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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

  • 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
  • Based on nursing theory developed by Jean Orlando in the 1950’s
  • Nursing care directed at improving outcomes for the resident, not nursing goals
  • Essential part of the care planning process
It takes time to understand the process and many fight it every step of the way, until one day a light bulb goes on.
The process provides a framework for planning and implementing resident care and helps to solve problems.
  • The interdisciplinary team has primary responsibility, but all personnel take part in the process such as in data collection or implementation.
the nursing process in 5 steps
The Nursing Process in 5 Steps
  • Assessment
  • Diagnosis
  • Planning
  • Implementation
  • Evaluation
Diagnosis: A complex problem requiring a series of intellectual steps to analyze the data collected.
  • Planning: Involves setting priorities, establishing goals or objectives, establishing outcome criteria, writing a plan of action and developing a resident care plan.
Implementation: Setting the plan in motion and delegating responsibility for each step. Communication is essential to the process. The health care team are responsible to report back all significant findings or changes.
Evaluation: The process is an ongoing event. Involves not only analyzing the success of the goals and interventions, but examining the need for adjustments as well. Evaluation leads back to assessment and the whole process begins again.
  • 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?
  • An assessment is not filling in a checklist or “assessment tool”.
Assessments need to be routinely done – the schedule often driven by resident need.
  • Not all needs and assessments will be addressed by the RAI process.
data collection
Data Collection
  • Objective Data: Detected by the observer and can be measured by accepted standards
  • Subjective Data: Can only be described by the resident/family
  • Data can be variable or constant
  • Interview formally and informally with specific questions
Once the data is collected, the members of the interdisciplinary team take the data and analyze it in order to complete the comprehensive assessment.
Critical thinking is the active, organized cognitive process of analyzing the data collected.
  • The interdisciplinary team draws on knowledge of standards of care, aging process, disease process, physical sciences, psychosocial knowledge, experience, and other areas to analyze the information collected.
Assessments can be: initial assessments, focused assessments, and/or time lapsed assessments
  • The KEY to the assessment process is asking the question why – when you have the answer to why – your assessment may be complete and interventions may be developed
assessment types
Assessment Types
  • The following assessments are required by the RAI process or based on resident need, review RAP tips
  • The list is NOT all inclusive
  • The assessment types completed with the ID Team will be driven by resident need
The summary of information identified with the assessment types are suggestions (triggers) for consideration when completing the assessment – if the suggestion is not an issue, don’t include it in the assessment
  • The triggers are not required in the assessment unless the IDT determines it pertinent to the resident’s assessment
delirium assessment
Delirium Assessment
  • Six Areas Usually the Underlying Cause of Delirium:
  • Medications
  • Infectious Process
  • Psychosocial Environment
  • Diagnoses/Conditions
  • Elimination Problems
  • Sensory Losses
  • Review all medications, number of meds – including PRN’s
  • Age 85 or older
  • Drug levels beyond or at the high end of therapeutic
New medications – correspond with onset?
  • OTC drugs with anticholinergic side effects
  • Medications with contraindications for the elderly
  • Keep abreast of medication updates
infectious process
Infectious Process
  • Elevation of baseline temperature
  • History of lower respiratory infection or urinary tract infection
  • History of chronic infection
psychosocial environmental issues
Psychosocial Environmental Issues
  • Recent relocation or change in personal space
  • Recent loss of family/friend/room mate
  • Isolation
  • Restraints
  • Increase in sensory stimulation
diagnoses and conditions
Diagnoses and Conditions
  • Diabetes – hypo/hyperglycemia
  • Hypo/Hyperthyroidism
  • Hypoxia-COPD, URI
  • ASHD
  • Cancer
  • Head Trauma - falls
  • Dehydration, Fever
  • Surgical Complications
  • Cardiac Dysrhythmias, CHF
elimination problems
Elimination Problems
  • Urinary Problems:
  • History of incontinence, retention, catheter
  • Signs/symptoms of dehydration, tenting, elevated BUN
  • Decreased urinary output
  • Taking anticholinergic medications
  • Abdominal distention
Gastrointestinal Problems:
  • Decreased number of BM’s or constipation
  • Decreased fluid and/or food intake
  • Abdominal distention
sensory losses
Sensory Losses
  • Hearing - hearing aid not functioning
  • Vision - glasses lost, misplaced
  • Recent sleep disturbances
  • Environmental changes such as a new room
Consider pain and pain management as a potential contributing factor to delirium – re evaluate pain status
  • New onset or poorly managed chronic pain
cognitive assessment
Cognitive Assessment
  • Complete a screening test for cognitive deficits – several available
  • Assess for memory loss vs. slow retrieval of info
  • Rule out delirium
Screen for depression – may be part of the dementia or mimic dementia
  • Screen for systemic illness – may cause or worsen dementia
  • Medications – review, any changes
  • History from resident/family/significant other
  • Determine forgetfulness vs. cognitive impairment
quick tool
Quick Tool
  • D – dehydration, depression
  • E – endocrine, environmental changes, electrolyte abnormalities
  • M – medications, metabolic diseases
  • E – eye/ear disease
N – nutritional deficiencies
  • T – tumor, trauma
  • I – infections, impaction, ischemia, insomnia
  • A – anemia, anorexia, alcoholism, anesthetics
Memory test – MMSE most common, many available
  • Competency – ability to make decisions regarding self; if unable, are there legal instruments in place to legally give decision making authority to another, if not, does a process need to be initiated – what decisions is the resident capable of still making
vision assessment
Vision Assessment
  • Ocular and medical history
  • Medications
  • History/surgeries
  • Degree of visual acuity/loss
One/both eyes affected
  • Is further loss expected
  • Most recent eye exam/current Rx
  • Signs of infection, trauma
  • Appropriate use of visual appliances
  • Environmental modifications – more light, less light, large numbers, bright colors
Any recent, acute changes
  • Complaints about vision, pain
  • Observe resident – compensating for vision, field cuts
communication assessment
Communication Assessment

