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Running head: GERIATRIC ANALYSIS PAPER

Geriatric Analysis Paper Amanda adgley N!RS "1#

$ GERIATRIC ANALYSIS PAPER A%stract Geriatric clients need t& %e cared '&r di''erently 'r&m a y&unger adult client( Creating nursing care plans '&r elderly clients is essential t& pr&)ide high *uality care '&r the client( The nursing pr&cess is e+pected t& %e used '&r a th&r&ugh care plan( Assessment, diagn&ses, planning, implementati&n, and e)aluati&n &' the plan &' care are e+tremely imp&rtant( y -riting a p&licy t& address an unmet need &' the client all&-s the nurse t& gain 'urther insight int& assisting the client.s needs(

" GERIATRIC ANALYSIS PAPER Geriatric Analysis Paper As a nurse, &ne sh&uld /n&- that caring '&r an elderly client is di''erent than caring '&r a y&unger adult client( All nurses need t& %e educated t& understand and treat the
&'ten c&mple+ physical and mental health needs &' &lder pe&ple( Creating a 'ictiti&us plan &' care '&r a client can %e &' assistance t& a nurse -h& is studying ger&nt&l&gy( y creating a plan &' care '&r a geriatric client can help a nurse learn h&- t& pr&tect their patient.s health and c&pe -ith changes in their mental and physical a%ilities, s& &lder pe&ple can stay independent and acti)e as l&ng as p&ssi%le( y using the nursing pr&cess, a student can gain a m&re in0depth understanding &' the elderly p&pulati&n h&- t& care '&r them %ased &n their uni*ueness( There are many case studies thr&ugh&ut the te+t%&&/ used '&r this c&urse( y ch&&sing &ne client 'r&m a single study, a student is a%le t& create a th&r&ugh indi)iduali1ed plan &' care '&r the client( 2ennie is a client presented in the te+t%&&/ thr&ugh a case study de)&ted t& the aging e+perience( This client pr&)ides en&ugh in'&rmati&n '&r a student t& learn a%&ut the elderly( Thr&ugh assessing, diagn&sing, planning, implementing, e)aluating, and creating a p&licy '&r a client.s unmet needs a nurse can learn a%&ut the geriatric p&pulati&n(

Assessment Pain and Fall Risk 3r&m the client in the te+t%&&/, 2ennie has se)eral assessment a%n&rmalities( 4uring her assessment, 2ennie -as '&und t& ha)e 5&int pain in multiple 5&ints( Pain is n&t a n&rmal part &' the aging pr&cess( 6Pain is n&t n&rmal -ith aging( The presence &' pain in the elderly necessitates aggressi)e assessment, diagn&sis, and management similar t& that &' pers&ns at any age,7 8T&uhy 9 2ett, $:1$;( 2ennie descri%ed her pain as a dull aching and a 'eeling &' sti''ness at times in her 5&ints( <n a pain scale &' :01:, 2ennie rated her a)erage &)erall pain -as at a " -ith rest, and a =0> up&n e+erti&n( The client

# GERIATRIC ANALYSIS PAPER als& has %een e+periencing 're*uent 'alls( 63alls are a sympt&m &' a pr&%lem and are rarely %enign in &lder pe&ple,7 8T&uhy 9 2ett, $:1$;( ?er 'alls c&uld %e related t& the 5&int pain that she is e+periencing( T& assess 2ennie.s 'all ris/ -ithin the nursing 'acility, the nurse shall use the @&rse 3all Ris/ Sc&re( The @&rse 3all Ris/ Sc&re 6is a rapid and simple meth&d &' assessing a patient.s li/elih&&d &' 'alling,7 8Net-&r/ &' Care, 1AAB;( A'ter applying the 'all ris/ scale t& 2ennie.s situati&n, 2ennie sc&red a >= &n the scale -hich re'lects a client -h& is at high ris/ '&r 'alls( Chile staying at the current 'acility she resides, all high 'all ris/ inter)enti&ns -ill need t& %e en'&rced( See appendi+ A '&r 2ennie.s indi)iduali1ed 'all ris/ sc&re( Neurological 2ennie.s c&gniti&n and mental status -ere -ithin n&rmal limits up&n assessment( 2ennie -as alert and &rientated t& all aspects and )ery sharp -ith her ans-ers( She dem&nstrated n& hallucinati&ns, appr&priate %eha)i&r, clear speech, and e*ual e+tremity m&)ements( She als& denied any suicidal ideati&ns and -as a%le t& appr&priately ans-er all *uesti&ns( 2ennie.s gait -as unsteady and re*uired the assistance &' a sta'' mem%er '&r am%ulati&n -ith a 'r&nt -heeled -al/er and a gait %elt '&r sa'ety( Chen *uesti&ned a%&ut her sleep pattern, 2ennie admitted that she d&es ha)e a di''icult time 'alling asleep at night and that she had her &-n 6h&me remedy7 that she used t& help her 'all asleep -hen she still li)ed at h&me( 6Ins&mnia has a higher pre)alence in &lder adults and, there are many in'luencing 'act&rs, %&th physi&l&gical and %eha)i&ral,7 8T&uhy 9 2ett, $:1$;( Respiratory and Cardiovascular 2ennie.s respirat&ry status als& -as '&und t& ha)e a 'e- a%n&rmalities( ?er respirati&ns -ere e)en and unla%&red( She maintained an &+ygen saturati&n &' ABD &n

