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 1950s
• 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, dont include it
  in the assessment
• The triggers are not required in the assessment
  unless the IDT determines it pertinent to the
  residents 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 PRNs
• 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 BMs 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

35

• 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 residents 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
  residents ability to complete ADLs
• Consider mobility limitations neurological,
  musculoskeletal
• Can any factors affecting ADLs/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 PVRs, UA/UC
  or evaluations assessing the residents 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 youre 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 residents
  needs or will something need to be added/changed

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• If the residents 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 Whys

• Why is the resident on the move?What are they
  trying to do?
• Why cant the resident stay upright?
• Why arent 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 residents 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
100
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

101
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

102
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

103

• 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
105

• 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

106

• Research has shown that a significant number of
  PUs 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

107

• 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

108

• 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

110

• 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 PUs
• Cognitive impairment

111

• 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

112
Pressure Points/Tissue Tolerance

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

113

• 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 PUs

114

• 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

115
Under-Nutrition and Hydration Deficits

• Severity of nutritional compromise
• Severity of risk for dehydration
• Rate of weight loss or appetite decline
• Probable causes
• The residents prognosis and projected clinical
  course
• Residents wishes and goals

116
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

117
Psychotropic Assessment
118

• What psychotropic(s) is the resident on
• Why is the resident on the medication(s)
• How does the medication maintain or improve the
  residents functional status
• When was the medication(s) started at what
  dose(s)

119

• 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

120

• 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

121
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 doesnt the resident need to be restrained

122

• 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

123

• 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

124

• 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

125

• 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

126
Pain Assessment

• A comprehensive assessment is essential to
  adequate pain relief
• Pain is a subjective experience its as real as
  the resident communicates it is
• Start the assessment process with the resident

127
Resident Interview

• Describe the pain location, onset, intensity,
  pattern
• Quality constant vs. intermittent, dull vs.
  sharp, burning vs. pressure
• Aggravating/relieving factors

128
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

129
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

130
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

131
Reassessment of Pain

• Its 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

132
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

133
Bowel Assessment

• Its 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

134
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

135
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, Crohns disease
• Metabolic disorders
• History of constipation and/or fecal impaction

136
Medication Use

• Diuretics
• Antibiotics
• Antihistamines
• Antispasmodics
• Tricylic Antidepressants
• Narcotics

137
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

138
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

139
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

140
Environmental Characteristics

• Accessible bathroom
• Bedside commode
• Restrictive clothing
• Availability of caregivers
• Adaptive devices to toilet

141
Physical Examination

• Abdominal examination presence of masses,
  distention, bowel sounds
• Neurological examination evidence of peripheral
  neuropathy

142

• Rectal exam
• -Condition of perineum excoriation
• -Anorectal conditions fissures, hemorrhoids,
  transient, deformity
• -External anal sphincter tone
• -Fecal mass or impaction
• -Prostatic enlargement

143
Laboratory and Other Tests

• Stool cultures
• Abdominal x-ray
• Barium enema
• Ova and Parasite

144
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

145
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 its
  for, how to administer, side effects
• Does the resident remember to store the
  medications securely after SAM

146
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

147

• 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

148
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

149
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

150

• 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

151

• Does resident understand smoking policy
• Does the resident need adaptive equipment to
  assist with smoking safety and/or independence

152
Review Elopement Risk

• Any history of elopement
• Psychosocial concerns adjustment issues, recent
  loss
• If eloping destination, purpose

153

• Previous lifestyle, occupation
• Assess the type of wandering
• Tactile wandering explore environment with hands

154

• 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

155

• 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

156

• 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

157
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

158
Acute Assessments

• When an acute change occurs assess for possible
  causes
• Review for any recent changes in treatments/meds
• Review medical history

159

• 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

160
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

161

• 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

162

• The comprehensive assessment is the key to
  developing effective, individualized resident care