Assessment may include:

  • Understanding
  • Speaking
  • Reading and writing
  • Appropriate use of language
Review medical history, medications
  • Does the resident have any problems with communication – hearing, vision, aphasia
  • Any communication devices – history, are/were they effective, concerns
  • Any limitations in ability to communicate – dyslexia, dementia
Consults – ST, OT, audiologist, etc – any already done, any referrals needed
  • Consider cultural, spiritual issues affecting language ability
  • Work with family, significant other on communication techniques
adl rehab potential assessment
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
Review consults – PT, OT – consider referral
  • Does the resident’s ability vary over the course of the day – any recent change in ability
  • Is the resident able to complete tasks if broken into shorter tasks, with step by step instructions
  • Does the resident need a device to complete the task – consider all devices, which would be appropriate for use – why, why not
How does culture, mood, behavior effect the resident’s ability to complete ADL’s
  • Consider mobility limitations – neurological, musculoskeletal
  • Can any factors affecting ADL’s/mobility be modified, improved – why, why not
Prior history of urinary incontinence – onset, duration, characteristics, precipitants, associated symptoms, previous treatment/management
  • Voiding patterns over several days – incontinent, voided on toilet, dry with routine toileting
  • Medication review
  • Patterns of fluid intake – amounts, times of day
Use of urinary tract stimulants or irritants
  • Pelvic and rectal exam – prolapsed uterus or bladder, prostate enlargement, constipation or fecal impaction, use of cath, atrophic vaginitis, distended bladder, bladder spasms
  • Identification and/or potential of developing complications – skin irritation, breakdown
Functional and cognitive capabilities – impaired cognitive function, dementia, impaired mobility, decreased manual dexterity, need for task segmentation, decreased upper/lower extremity muscle strength, decreased vision, pain with movement, behaviors effecting toileting
  • Types of physical assistance necessary to access toilet and prompting needed to encourage urination
  • 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
  • Urge incontinence – urgency, frequency, nocturia
  • Stress incontinence – loss of small amounts of urine with activity
  • Mixed incontinence – combination urge and stress incontinence
Overflow incontinence – bladder is distended from urinary retention
  • Functional incontinence – secondary to factors other than inherently abnormal urinary tract function
  • Transient incontinence – temporary or occasional incontinence
indwelling catheter
Indwelling Catheter
  • Clinical rationale for use of an indwelling catheter and ongoing need
  • Determination of which factors can be modified or reversed
  • Alternatives to extended use of an indwelling catheter
Assess the risks vs. benefits of an indwelling catheter
  • Potential for removal of the catheter
  • Consideration of complications resulting from the use of an indwelling catheter
  • Develop plan for removal of the indwelling catheter based on assessment
psychosocial assessment
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
Social history
  • Psychosocial well being
  • Social interactions
  • Spiritual/Legal/