= GERIATRIC ANALYSIS PAPER r&&m air and denied any c&ugh( <n &ccasi&n, 2ennie c&mplained &' %eing sh&rt &' %reath up&n e+erti&n( ?er lung s&unds -ere diminished thr&ugh&ut and a 'e- 'ine crac/les in her right lung %ase -ere als& n&ted up&n assessment( 2ennie als& c&mplained &' ha)ing s&me trace %ilateral l&-er e+tremity edema( She claims that the s-elling t& her legs n&thing ne- '&r her and has had pr&%lems -ith s-elling '&r se)eral years n&-( 2ennie.s capillary re'ill -as less than $ sec&nds, heart rhythm regular, and upper and l&-er e+tremities -ere -arm t& the t&uch( Gastrointestinal and Genitourinary !p&n assessing 2ennie.s gastr&intestinal and genit&urinary systems, it -as n&ticed that she -as di''iculties -ith stress urinary inc&ntinence( 2ennie -&uld ha)e di''iculties h&lding her urine and lea/ing due t& -ea/ pel)ic 'l&&r muscles, and -&re a pr&tecti)e undergarment -hich she managed -ith minimal t& m&derate assistance( ?er urine -as clear, yell&-, and &d&rless -ith n& %ladder distenti&n n&ted( She did rep&rt ha)ing &ccasi&nal 're*uency and urgency -ith urinati&n as -ell( 2ennie did n&t p&rtray any a%n&rmalities -ith her gastr&intestinal assessment( ?er last %&-el m&)ement had &ccurred the pre)i&us day, all her %&-el s&unds -ere acti)e in all *uadrants and her a%d&men -as n&n0tender, s&'t and r&unded( Skin and Braden ?er s/in assessment pr&)ed t& %e unremar/a%le as -ell( 2ennie.s s/in -as m&ist, -arm, n&rmal c&l&r '&r her ethnicity, g&&d s/in turg&r, and intact -ith n& a%n&rmalities( She had n& -&unds present and sc&red high &n the raden S/in Assessment T&&l( The raden S/in Assessment T&&l is a, 6t&&l can %e used t& identi'y patients at0ris/ '&r pressure
ulcers,7 8Pre)enti&n Plus, $:1:;( The raden scale is used in many 'acilities &n a -ide )ariety &' patients t& determine their ris/ &' de)el&ping a pressure ulcer -hile under the care &' nursing

> GERIATRIC ANALYSIS PAPER


sta''( 2ennie sc&red a 1A &n the scale( See appendi+ indi)iduali1ed sc&re( '&r 'urther in'&rmati&n &n 2ennie.s

