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

 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.

 Due to the

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

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

 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

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.

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?

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
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
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, dont include it in the assessment The triggers are not required in the assessment unless the IDT determines it pertinent to the residents assessment

Delirium Assessment
Six Areas Usually the Underlying

Cause of Delirium: Medications Infectious Process Psychosocial Environment Diagnoses/Conditions Elimination Problems Sensory Losses

Medications
Review all medications, number of

meds including PRNs 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
Elevation of baseline temperature History of lower respiratory infection or

urinary tract infection History of chronic infection

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

Diabetes hypo/hyperglycemia Hypo/Hyperthyroidism Hypoxia-COPD, URI ASHD Cancer Head Trauma - falls Dehydration, Fever Surgical Complications Cardiac Dysrhythmias, CHF

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 BMs or

constipation Decreased fluid and/or food intake Abdominal distention

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
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
DEMENTIA 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
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
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

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 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

 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

Urinary Incontinence/Catheters Assessment

 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

 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

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
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
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/ Emotional Financial Discharge potential/ Placement

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
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
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

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.

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
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
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
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

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 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

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
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 residents needs or will something need to be added/changed

 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

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 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?

Environmental Risks
Poor Lighting Clutter Incorrect bed height Ill functioning safety devices Improperly maintained or fitted wheelchairs Wet floors Staffing issues

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

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

What are the residents

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

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

Identifying the

resident at risk for dehydration and minimizing the risk

Identifying

dehydration in a resident and assessing the cause

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

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
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

Dental Care Assessment

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

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
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

Pressure Ulcer Assessment

 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 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

 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
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 PUs 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

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 PUs

 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

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

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

Psychotropic Assessment

 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)

 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

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

 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
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

Resident Interview
Describe the pain

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

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
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

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
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

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
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

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

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

Medication Use
Diuretics
Antibiotics Antihistamines

Antispasmodics
Tricylic Antidepressants Narcotics

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
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
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
Accessible bathroom Bedside commode Restrictive clothing Availability of caregivers

Adaptive devices to toilet

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

Stool cultures
Abdominal x-ray Barium enema Ova and Parasite

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

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

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
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

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

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

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
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

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

 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