  • Financial
  • Discharge potential/


social history
Social History
  • Born and raised? Where did they live throughout their adult life?
  • Siblings, parents – still alive, relationship
  • Education, military
  • Marriage, children, significant others – current involvement
  • Work history
  • Organizations member of, hobbies, religion
  • Cultural/ethnic background/traditions
  • Pets
psychosocial well being
Psychosocial Well-Being
  • Personality – abuse history
  • Speech/communication, hearing, vision – any impairments, any outside services needed
  • General behavior/mood
  • General cognition
  • General interactions with others
  • Related diagnoses, psych history
social interactions
Social Interactions
  • With family, spouse, significant other, friends
  • Sexual
  • Other residents
  • Staff
  • Others
  • Recent losses/Significant losses – family, home, pets
spiritual emotional legal
  • Adjustment issues
  • Spiritual/cultural beliefs related to medical care and receipt of treatment
  • Abuse – financial, physical, emotional, sexual – consider restraining orders
  • Advanced directives, living wills, health care proxy, POA, financial guardian, guardian of person or guardian of both
  • Sale of large items – home, business
  • Pay Source
  • Business matters – does the resident complete their own business or does a family member, POA, trustee, guardian, etc.
  • Will the resident need help related to insurance issues, qualifying and applying for medical assistance, etc.
placement discharge
  • Adjustment/length of stay
  • Pets – who is caring for the pets
  • Services needed after discharge if short term
  • Coordination with family, significant others – any training/education needed prior to discharge
mood assessment
Mood Assessment
  • Evaluated by observation of the resident and verbal content
  • Most common, although under treated, mood disorder is depression
Mood can affect cognitive function
  • Depression can create a pseudodementia
  • Anxiety often related to depression, phobias, obsessions
  • Delusions common in 40% of residents with dementia
  • Many tools available to assist with assessing mood disorders
  • What signs/symptoms is resident displaying
Review diagnoses, medications
  • Utilize tools, as appropriate
  • History of abuse, alcohol or drug use, mood disorder
Is this a short term issue/adjustment reaction
  • Is there a pattern, is it cyclical
  • Has the resident received mental health services in the past, would a referral be appropriate
  • Does mood respond to treatment – meds, psychosocial therapy
behavior assessment
Behavior Assessment
  • Define the behavior and the scope
  • Determine if there is a pattern to the behavior
  • What, if anything, does the resident behavior respond to
  • Rule out delirium
Listen carefully to what the resident is saying during the behaviors
  • Observe the resident for periods of time over the course of several days – what do they say, what do they do before, during, and after the behaviors – pay particular attention to the antecedents of the behavior
  • Review the social history including the cultural background
Is the behavior truly a behavior or is it something that is outside the accepted societal norms
  • Is the behavior creating a danger to the resident or someone else – immediacy of the issue, effectiveness of interventions, level of supervision required
physiological causes
Physiological Causes
  • Diagnoses
  • Medications
  • Fatigue – how is the resident sleeping
  • Physical discomfort - pain, constipation, gas
Infectious process
  • Trauma to the head
  • Physical assessment – vital signs, O2 sats, bowel and lung sounds, blood sugar, palpate for pain/distress
environmental causes
Environmental Causes
  • Sudden movements
  • Unfamiliar surroundings, people
  • Difficulty adjusting to changes in lighting
Temperature – too hot, too cold
  • Uncomfortable, ill-fitting clothing
  • Disruption in routine
  • Staffing issues
sensory causes
Sensory Causes
  • Sensory overload – too much noise, clutter, activity
  • Hearing – does the resident understand what you are saying
  • Vision – can the resident see what you’re doing, is the lighting adequate
  • Sudden physical contact, startling noises
other causes
Other Causes
  • Tasks not broken into manageable steps
  • Activity not age appropriate
  • Change in routine
Resident feelings – belittled, reprimanded, scolded
  • Lack of control, feelings of loss
  • Lack of validation
  • Inability to communicate
  • Depression
activity assessment
Activity Assessment
  • Review medical history – any limitations to activity type/level
  • Obtain history of activities – level of activity, preferences, dislikes, group vs. individual, outside groups
How much assistance does the resident need to attend and participate in activities – what needs to be done to improve independence
  • How does the resident feel about leisure activities – good idea, waste of time
  • Do the scheduled activities meet the resident’s needs or will something need to be added/changed
If the resident’s activity level has declined – why – illness, fatigue, mood, isolation, adjustment issues, disinterest in activities offered
  • If behaviors/moods are identified, are there activities that could be provided to assist with improving them
falls assessment
Falls Assessment
  • 10-20% of falls cause serious injuries
  • Falls usually occur due to environmental or physical reasons
  • For many, goal is to minimize, not eliminate falls
the three why s
The Three Why’s
  • Why is the resident on the move?What are they trying to do?
  • Why can’t the resident stay upright?
  • Why aren’t the existing interventions effective? Are they as effective as they can be?
environmental risks
Environmental Risks
  • Poor Lighting
  • Clutter
  • Incorrect bed height
  • Ill functioning safety devices
  • Improperly maintained or fitted wheelchairs
  • Wet floors
  • Staffing issues
physical risks
Physical Risks
  • Weakness
  • Gait disturbance
  • Medications – especially psychoactive drugs, vascular medications
  • Diagnoses
Poor foot care – ill fitting shoes
  • Inappropriate use of walking aids
  • Infectious process
  • Sensory changes
  • Decreased/change in range of motion
nutritional status assessment
Nutritional Status Assessment
  • Medical history – diagnoses, meds, pain
  • Weight/Lab data
  • Clinical findings
  • Dietary history
Weight Data
  • Height, weight – usual/norm, desirable
  • Any recent weight changes – were changes planned
  • Measurements – as appropriate – girth, LE, UE