Diagnoses Urinary Incontinence 4ue t& 2ennie.s stress urinary inc&ntinence, her c&nditi&n *uali'ies '&r se)eral nursing diagn&ses( A nursing diagn&sis &' 6Stress !rinary Inc&ntinence related t& -ea/ pel)ic musculature,7 8Tayl&r 9 Ralph, $::E; is appr&priate( This diagn&sis can %e de'ined as, 6l&ss &' urine 8less than =: ml; resulting 'r&m increased a%d&minal pressure,7 8Tayl&r 9 Ralph, $::E;( 4e'ining characteristics &' this diagn&sis include 6're*uency, urgency, and dri%%ling -ith increased a%d&minal pressure,7 8Tayl&r 9 Ralph, $::E;( She als& sh&-s characteristics &' lea/age &' urine during e+cessi)e snee1ing, laughing, and c&ughing( 2ennie has displayed all &' these characteristics during her assessment and up&n *uesti&ning her( 2ennie has %een using an inc&ntinence pr&tecti)e pad '&r a 'eyears n&-( C ronic Pain 2ennie has hist&ry &' chr&nic 5&int pain( An appr&priate nursing diagn&sis '&r this pr&%lem is 6Chr&nic Pain related t& physical disa%ility,7 8Tayl&r 9 Ralph, $::E;( This can %e de'ined as, 6an unpleasant sens&ry and em&ti&nal e+perience arising 'r&m actual &r p&tential tissue damage &r descri%ed in terms &' such damageF pain may %e &' sudden &r sl&- &nset, )ary in intensity 'r&m mild t& se)ere, and %e c&nstant &r recurring,7 8Tayl&r 9 Ralph, $::E;( S&me de'ining characteristics &' this diagn&sis includes, 6changes in sleep pattern, altered a%ility t& c&ntinue pre)i&us acti)ities, and 'ear &' in5ury,7 8Tayl&r 9 Ralph, $::E;( 4uring 2ennie.s assessment, she did c&mplain &' ha)ing pain in multiple 5&ints( She als& claimed that she has had 5&int pain '&r se)eral years n&-(

B GERIATRIC ANALYSIS PAPER Fre!uent Falling Since 2ennie has %een e+periencing 're*uent 'alls, her ris/ '&r %eing in5ured is high( An appr&priate nursing diagn&sis '&r 2ennie related t& her 're*uent 'alls is, 6Ris/ '&r In5ury related t& m&t&r de'icits,7 8Tayl&r 9 Ralph, $::E;( This nursing diagn&sis means that 2ennie is, 6at ris/ '&r in5ury as a result &' en)ir&nmental c&nditi&ns interacting -ith the indi)idual.s adapti)e and de'ensi)e res&urces,7 8Tayl&r 9 Ralph, $::E;( S&me de'ining characteristics &' this diagn&sis includes, 6limited m&%ility, unsteady gait, /n&-n 'all pre)i&usly, and urgencyG're*uency &r inc&ntinence,7 8@id@ichigan ?ealth, $:11;( Acc&rding t& the case study, 2ennie had %een ha)ing 're*uent 'alls( Sa'ety is a )ery imp&rtant aspect &' nursing, and the nurse must %e &n high alert '&r clients -h& are at high ris/ '&r 'alling -hile under their care( 2ennie needs g&&d nursing inter)enti&ns %ased &n this diagn&sis t& help pre)ent her 'r&m &%taining and in5ury 'r&m 'alling( Planning Urinary Incontinence The nurse -ill need t& plan e+pected &utc&mes and appr&priate nursing inter)enti&ns '&r 2ennie t& impr&)e her current situati&n -ith her stress urinary inc&ntinence( S&me e+pected &utc&mes '&r 2ennie includes, 2ennie %eing a%le t& manage her pr&tecti)e undergarment independently( An&ther g&al &r &utc&me is the client -ill )er%ali1e understanding &' and dem&nstrate a%ility t& '&ll&- a %ladder pr&gram 8@id@ichigan ?ealth, $:11;( The client -ill als& state that she has increased c&m'&rt 8Tayl&r 9 Ralph, $::E;( <)erall, the ultimate g&al '&r 2ennie is t& e+press satis'acti&n -ith the pr&gress made in &)erc&ming her stress urinary inc&ntinence( C ronic Pain

