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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.

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Comprehensive assessment

Comprehensive Assessment

The Keys to Unlocking the Mystery of Assessment


Objectives
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.



Nursing process
Nursing Process allowed to know what I am doing.

  • 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



  • 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
The Nursing Process in 5 Steps implementing resident care and helps to solve problems.

  • Assessment

  • Diagnosis

  • Planning

  • Implementation

  • Evaluation


  • Diagnosis implementing resident care and helps to solve problems.: 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 implementing resident care and helps to solve problems.: 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 implementing resident care and helps to solve problems.: 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
Assessment implementing resident care and helps to solve problems.

  • 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
What is an assessment? implementing resident care and helps to solve problems.

  • An assessment is not filling in a checklist or “assessment tool”.



Data collection
Data Collection driven by resident need.

  • 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



  • 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
Assessment Types assessments, and/or time lapsed assessments

  • 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
Delirium 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

  • Six Areas Usually the Underlying Cause of Delirium:

  • Medications

  • Infectious Process

  • Psychosocial Environment

  • Diagnoses/Conditions

  • Elimination Problems

  • Sensory Losses


Medications
Medications types are suggestions (triggers) for consideration when completing the assessment – if the suggestion is not an issue, don’t include it in the assessment

  • 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? types are suggestions (triggers) for consideration when completing the assessment – if the suggestion is not an issue, don’t include it in the assessment

  • OTC drugs with anticholinergic side effects

  • Medications with contraindications for the elderly

  • Keep abreast of medication updates


Infectious process
Infectious Process types are suggestions (triggers) for consideration when completing the assessment – if the suggestion is not an issue, don’t include it in the assessment

  • Elevation of baseline temperature

  • History of lower respiratory infection or urinary tract infection

  • History of chronic infection


Psychosocial environmental issues
Psychosocial Environmental Issues types are suggestions (triggers) for consideration when completing the assessment – if the suggestion is not an issue, don’t include it in the assessment

  • Recent relocation or change in personal space

  • Recent loss of family/friend/room mate

  • Isolation

  • Restraints

  • Increase in sensory stimulation


Diagnoses and conditions
Diagnoses and Conditions types are suggestions (triggers) for consideration when completing the assessment – if the suggestion is not an issue, don’t include it in the assessment

  • Diabetes – hypo/hyperglycemia

  • Hypo/Hyperthyroidism

  • Hypoxia-COPD, URI

  • ASHD

  • Cancer

  • Head Trauma - falls

  • Dehydration, Fever

  • Surgical Complications

  • Cardiac Dysrhythmias, CHF


Elimination problems
Elimination Problems types are suggestions (triggers) for consideration when completing the assessment – if the suggestion is not an issue, don’t include it in the assessment

  • Urinary Problems:

  • History of incontinence, retention, catheter

  • Signs/symptoms of dehydration, tenting, elevated BUN

  • Decreased urinary output

  • Taking anticholinergic medications

  • Abdominal distention


  • Gastrointestinal Problems types are suggestions (triggers) for consideration when completing the assessment – if the suggestion is not an issue, don’t include it in the assessment:

  • Decreased number of BM’s or constipation

  • Decreased fluid and/or food intake

  • Abdominal distention


Sensory losses
Sensory Losses types are suggestions (triggers) for consideration when completing the assessment – if the suggestion is not an issue, don’t include it in the assessment

  • Hearing - hearing aid not functioning

  • Vision - glasses lost, misplaced

  • Recent sleep disturbances

  • Environmental changes such as a new room



Cognitive assessment
Cognitive Assessment contributing factor to delirium – re evaluate pain status