Lab data – review any pertinent labs – high/low, dietary needs

Clinical Findings
  • Physical signs – hair, skin, eyes, mouth
  • Daily routines – meal times, alcohol use, drug use, smoking history, exercise
  • GI function – appetite, sense of taste, problems chewing/swallowing, sense of smell, digestive upset (nausea, vomiting, heartburn, distention, cramping)
  • Bowel history
Dietary History
  • Favorite foods – how often do you eat them
  • Food dislikes
  • How do you feel about food
  • Food allergies
  • Special diet – history, family history
  • Typical food intake
  • At home – who cooked, facilities available, shopping availability
assess data gathered
Assess Data Gathered
  • What are the resident’s nutrition/hydration needs
  • Consider appropriate diet – altered diet, special diet, increased protein, increased fiber, supplements, etc.
Consider any additional monitoring, follow up needed
  • Consider any meal time assistance needed
  • Consider diet changes to increase independence – finger foods
feeding tube assessment
Feeding Tube Assessment
  • Why is the tube feeding necessary
  • Were alternatives assessed prior to placement
  • Is the resident NPO or is some oral intake allowed
  • Is the tube intended to be long or short term
Review risks and benefits of placement
  • Assess the efficacy of the tube feeding – calorie and hydration needs, type of formula
  • Assess for complications – irritation at site, infection, diarrhea, aspiration, displacement, pain, distention, cardiac issues
  • Assess for ongoing need
dehydration fluid maintenance assessment
Dehydration/Fluid Maintenance Assessment
  • Identifying the resident at risk for dehydration and minimizing the risk
  • Identifying dehydration in a resident and assessing the cause
risks for dehydration
Risks for Dehydration
  • Fluid loss and increased fluid need – diarrhea, fever
  • Fluid restrictions related to diagnosis – renal failure, CHF
  • Functional impairments – unable to obtain fluid on their own or ask for it
  • Cognitive impairments – forget to drink or how to drink, behaviors
  • Availability, consistency
assess for dehydration
Assess for Dehydration
  • Diagnoses? Does the resident have a lack of sensation of thirst or inability to express feelings of thirst?
  • Any changes in medications?
  • Recent infection? Fever?
Intake and output – are they balanced?
  • Current lab tests – hematocrit, serum osmolality, sodium, urine specific gravity, BUN
  • Physical assessment – review for signs of dehydration
  • Cognitive assessment – does the resident remember to drink or know how?
  • Physical limitations – is the resident physically capable of obtaining their own fluid?
symptoms of dehydration
Symptoms of Dehydration
  • Irritability and confusion
  • Drowsiness
  • Weakness
  • Extreme Thirst
  • Fever
  • Dry skin and mucous membranes
Sunken eyeballs
  • Poor skin turgor
  • Decreased urine output
  • Increased heart rate with decreased BP
  • Lack of edema in someone with history of edema
  • Constipation/impaction
non oral considerations
Non-Oral Considerations
  • Assess cognitive impairment
  • Assess functional impairment
  • Institutionalized residents at very high risk for oral disease
  • Medications and radiation used
  • Behaviors/attitudes/culture
oral related factors
Oral Related Factors
  • Mouth related conditions, history of oral disease, periodontal disease
  • Xerostomia (complaints of dry mouth) and/or SGH (salivary gland hypofunction – reduced saliva flow)
  • Excessive salivation – review diagnoses, medications
oral assessment
Oral Assessment
  • Tools available for screening – Brief Oral Health Status Examination (BOHSE)
  • Natural teeth, dentures, partials, implants
  • Observe oral cavity – condition of tissue, soft palate, hard palate, gums
  • Natural teeth – broken, caries
Condition/fit of dentures, partial
  • Saliva – over/under production
  • Oral cleanliness – review dental habits
  • Any complaints of pain, oral concerns
A resident at risk can develop a pressure ulcer in 2 to 6 hours
  • Identify which risk factors can be removed or modified
  • Should address the factors that have been identified as having an impact on the development, treatment and/or healing of pressure ulcers
Research has shown that a significant number of PU’s develop within the first four weeks after admission to a LTC facility
