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Transcript of Comprehensive Assessment
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Comprehensive Assessment
The Keys to Unlocking the Mystery of Assessment
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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
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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.
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Due to the confidential nature of my position, I am not allowed to know what I am doing.
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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
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It takes time to understand the process and many fight it every step of the way, until one day a light bulb goes on.
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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.
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The Nursing Process in 5 Steps
Assessment Diagnosis Planning Implementation Evaluation
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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.
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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.
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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.
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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?
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What is an assessment?
An assessment is not filling in a checklist or “assessment tool”.
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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.
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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
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Once the data is collected, the members of the interdisciplinary team take the data and analyze it in order to complete the comprehensive assessment.
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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.
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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
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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
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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
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Delirium Assessment
Six Areas Usually the Underlying Cause of Delirium:
Medications Infectious Process Psychosocial Environment Diagnoses/Conditions Elimination Problems Sensory Losses
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Medications
Review all medications, number of meds – including PRN’s
Age 85 or older Drug levels beyond or at the high
end of therapeutic
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New medications – correspond with onset?
OTC drugs with anticholinergic side effects
Medications with contraindications for the elderly
Keep abreast of medication updates
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Infectious Process
Elevation of baseline temperature History of lower respiratory
infection or urinary tract infection History of chronic infection
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Psychosocial Environmental Issues
Recent relocation or change in personal space
Recent loss of family/friend/room mate
Isolation Restraints Increase in sensory stimulation
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Diagnoses and Conditions
Diabetes – hypo/hyperglycemia Hypo/Hyperthyroidism Hypoxia-COPD, URI ASHD Cancer Head Trauma - falls Dehydration, Fever Surgical Complications Cardiac Dysrhythmias, CHF
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Elimination Problems
Urinary Problems:
History of incontinence, retention, catheter Signs/symptoms of dehydration, tenting,
elevated BUN Decreased urinary output Taking anticholinergic medications Abdominal distention
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Gastrointestinal Problems:
Decreased number of BM’s or constipation
Decreased fluid and/or food intake Abdominal distention
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Sensory Losses
Hearing - hearing aid not functioning Vision - glasses lost, misplaced Recent sleep disturbances Environmental changes such as a
new room
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Consider pain and pain management as a potential contributing factor to delirium – re evaluate pain status
New onset or poorly managed chronic pain
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Cognitive Assessment
Complete a screening test for cognitive deficits – several available
Assess for memory loss vs. slow retrieval of info
Rule out delirium
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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
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Quick Tool
DEMENTIA
D – dehydration, depression E – endocrine, environmental
changes, electrolyte abnormalities M – medications, metabolic diseases E – eye/ear disease
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N – nutritional deficiencies T – tumor, trauma I – infections, impaction, ischemia,
insomnia A – anemia, anorexia, alcoholism,
anesthetics
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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
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Vision Assessment
Ocular and medical history
Medications History/surgeries Degree of visual
acuity/loss
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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
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Any recent, acute changes
Complaints about vision, pain
Observe resident – compensating for vision, field cuts
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Communication Assessment
Assessment may include:
Understanding Speaking Reading and
writing Appropriate use
of language
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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
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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
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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
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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
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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
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Urinary Incontinence/Catheters
Assessment
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Social history Psychosocial
well being Social
interactions Spiritual/Legal/Emotional Financial Discharge
potential/Placement
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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
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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
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Social Interactions
With family, spouse, significant other, friends
Sexual Other residents Staff Others Recent losses/Significant losses –
family, home, pets
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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
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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.
