Comprehensive Assessment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

21. The summary of information identified with the assessment types are suggestions (triggers) for consideration when completing the assessment – if the suggestion is not an issue, 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

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

23. Medications • Review all medications, number of meds – including PRN’s • Age 85 or older • Drug levels beyond or at the high end of therapeutic

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

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

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

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

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

29. Gastrointestinal Problems: • Decreased number of BM’s or constipation • Decreased fluid and/or food intake • Abdominal distention

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

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

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

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

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

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

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

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

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

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

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

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

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

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

44. Review consults – PT, OT – consider referral • Does the 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

45. 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

46. Urinary Incontinence/Catheters Assessment

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

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

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

50. Diagnoses • Tests or studies indicated to identify the type(s) of urinary incontinence – 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