  • Many clinicians recommend using a standardized pressure ulcer risk assessment tool to assess pressure ulcer risk upon admission, weekly for the first four weeks after admission, then quarterly and as needed with change in cognition or functional ability
An overall risk score indicating the resident is not at high risk of developing pressure ulcers does not mean that existing risk factors or causes should be considered less important or addressed less vigorously
Risk Factors
  • Pressure Points
  • Under Nutrition and Hydration Deficits
  • Moisture and its Impact on Skin
risk factors
Risk Factors
  • Impaired/decreased mobility and decreased functional ability
  • Co-morbid conditions – end stage renal disease, thyroid disease, diabetes
  • Drugs that may effect wound healing - steroids
Impaired diffuse or localized blood flow – generalized atherosclerosis, lower extremity arterial insufficiency
  • Resident refusal of some aspects of care and treatment – what behaviors and how do they impact the development of PU’s
  • Cognitive impairment
Exposure of skin to urinary and fecal incontinence
  • Under nutrition, malnutrition, hydration deficits
  • A healed ulcer – history of a healed pressure ulcer and its stage
pressure points tissue tolerance
Pressure Points/Tissue Tolerance
  • Include an evaluation of the skin integrity and tissue tolerance after pressure to that area has been reduced or redistributed
Pressure ulcers are usually located over a bony prominence but may develop at other sites where pressure has impaired the circulation to the tissue
  • Regularly assess the skin of residents identified at risk for PU’s
If the resident is dependent for positioning and spends time up in a chair and in bed, it may be appropriate to review the tissue tolerance both lying and sitting
  • When reviewing tissue tolerance, identify if the resident was sitting or lying, any pressure reducing/relieving devices utilized, the amount of time sitting/lying before the tissue was observed
under nutrition and hydration deficits
Under-Nutrition and Hydration Deficits
  • Severity of nutritional compromise
  • Severity of risk for dehydration
  • Rate of weight loss or appetite decline
  • Probable causes
  • The resident’s prognosis and projected clinical course
  • Resident’s wishes and goals
moisture and its impact
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
What psychotropic(s) is the resident on
  • Why is the resident on the medication(s)
  • How does the medication maintain or improve the resident’s functional status
  • When was the medication(s) started – at what dose(s)
What is the history of psychotropic use for the resident – medications, dosages, response to the med/dose
  • Medical history including diagnoses, hospitalizations
  • Based on the review of the medication(s)-
  • What are the specific behaviors being targeted
Has the behavior(s) being targeted improved/declined – what is the frequency and severity – how are you monitoring/tracking
  • What are the non-pharmaceutical interventions in place and what is the effectiveness
  • Are there any side effects from the medication(s)
  • Is a reduction appropriate/required – ensure minimal effective dose
physical restraint assessment
Physical Restraint Assessment
  • Why is the restraint being used
  • What are the least restrictive options for restraint use
  • When does the resident need to be restrained – when doesn’t the resident need to be restrained
Unless an emergent situation is identified, complete a comprehensive assessment before applying the restraint
  • What is the benefit of restraint use for the resident
  • Compare the identified risks to the identified benefits
  • Use the assessment process to avoid or minimize the use of restraints
If a diagnosis is driving the use of the restraint, individualize that diagnosis to the resident – what does it mean for that resident to have that diagnosis
  • If a behavior is driving the use of the restraint, individualize that behavior to the resident – what does it mean for that resident to have that behavior
If a cognitive issue is driving the use of the restraint, individualize that issue to the resident – what does it mean for that resident to have that issue
Once the reason for the restraint has been determined, assess the least restrictive options available
  • Determine what interventions, in conjunction with restraint use, could be utilized to minimize restraint use
