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 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

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, 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

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 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

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 BM’s 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 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

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 – 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

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 you’re 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 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

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

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

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 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

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 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

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

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

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

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 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 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

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

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

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 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

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

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, Crohn’s 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 it’s 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