Professional Documents
Culture Documents
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
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
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.
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.
Planning
Implementation Evaluation
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.
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.
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?
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
collected, the members of the interdisciplinary team take the data and analyze it in order to complete the comprehensive assessment.
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, 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
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
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
personal space Recent loss of family/friend/room mate Isolation Restraints Increase in sensory stimulation
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
Sensory Losses
Hearing - hearing aid not functioning Vision - glasses lost, misplaced
room
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
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
N nutritional deficiencies
T tumor, trauma I infections, impaction, ischemia,
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
changes Complaints about vision, pain Observe resident compensating for vision, field cuts
Communication Assessment
Assessment may include:
Understanding
Speaking
Reading and
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
audiologist, etc any already done, any referrals needed Consider cultural, spiritual issues affecting language ability Work with family, significant other on communication techniques
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
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
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
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
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
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
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
frequency, nocturia Stress incontinence loss of small amounts of urine with activity Mixed incontinence combination urge and stress incontinence
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
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
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
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
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
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
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
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
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
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
lighting
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
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
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
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
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
shopping availability
nutrition/hydration needs Consider appropriate diet altered diet, special diet, increased protein, increased fiber, supplements, etc.
follow up needed Consider any meal time assistance needed Consider diet changes to increase independence finger foods
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
Identifying
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
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
Sunken eyeballs
of edema Constipation/impaction
Non-Oral Considerations
Assess cognitive impairment
Assess functional impairment Institutionalized residents at very high
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 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
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
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
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
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
incontinence Under nutrition, malnutrition, hydration deficits A healed ulcer history of a healed pressure ulcer and its stage
evaluation of the skin integrity and tissue tolerance after pressure to that area has been reduced or redistributed
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
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
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
medication(s) How does the medication maintain or improve the residents functional status When was the medication(s) started at what dose(s)
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
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
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
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
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
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
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
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
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
meals Associated symptoms urgency, straining, blood in stools Normal bowel pattern History of laxative use stimulants, bulk laxatives, suppositories
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
Cognitive Status
Memory loss short or long term
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
Physical Examination
Abdominal examination presence
Rectal exam
-Condition of perineum excoriation -Anorectal conditions fissures, hemorrhoids, transient, deformity -External anal sphincter tone -Fecal mass or impaction -Prostatic enlargement
wish to SAM Review medical history including medications Any history of concerns related to administering own medications
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
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
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
cognitively aware of safety needs when smoking Is resident physically capable of managing smoking materials Review resident smoking history and any previous safety concerns
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
policy Does the resident need adaptive equipment to assist with smoking safety and/or independence
elopement Psychosocial concerns adjustment issues, recent loss If eloping destination, purpose
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
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
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
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
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
assessment, keep asking WHY Incomplete or inaccurate data is not helpful in completing a comprehensive assessment and should not be used
The