  • Determine any times the resident may be without restraint – meal times, activities, toileting – how much supervision is required when not restrained
pain assessment
Pain Assessment
  • A comprehensive assessment is essential to adequate pain relief
  • Pain is a subjective experience – it’s as real as the resident communicates it is
  • Start the assessment process with the resident
resident interview
Resident Interview
  • Describe the pain – location, onset, intensity, pattern
  • Quality – constant vs. intermittent, dull vs. sharp, burning vs. pressure
  • Aggravating/relieving factors
physiological indicators
Physiological Indicators
  • Abnormal vital signs
  • Change in level of consciousness
  • Functional status
  • Head to toe assessment – focus on musculoskeletal and neurological
  • Observe the pain response in relation to activity
behavioral indicators
Behavioral Indicators
  • Muscle tensing, rigid posturing
  • Facial grimaces/wincing, furrowed brow, narrowed eyes, clenched teeth, tightened lips
  • Pallor/flushing
  • Agitation, restlessness
  • Crying, moaning, grunts, gasps, sighs
  • Resisting cares, combative
other factors to consider
Other Factors to Consider
  • History of pain experience and past management
  • Sleep patterns – increased fatigue may decrease the ability to tolerate pain
  • Environment – moist, cold, hot
  • Religious beliefs
  • Cultural beliefs, social issues/attitudes
  • Interview staff – what is their knowledge of the residents pain
reassessment of pain
Reassessment of Pain
  • It’s essential to an effective pain management program to have systems ensuring ongoing assessments of pain management interventions
  • With changes in interventions, ensure the assessment is completed for a period of time long enough to determine the effectiveness of the implemented intervention
assessing pain in cognitively impaired residents
Assessing Pain in Cognitively Impaired Residents
  • Interview family/significant others
  • Any functional changes in activity
  • Complete a physical assessment and assess physiologic and behavioral indicators as well as other factors
  • If pain is suspected, consider a time limited trial of an analgesic and closely monitor and continually reassess
bowel assessment
Bowel Assessment
  • It’s important to assess bowel habits with a 3 to 5 day history of patterns – some resources recommend a longer period of time to establish a reliable pattern
characteristics of the bowel incontinence
Characteristics of the Bowel Incontinence
  • Onset, duration, frequency
  • Stool consistency and amount
  • Timing – night, day or both, relationship to meals
  • Associated symptoms – urgency, straining, blood in stools
  • Normal bowel pattern
  • History of laxative use – stimulants, bulk laxatives, suppositories
relevant past medical history
Relevant Past Medical History
  • Past surgeries – anorectal, intestinal, laminectomy
  • Past childbirth – number of children, traumatic deliveries
  • History of pelvic radiation
  • Gastrointestinal disorders – bowel infection, irritable bowel syndrome, diverticulitis, ulcerative colitis, Crohn’s disease
  • Metabolic disorders
  • History of constipation and/or fecal impaction
medication use
Medication Use
  • Diuretics
  • Antibiotics
  • Antihistamines
  • Antispasmodics
  • Tricylic Antidepressants
  • Narcotics
level of activity functional status
Level of Activity/Functional Status
  • Able to toilet self
  • Ambulatory/Non-ambulatory
  • Bedfast
  • Independent with transfers
  • Assistance with transfers – mechanical or 1-2 person assist
cognitive status
Cognitive Status
  • Memory loss – short or long term
  • Resident can/can not identify the need to have a BM
  • Resident is able/unable to ask for help to get to the bathroom
  • Resident can recognize the toilet and know its use
diet history
Diet History
  • Hydration status – ability to obtain fluid on their own
  • Caffeine use
  • Amount of bulk in diet
  • Eating pattern – consistently eats 3 meals a day or only eats breakfast
environmental characteristics
Environmental Characteristics
  • Accessible bathroom
  • Bedside commode
  • Restrictive clothing
  • Availability of caregivers
  • Adaptive devices to toilet
physical examination
Physical Examination
  • Abdominal examination – presence of masses, distention, bowel sounds
  • Neurological examination – evidence of peripheral neuropathy
Rectal exam