  • Complete a screening test for cognitive deficits – several available

  • Assess for memory loss vs. slow retrieval of info

  • Rule out delirium



Quick tool
Quick Tool mimic dementia

  • DEMENTIA

  • D – dehydration, depression

  • E – endocrine, environmental changes, electrolyte abnormalities

  • M – medications, metabolic diseases

  • E – eye/ear disease


  • N mimic dementia – nutritional deficiencies

  • T – tumor, trauma

  • I – infections, impaction, ischemia, insomnia

  • A – anemia, anorexia, alcoholism, anesthetics


  • Memory test – MMSE most common, many available mimic dementia

  • 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
Vision Assessment mimic dementia

  • Ocular and medical history

  • Medications

  • History/surgeries

  • Degree of visual acuity/loss


  • One/both eyes affected mimic dementia

  • 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 mimic dementia

  • Complaints about vision, pain

  • Observe resident – compensating for vision, field cuts


Communication assessment
Communication Assessment mimic dementia

Assessment may include:

  • Understanding

  • Speaking

  • Reading and writing

  • Appropriate use of language


  • Review medical history, medications mimic dementia

  • 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



Adl rehab potential assessment
ADL/Rehab Potential Assessment any referrals needed

  • 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


  • Review consults – PT, OT – consider referral any referrals needed

  • 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



Urinary incontinence catheters assessment
Urinary Incontinence/Catheters Assessment ability to complete ADL’s


  • 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 characteristics, precipitants, associated symptoms, previous treatment/management

  • 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 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

  • 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
Assess Type of Incontinence 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

  • Urge incontinence – urgency, frequency, nocturia

  • Stress incontinence – loss of small amounts of urine with activity

  • Mixed incontinence – combination urge and stress incontinence



Indwelling catheter
Indwelling Catheter retention

  • 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



Psychosocial assessment
Psychosocial Assessment retention

  • 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


  • Social history retention

  • Psychosocial well being

  • Social interactions

  • Spiritual/Legal/

    Emotional

  • Financial

  • Discharge potential/

    Placement


Social history
Social History retention

  • 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
Psychosocial Well-Being retention

  • 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
Social Interactions retention

  • With family, spouse, significant other, friends

  • Sexual

  • Other residents

  • Staff

  • Others

  • Recent losses/Significant losses – family, home, pets


Spiritual emotional legal
Spiritual/Emotional/Legal retention

  • 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
Financial retention

  • 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
Placement/Discharge retention

  • 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
Mood Assessment retention

  • Evaluated by observation of the resident and verbal content

  • Most common, although under treated, mood disorder is depression


  • Mood can affect cognitive function retention

  • 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



  • Is this a short term issue/adjustment reaction retention

  • 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
Behavior Assessment retention

  • 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



Physiological causes
Physiological Causes outside the accepted societal norms

  • Diagnoses

  • Medications

  • Fatigue – how is the resident sleeping

  • Physical discomfort - pain, constipation, gas


  • Infectious process outside the accepted societal norms

  • Trauma to the head

  • Physical assessment – vital signs, O2 sats, bowel and lung sounds, blood sugar, palpate for pain/distress


Environmental causes
Environmental Causes outside the accepted societal norms

  • Sudden movements

  • Unfamiliar surroundings, people

  • Difficulty adjusting to changes in lighting



Sensory causes
Sensory Causes outside the accepted societal norms

  • 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
Other Causes outside the accepted societal norms

  • Tasks not broken into manageable steps

  • Activity not age appropriate

  • Change in routine



Activity assessment
Activity Assessment outside the accepted societal norms

  • 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



Falls assessment
Falls Assessment illness, fatigue, mood, isolation, adjustment issues, disinterest in activities offered

  • 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
The Three Why’s illness, fatigue, mood, isolation, adjustment issues, disinterest in activities offered

  • 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
Environmental Risks illness, fatigue, mood, isolation, adjustment issues, disinterest in activities offered

  • Poor Lighting

  • Clutter

  • Incorrect bed height

  • Ill functioning safety devices

  • Improperly maintained or fitted wheelchairs

  • Wet floors

  • Staffing issues


Physical risks
Physical Risks illness, fatigue, mood, isolation, adjustment issues, disinterest in activities offered