E GERIATRIC ANALYSIS PAPER <ne &' the g&als '&r 2ennie regarding her chr&nic pain includes the client %eing a%le t& identi'y characteristics &' pain( It is e+pected that 2ennie -ill %e pain 'ree is 'easi%le &r her pain -ill %e managed t& a le)el that she c&nsiders t&lera%le 8@id@ichigan ?ealth, $:11;( 2ennie.s chr&nic pain c&uld als& %e a s&urce &' her sleep depri)ati&n( It -ill %e e+pected that 2ennie -ill ha)e ade*uate sleepGrest a'ter pain is t&lera%le 8Tayl&r 9 Ralph, $::E;( Pain management is an imp&rtant part /eeping client.s healthy and satis'ied( <)erall, the g&al '&r 2ennie is '&r her t& rep&rt achie)ing pain relie' t& a t&lera%le le)el and she states satis'acti&n -ith her pain management regime( Fre!uent Falling Sa'ety is al-ays a t&p nursing c&ncern( Thr&ugh appr&priate nursing inter)enti&ns, it -&uld %e e+pected that the client -ill identi'y 'act&rs that increase p&tential '&r in5ury 8Tayl&r 9 Ralph, $::E;( 2ennie -ill %e a%le t& help identi'y and apply sa'ety measures t& pre)ent in5ury( The ultimate g&al '&r 2ennie is t& remain 'ree &' in5ury, e)en in the e)ent &' a 'all 8@id@ichigan ?ealth, $:11;( Thr&ugh patient educati&n, 2ennie is e+pected t& %e a%le t& '&ll&- all sa'ety precauti&ns set '&rth %y the healthcare pers&nnel( Implementation Urinary Incontinence T& %e a%le t& achie)e the g&alsG&utc&mes set '&rth %y the nurse, pr&per implementati&n must &ccur( 3&r 2ennie t& %e a%le t& achie)e the g&al &' independently managing her pr&tecti)e inc&ntinence pr&duct, she must ha)e c&nstant access t& the pr&tecti)e pads( y pr&)iding 2ennie an assisti)e de)ice '&r her stress inc&ntinence, it -ill pr&tect her s/in, a%s&r% any urine lea/age, and c&ntr&l &d&rs 8Tayl&r 9 Ralph, $::E;(

A GERIATRIC ANALYSIS PAPER 2ennie als& needs t& %e placed &n a timed t&ileting schedule( T&ileting e)ery t-& h&urs -hile a-a/e and t&ileting e)ery '&ur h&urs during sleeping h&urs -&uld %e appr&priate '&r 2ennie( Thr&ugh all e''&rts t& help c&ntr&l her stress urinary inc&ntinence, 2ennie sh&uld 'eel c&m'&rta%le during this pr&cess( 6Enc&uraging the client t& e+press 'eelings and c&ncerns related t& ur&l&gic pr&%lems helps the client '&cus &n a speci'ic pr&%lem,7 8Tayl&r 9 Ralph, $::E;( C ronic Pain Teaching the patient a%&ut the characteristics &' pain can help the client t& manage her pain issues 8Tayl&r 9 Ralph, $::E;( y implementing the use &' medicati&ns and n&n0pharmac&l&gical inter)enti&ns, reducing 2ennie.s pain le)el t& a t&lera%le le)el can %e achie)ed( Trying multiple n&n0pharmac&l&gical inter)enti&ns in c&n5uncti&n -ith medicati&n management usually is the %est e''&rt '&r %etter patient &utc&mes 8@id@ichigan ?ealth, $:11;( A'ter achie)ing a t&lera%le le)el &' pain, the client sh&uld %e a%le t& rest e''ecti)ely( 6Pain management measures sh&uld %e scheduled t& cause little disrupti&n &' sleep and rest,7 8@id@ichigan ?ealth, $:11;( Fre!uent Falling 2ennie needs t& %e taught -hat c&uld p&tentially ma/e her 'all( Thr&ugh teaching 2ennie -hat increases her ris/ &' 'alling, she can a)&id th&se things( Ensuring that 2ennie.s call light is -ithin reach at all times, she -ears n&n0s/id '&&t-ear, and her %ra/es are al-ays l&c/ed &n a -heelchair &r %ed is s&me %asic sa'ety measures 8@id@ichigan ?ealth, $:11;( 2ennie needs t& %e taught sa'ety -hile am%ulating -ith a -al/er and using her assisti)e de)ices( Rem&)al &' &%stacles, /eeping a night light &n -hen it.s dar/, and /eeping all sens&ry assisti)e de)ices -ithin reach are als& help'ul '&r