-Condition of perineum – excoriation

-Anorectal conditions – fissures, hemorrhoids, transient, deformity

-External anal sphincter tone

-Fecal mass or impaction

-Prostatic enlargement

laboratory and other tests
Laboratory and Other Tests
  • Stool cultures
  • Abdominal x-ray
  • Barium enema
  • Ova and Parasite
self administration of medication sam assessment
Self Administration of Medication (SAM) Assessment
  • Does the resident wish to SAM
  • Review medical history including medications
  • Any history of concerns related to administering own medications
review cognitive ability
Review Cognitive Ability
  • Are there any cognitive deficits – would they affect the residents ability to SAM – how
  • Is the resident able to verbalize the medication(s) they will SAM including what it’s for, how to administer, side effects
  • Does the resident remember to store the medications securely after SAM
review physical ability
Review Physical Ability
  • Is the resident able to obtain the medication – get to where it is stored, open the storage area, open the medication, administer the med
  • What modifications could be made to enable resident to become physically capable of SAM
Can the resident administer some meds but not others
  • Can the resident SAM with set up
  • What monitoring should the resident receive for the SAM process
safety assessment
Safety Assessment
  • Assess any threats to resident safety
  • Does resident have any behaviors/habits that put them at risk of injury from themselves or others
  • Assess the identified risk factors
review smoking risk
Review Smoking Risk
  • Is resident cognitively aware of safety needs when smoking
  • Is resident physically capable of managing smoking materials
  • Review resident smoking history and any previous safety concerns
Is the resident capable of extinguishing a lit cigarette/ash that has fallen on themselves/others
  • Is the resident able to call for help if needed
  • Past history of poor safety judgment
  • If using O2, does resident understand oxygen use as it relates to smoking safety
Does resident understand smoking policy
  • Does the resident need adaptive equipment to assist with smoking safety and/or independence
review elopement risk
Review Elopement Risk
  • Any history of elopement
  • Psychosocial concerns – adjustment issues, recent loss
  • If eloping – destination, purpose
Previous lifestyle, occupation

Assess the type of wandering

  • Tactile wandering – explore environment with hands
Environmentally cued wandering – appear calm and led by the environment, sees window – looks out, chair – sits, door – exits
  • Reminiscent wandering – wandering stems from a delusion or fantasy from the past – going to the market, work – announce leaving
  • Recreational wandering – wandering based on previous active lifestyle
If resident identified as an elopement risk, assess environmental risks
  • Are all doors alarmed and/or wanderguarded
  • Where is the residents room in relation to exits and the nursing station
  • Is the resident capable of exiting through a window – can the windows be exited through
Are the grounds easily visible from the facility, are they well lit
  • Is the facility on or near a busy street
  • Are there hills, woods, water on the grounds
  • Is public transportation available near the facility
review injury risk
Review Injury Risk
  • Does resident receive frequent bruises, skin tears, etc.
  • Does the resident exhibit behaviors that place them at risk for abuse from others
  • Are there objects in the environment which place the resident at risk for injury – sharps, chemicals, stairwells
acute assessments
Acute Assessments
  • When an acute change occurs – assess for possible causes
  • Review for any recent changes in treatments/meds
  • Review medical history
Interview resident as able – any changes, concerns
  • Interview staff for any identified changes
  • Conduct physical assessment as determined appropriate – vitals, neuros, auscultate lungs, abdomen, palpate area(s) of concern, recent labs, last BM, last void – anything unusual with stool or urine
  • Conduct brief cognitive assessment
  • Not all identified risk factors need to be addressed in the comprehensive assessment – only those the ID Team determines to be pertinent to the resident
  • When addressing a risk factor in the assessment, indicate how it does impact the resident, not how it could
When completing the comprehensive assessment, keep asking “WHY”
  • Incomplete or inaccurate data is not helpful in completing a comprehensive assessment and should not be used
The comprehensive assessment is the key to developing effective, individualized resident care