  • Weakness

  • Gait disturbance

  • Medications – especially psychoactive drugs, vascular medications

  • Diagnoses


  • Poor foot care – ill fitting shoes illness, fatigue, mood, isolation, adjustment issues, disinterest in activities offered

  • Inappropriate use of walking aids

  • Infectious process

  • Sensory changes

  • Decreased/change in range of motion


Nutritional status assessment
Nutritional Status Assessment illness, fatigue, mood, isolation, adjustment issues, disinterest in activities offered

  • Medical history – diagnoses, meds, pain

  • Weight/Lab data

  • Clinical findings

  • Dietary history


Weight Data illness, fatigue, mood, isolation, adjustment issues, disinterest in activities offered

  • 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 illness, fatigue, mood, isolation, adjustment issues, disinterest in activities offered

  • 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 illness, fatigue, mood, isolation, adjustment issues, disinterest in activities offered

  • 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
Assess Data Gathered illness, fatigue, mood, isolation, adjustment issues, disinterest in activities offered

  • What are the resident’s nutrition/hydration needs

  • Consider appropriate diet – altered diet, special diet, increased protein, increased fiber, supplements, etc.



Feeding tube assessment
Feeding Tube Assessment illness, fatigue, mood, isolation, adjustment issues, disinterest in activities offered

  • 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 illness, fatigue, mood, isolation, adjustment issues, disinterest in activities offered

  • 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
Dehydration/Fluid Maintenance Assessment illness, fatigue, mood, isolation, adjustment issues, disinterest in activities offered

  • Identifying the resident at risk for dehydration and minimizing the risk

  • Identifying dehydration in a resident and assessing the cause


Risks for dehydration
Risks for Dehydration illness, fatigue, mood, isolation, adjustment issues, disinterest in activities offered

  • 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
Assess for Dehydration illness, fatigue, mood, isolation, adjustment issues, disinterest in activities offered

  • 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? illness, fatigue, mood, isolation, adjustment issues, disinterest in activities offered

  • 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
Symptoms of Dehydration illness, fatigue, mood, isolation, adjustment issues, disinterest in activities offered

  • Irritability and confusion

  • Drowsiness

  • Weakness

  • Extreme Thirst

  • Fever

  • Dry skin and mucous membranes


  • Sunken eyeballs illness, fatigue, mood, isolation, adjustment issues, disinterest in activities offered

  • 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
Dental Care Assessment illness, fatigue, mood, isolation, adjustment issues, disinterest in activities offered


Non oral considerations
Non-Oral Considerations illness, fatigue, mood, isolation, adjustment issues, disinterest in activities offered

  • 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
Oral Related Factors illness, fatigue, mood, isolation, adjustment issues, disinterest in activities offered

  • 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
Oral Assessment illness, fatigue, mood, isolation, adjustment issues, disinterest in activities offered

  • 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 illness, fatigue, mood, isolation, adjustment issues, disinterest in activities offered

  • Saliva – over/under production

  • Oral cleanliness – review dental habits

  • Any complaints of pain, oral concerns


Pressure ulcer assessment
Pressure Ulcer Assessment illness, fatigue, mood, isolation, adjustment issues, disinterest in activities offered



  • 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



  • Risk Factors risk of developing pressure ulcers does not mean that existing risk factors or causes should be considered less important or addressed less vigorously

  • Pressure Points

  • Under Nutrition and Hydration Deficits

  • Moisture and its Impact on Skin


Risk factors
Risk Factors risk of developing pressure ulcers does not mean that existing risk factors or causes should be considered less important or addressed less vigorously

  • Impaired/decreased mobility and decreased functional ability

  • Co-morbid conditions – end stage renal disease, thyroid disease, diabetes

  • Drugs that may effect wound healing - steroids




Pressure points tissue tolerance
Pressure Points/Tissue Tolerance atherosclerosis, lower extremity arterial insufficiency