1: GERIATRIC ANALYSIS PAPER the client 8Tayl&r 9 Ralph, $::E;( 2ennie -ill als& need educati&n regarding the 'acilities p&licies &n 'all pre)enti&n and -hy the sta'' d&es certain things '&r sa'ety( "valuation Urinary Incontinence T& ensure that the inter)enti&ns used '&r 2ennie.s pr&%lems -ere e''ecti)e, an e)aluati&n needs t& ta/e place( y &%ser)ing 2ennie independently using the pr&tecti)e inc&ntinence pads c&rrectly, the nurse can assume that this g&alG&utc&me -as met( 2ennie %eing a%le t& )er%ali1e her t&ileting schedule and dem&nstrating that she remem%ers her scheduled t&ileting times pr&)es that her indi)iduali1ed nursing care plan -as e''ecti)e 8Tayl&r 9 Ralph, $::E;( A'ter 2ennie states that she 'eels m&re c&m'&rta%le regarding her stress urinary inc&ntinence, the nurse can presume that 2ennie has achie)ed her g&als( C ronic Pain T& e)aluate the e''ecti)eness &' the nursing inter)enti&ns '&r 2ennie.s chr&nic pain issues, the nurse needs t& &%ser)e the client( 2ennie sh&uld %e a%le t& )er%ali1e the characteristics &' pain that she is e+periencing( y ha)ing a 'uller understanding &' the type &' pain that she is e+periencing, it -ill ma/e it easier '&r the nurse and &ther healthcare sta'' t& manage( !sing multiple appr&aches t& 2ennie.s pain management -ill help her ha)e %etter pain c&ntr&l( Rep&siti&ning, -arm %lan/ets, and massage are t&&ls that ha)e -&r/ed '&r 2ennie in the past and can %e e)aluated i' they are currently helping her n&-( The nurse can &%ser)e 2ennie t& e)aluate her a%ility t& rest %ased &n her pain c&ntr&l( I' 2ennie is recei)ing a %etter night &' sleep, and can 'all asleep *uic/ly the nurse can presume that 2ennie has achie)ed ade*uate pain c&ntr&l thr&ugh the measures that the nurse pr&)ided(

11 GERIATRIC ANALYSIS PAPER Fre!uent Falling 3&r e)aluating 2ennie.s plan t& pre)ent 'alls, the nurse can m&nit&r the num%er &' times 2ennie has 'allen -ithin a gi)en peri&d &' time( y rec&rding any 'alls that 2ennie

has %een in)&l)ed in, -ill all&- the nurse t& determine i' the inter)enti&ns used -ere appr&priate( The teaching that -as pr&)ided t& 2ennie can als& %e e)aluated thr&ugh )er%ali1ing understanding &' the material taught t& her( y ha)ing 2ennie )er%ali1e the need '&r n&n0s/id '&&t-ear, using her call light '&r assistance, and all &ther inter)enti&ns set in place '&r her sa'ety, 2ennie has a l&-er ris/ that she -ill sustain a 'all -hile under the care &' the nurse(

Policy 2ennie and her 'amily ha)e an unmet need( Since 2ennie has a rather large 'amily, she needs m&re space '&r -hen her 'amily c&mes '&r a )isit &r plans an e)ent that in)&l)es 2ennie( Currently, the 'acility -here 2ennie resides d&es n&t ha)e a p&licy regarding the use the large day r&&m( T& help 'acilitate 2ennie and her 'amily, a nep&licy must %e created t& ensure the c&rrect l&gistics -hile planning an e)ent in the day r&&m %y a resident.s 'amily mem%ers( Purpose The purp&se &' this p&licy is t& &utline the pr&cedure '&r re*uesting the use &' the day r&&m '&r residentG'amily 'uncti&ns '&r large cr&-ds &' pe&ple( Policy

1$ GERIATRIC ANALYSIS PAPER It is the intent &' the 'acility t& create an en)ir&nment '&r residents and their 'amilies that is resident and 'amily &rientated and creates an atm&sphere &' caring and c&mpassi&n( Procedure 1( Either a 'amily mem%er &r the resident must c&ntact that acti)ities department manager '&r a)aila%ility &' the day r&&m( The 'amily mem%er &r the resident must pr&)ide the '&ll&-ing in'&rmati&n '&r the re*uest: date time length &' use num%er &' seating re*uired any special re*uests &r needs '&r the gathering c&ntact in'&rmati&n '&r call %ac/s

