental Characteristics


 Accessible bathroom
 Bedside commode
 Restrictive clothing
 Availability of caregivers
 Adaptive devices to toilet
     Physical Examination

 Abdominal examination – presence
  of masses, distention, bowel
  sounds
 Neurological examination –
  evidence of peripheral neuropathy
 Rectal exam
 -Condition of perineum – excoriation
 -Anorectal conditions – fissures,
 hemorrhoids, transient, deformity
 -External anal sphincter tone
 -Fecal mass or impaction
 -Prostatic enlargement
Laboratory and Other Tests

 Stool cultures
 Abdominal x-ray
 Barium enema
 Ova and Parasite
   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
    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 it’s for, how to administer, side
  effects
 Does the resident remember to store
  the medications securely after SAM
      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
 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
     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
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
 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
 Does resident understand smoking
  policy
 Does the resident need adaptive
  equipment to assist with smoking safety
  and/or independence
    Review Elopement Risk
 Any history of
  elopement
 Psychosocial
  concerns –
  adjustment
  issues, recent loss
 If eloping –
  destination,
  purpose
 Previous lifestyle, occupation


Assess the type of wandering

 Tactile wandering – explore
 environment with hands
 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
 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
 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
       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
Acute Assessments
          When an acute
           change occurs –
           assess for possible
           causes
          Review for any
           recent changes in
           treatments/meds
          Review medical
           history
 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
             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
 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
 The
 comprehensive
 assessment is
 the key to
 developing
 effective,
 individualized
 resident care