  • Include an evaluation of the skin integrity and tissue tolerance after pressure to that area has been reduced or redistributed



  • 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
Under-Nutrition and Hydration Deficits up in a chair and in bed, it may be appropriate to review the tissue tolerance both lying and sitting

  • 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
Moisture and Its Impact up in a chair and in bed, it may be appropriate to review the tissue tolerance both lying and sitting

  • 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
Psychotropic Assessment up in a chair and in bed, it may be appropriate to review the tissue tolerance both lying and sitting


  • What psychotropic(s) is the resident on up in a chair and in bed, it may be appropriate to review the tissue tolerance both lying and sitting

  • 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)



  • 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
Physical Restraint Assessment what is the frequency and severity – how are you monitoring/tracking

  • 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



  • 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
Pain Assessment assess the least restrictive options available

  • 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
Resident Interview assess the least restrictive options available

  • Describe the pain – location, onset, intensity, pattern

  • Quality – constant vs. intermittent, dull vs. sharp, burning vs. pressure

  • Aggravating/relieving factors


Physiological indicators
Physiological Indicators assess the least restrictive options available

  • 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
Behavioral Indicators assess the least restrictive options available

  • 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
Other Factors to Consider assess the least restrictive options available

  • 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
Reassessment of Pain assess the least restrictive options available

  • 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
Assessing Pain in Cognitively Impaired Residents assess the least restrictive options available

  • 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
Bowel Assessment assess the least restrictive options available

  • 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
Characteristics of the Bowel Incontinence assess the least restrictive options available

  • 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
Relevant Past Medical History assess the least restrictive options available

  • 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
Medication Use assess the least restrictive options available

  • Diuretics

  • Antibiotics

  • Antihistamines

  • Antispasmodics

  • Tricylic Antidepressants

  • Narcotics


Level of activity functional status
Level of Activity/Functional Status assess the least restrictive options available

  • Able to toilet self

  • Ambulatory/Non-ambulatory

  • Bedfast

  • Independent with transfers

  • Assistance with transfers – mechanical or 1-2 person assist


Cognitive status
Cognitive Status assess the least restrictive options available

  • 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
Diet History assess the least restrictive options available

  • 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
Environmental Characteristics assess the least restrictive options available

  • Accessible bathroom

  • Bedside commode

  • Restrictive clothing

  • Availability of caregivers

  • Adaptive devices to toilet


Physical examination
Physical Examination assess the least restrictive options available

  • Abdominal examination – presence of masses, distention, bowel sounds

  • Neurological examination – evidence of peripheral neuropathy


  • Rectal exam assess the least restrictive options available

    -Condition of perineum – excoriation

    -Anorectal conditions – fissures, hemorrhoids, transient, deformity

    -External anal sphincter tone

    -Fecal mass or impaction

    -Prostatic enlargement


Laboratory and other tests
Laboratory and Other Tests assess the least restrictive options available

  • Stool cultures

  • Abdominal x-ray

  • Barium enema

  • Ova and Parasite


Self administration of medication sam assessment
Self Administration of Medication (SAM) Assessment assess the least restrictive options available

  • Does the resident wish to SAM

  • Review medical history including medications

  • Any history of concerns related to administering own medications


Review cognitive ability
Review Cognitive Ability assess the least restrictive options available

  • 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
Review Physical Ability assess the least restrictive options available

  • 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



Safety assessment
Safety Assessment assess the least restrictive options available

  • 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
Review Smoking Risk assess the least restrictive options available

  • 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




Review elopement risk
Review Elopement Risk that has fallen on themselves/others

  • Any history of elopement

  • Psychosocial concerns – adjustment issues, recent loss

  • If eloping – destination, purpose


  • Previous lifestyle, occupation that has fallen on themselves/others

    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



Review injury risk
Review Injury Risk well lit

  • 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
Acute Assessments well lit

  • 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 well lit

  • 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
REMEMBER… well lit

  • 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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