$( The acti)ities manager must gi)e n&ti'icati&n &' either appr&)al &r denial -ithin $# h&urs &' re*uest %eing made( The acti)ities manager -ill n&ti'y the c&ntact pers&n in regards t& any c&mplicati&ns that may arise( "( Catering is a)aila%le &n a )ery limited %asis( I' the gathering re*uires this ser)ice the c&ntact pers&n must 'ill &ut a Catering Re*uest 3&rm and send it t& '&&d ser)ices( 3&&d ser)ice must %e n&ti'ied immediately i' the e)ent is cancelled and als& a'ter the e)ent '&r clean up( #( The resident.s 'amily is resp&nsi%le '&r their &-n clean up a'ter the e)ent( Trash %ags -ill %e pr&)ided, %ut it is N<T the resp&nsi%ility &' the h&use/eeping sta'' t& clean up a'ter an e)ent n&t sp&ns&red %y the 'acility(

1" GERIATRIC ANALYSIS PAPER Applica#ility This p&licy applies t& all residents and their 'amilies -h& currently reside -ithin the 'acility( <)erall, caring '&r an elderly client is di''erent than caring '&r an a)erage adult client( y creating a 'ictiti&us plan &' care '&r a client, created a learning &pp&rtunity '&r the student nurse( y using a th&r&ugh assessment, diagn&sing, planning, implementing, and e)aluating the client a nurse can pr&)ide a higher *uality &' care '&r each geriatric client heGshe enc&unters(

1# GERIATRIC ANALYSIS PAPER Re'erences


@ay& Clinic( 8$:1$;( Urinary incontinence ( Retrie)ed 'r&m http:GG---(may&clinic(c&mGhealthGurinary0inc&ntinenceG4S::#:# @id@ichigan ?ealth( 8$:11;( Nursing care plans: pain-alteration in comfort( Retrie)ed 'r&m http:GG---(intranet(grati&tGnursing0care0plans @id@ichigan ?ealth( 8$:11;( Nursing care plans: fall risk-bed entrapment. Retrie)ed 'r&m http:GG---(intranet(grati&tGnursing0care0plans @id@ichigan ?ealth( 8$:11;( Nursing care plans: urinary elimination, alteration-incontinence ( Retrie)ed 'r&m http:GG---(intranet(grati&tGnursing0care0plans Net-&r/ &' Care( 81AAB;( Morse fall scale( Retrie)ed 'r&m http:GG---(net-&r/&'care(&rgGli%raryG@&rse 3all Scale(pd' Nursingtimes(net( 8$:1$, @arch 1>;( Creating a protocol to reduce inpatient falls ( Retrie)ed 'r&m http:GG---(nursingtimes(netGcreating0a0pr&t&c&l0t&0reduce0inpatient0 'allsG=:#$B=1(article PartnersAgainstPain(&rg( 8$:1$;( Pain in the elderly: When someone you lo e is in pain( Retrie)ed 'r&m http:GG---(partnersagainstpain(c&mGpain0caregi)erGelderly(asp+

Pre)enti&n Plus( 8$:1:;( !istory of the "raden scale( Retrie)ed 'r&m


http:GG---(%radenscale(c&mGinde+(htm Tayl&r, C( @(, 9 Ralph, S( S( 8$::E;( Nursing diagnosis reference manual( 8Bth ed(;( Philadelphia, PA: Lippinc&tt Cilliams 9 Cil/ins(

T&uhy, T(, 9 2ett, H( 8$:1$;( #bersole, and !ess$ to%ard healthy aging: !uman needs and nursing response( 8E ed(;( St( L&uis: Else)ier @&s%y(

1= GERIATRIC ANALYSIS PAPER Appendi+ A @&rse 3all Ris/ Sc&re 1( ?ist&ry &' 'allingF immediate &r -ithin " m&nths $( Sec&ndary diagn&sis N& I : Yes I $= N& I : Yes I 1=

$% &%

"( Am%ulat&ry aid

N&ne, %ed rest, -heel chair, nurse I : Crutches, cane, -al/er I 1= 3urniture I ": '( N& I : Yes I $: N&rmal, %ed rest, imm&%ile I : Cea/ I 1: Impaired I $: <riented t& &-n a%ility I : 3&rgets limitati&ns I 1= (