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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
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Mood Assessment
Evaluated by observation of the resident and verbal content
Most common, although under treated, mood disorder is depression
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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
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Review diagnoses, medications
Utilize tools, as appropriate
History of abuse, alcohol or drug use, mood disorder
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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
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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
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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
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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
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Physiological Causes
Diagnoses Medications Fatigue – how is the resident sleeping Physical discomfort - pain,
constipation, gas
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Infectious process Trauma to the head Physical assessment – vital signs, O2
sats, bowel and lung sounds, blood sugar, palpate for pain/distress
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Environmental Causes
Sudden movements Unfamiliar surroundings, people Difficulty adjusting to changes in
lighting
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Temperature – too hot, too cold Uncomfortable, ill-fitting clothing Disruption in routine Staffing issues
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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
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Other Causes
Tasks not broken into manageable steps
Activity not age appropriate
Change in routine
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Resident feelings – belittled, reprimanded, scolded
Lack of control, feelings of loss Lack of validation Inability to communicate Depression
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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
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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
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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
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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
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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?
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Environmental Risks
Poor Lighting Clutter Incorrect bed
height Ill functioning
safety devices Improperly
maintained or fitted wheelchairs
Wet floors Staffing issues
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Physical Risks
Weakness Gait disturbance Medications – especially psychoactive
drugs, vascular medications Diagnoses
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Poor foot care – ill fitting shoes Inappropriate use of walking aids Infectious process Sensory changes Decreased/change in range of motion
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Nutritional Status Assessment
Medical history – diagnoses, meds, pain
Weight/Lab data Clinical findings Dietary history
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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
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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
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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
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Assess Data Gathered
What are the resident’s nutrition/hydration needs
Consider appropriate diet – altered diet, special diet, increased protein, increased fiber, supplements, etc.
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Consider any additional monitoring, follow up needed
Consider any meal time assistance needed
Consider diet changes to increase independence – finger foods
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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
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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
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Dehydration/Fluid Maintenance Assessment
Identifying the resident at risk for dehydration and minimizing the risk
Identifying dehydration in a resident and assessing the cause
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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
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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?
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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?
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Symptoms of Dehydration
Irritability and confusion Drowsiness Weakness Extreme Thirst Fever Dry skin and mucous membranes
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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
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Dental Care Assessment
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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
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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
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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
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Condition/fit of dentures, partial
Saliva – over/under production
Oral cleanliness – review dental habits
Any complaints of pain, oral concerns
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Pressure Ulcer Assessment
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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
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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
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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
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Risk Factors Pressure Points Under Nutrition
and Hydration Deficits
Moisture and its Impact on Skin
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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
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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
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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
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Pressure Points/Tissue Tolerance
Include an evaluation of the skin integrity and tissue tolerance after pressure to that area has been reduced or redistributed
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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
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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
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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
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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
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Psychotropic Assessment
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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)
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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
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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
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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
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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
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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
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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
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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
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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
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Resident Interview
Describe the pain – location, onset, intensity, pattern
Quality – constant vs. intermittent, dull vs. sharp, burning vs. pressure
Aggravating/relieving factors
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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
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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
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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
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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
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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
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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
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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
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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
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Medication Use
Diuretics Antibiotics Antihistamines Antispasmodics Tricylic Antidepressants Narcotics
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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
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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
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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
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Environmental Characteristics
Accessible bathroom Bedside commode Restrictive clothing Availability of caregivers Adaptive devices to toilet
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Physical Examination
Abdominal examination – presence of masses, distention, bowel sounds
Neurological examination – evidence of peripheral neuropathy
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Rectal exam-Condition of perineum – excoriation-Anorectal conditions – fissures, hemorrhoids, transient, deformity-External anal sphincter tone-Fecal mass or impaction-Prostatic enlargement
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Laboratory and Other Tests
Stool cultures Abdominal x-ray Barium enema Ova and Parasite
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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
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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
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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
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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
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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
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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
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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
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Does resident understand smoking policy
Does the resident need adaptive equipment to assist with smoking safety and/or independence
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Review Elopement Risk
Any history of elopement
Psychosocial concerns – adjustment issues, recent loss
If eloping – destination, purpose
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Previous lifestyle, occupation
Assess the type of wandering
Tactile wandering – explore environment with hands
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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
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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
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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
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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
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Acute Assessments
When an acute change occurs – assess for possible causes
Review for any recent changes in treatments/meds
Review medical history
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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
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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
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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
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The comprehensive assessment is the key to developing effective, individualized resident care