#( IJG?eparin L&c/

=( GaitGTrans'erring

$( (

>( @ental status

)ennie*s +otal Score

,(

Sample Risk -evel Risk -evel N& Ris/ L&- Ris/

.FS Score : 0 $# $= 0 =:

?igh Ris/

K =1

Action G&&d asic Nursing Care Implement Standard 3all Pre)enti&n Inter)enti&ns Implement ?igh Ris/ 3all Pre)enti&n Inter)enti&ns

1> GERIATRIC ANALYSIS PAPER Appendi+ raden S/in Assessment T&&l


S"NS/R0 P"RC"P+I/N a%ility t& resp&nd meaning'ully t& pressure0 related disc&m'&rt &1 Completely -imited !nresp&nsi)e 8d&es n&t m&an, 'linch, &r grasp; t& pain'ul stimuli, due t& diminished le)el &' C&nsci&usness &r sedati&n( <R limited a%ility t& 'eel pain &)er m&st &' %&dy $1 2ery -imited Resp&nds &nly t& pain'ul stimuli( Cann&t c&mmunicate disc&m'&rt e+cept %y m&aning &r restlessness <R has a sens&ry impairment -hich limits the a%ility t& 'eel pain &r disc&m'&rt &)er $ &' %&dy '1 Slig tly -imited Resp&nds t& )er%al c&mmands, %ut cann&t al-ays c&mmunicate disc&m'&rt &r the need t& %e turned( <R has s&me sens&ry impairment -hich limits a%ility t& 'eel pain &r disc&m'&rt in 1 &r $ e+tremities( '1 /ccasionally .oist4 S/in is &ccasi&nally m&ist, re*uiring an e+tra linen change appr&+imately &nce a day( 31 No Impairment Resp&nds t& )er%al c&mmands( ?as n& sens&ry de'icit -hich -&uld limit a%ility t& 'eel &r )&ice pain &r disc&m'&rt(

./IS+UR" degree t& -hich s/in is e+p&sed t& m&isture

&1 Constantly .oist S/in is /ept m&ist alm&st c&nstantly %y perspirati&n, urine, etc( 4ampness is detected e)ery time patient is m&)ed &r turned

$1 2ery .oist S/in is &'ten, %ut n&t al-ays m&ist( Linen must %e changed at least &nce a shi't(

31 Rarely .oist S/in is usually dry, linen &nly re*uires changing at r&utine inter)als 31 6alks Fre!uently Cal/s &utside r&&m at least t-ice a day and inside r&&m at least &nce e)ery t-& h&urs during -a/ing h&urs 31 No -imitation @a/es ma5&r and 're*uent changes in p&siti&n -ith&ut assistance 31 "7cellent Eats m&st &' e)ery meal( Ne)er re'uses a meal( !sually eats a t&tal &' # &r m&re ser)ings &' meat and dairy pr&ducts( <ccasi&nally eats %et-een meals( 4&es

AC+I2I+0 degree &' physical acti)ity

&1 Bed5ast C&n'ined t& %ed(

$1 C air5ast A%ility t& -al/ se)erely limited &r n&n0e+istent( Cann&t %ear &-n -eight andG&r must %e assisted int& chair &r -heelchair

'1 6alks /ccasionally Cal/s &ccasi&nally during day, %ut '&r )ery sh&rt distances, -ith &r -ith&ut assistance( Spends ma5&rity &' each shi't in %ed &r chair

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./BI-I+0 a%ility t& change and c&ntr&l %&dy p&siti&n

&1 Completely Immo#ile 4&es n&t ma/e e)en slight changes in %&dy &r e+tremity p&siti&n -ith&ut assistance

$1 2ery -imited @a/es &ccasi&nal slight changes in %&dy &r e+tremity p&siti&n %ut una%le t& ma/e 're*uent &r signi'icant changes independently

'1 Slig tly -imited @a/es 're*uent th&ugh slight changes in %&dy &r e+tremity p&siti&n independently(

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NU+RI+I/N usual '&&d inta/e pattern

&1 2ery Poor Ne)er eats a c&mplete meal( Rarely eats m&re than a &' any '&&d &''ered( Eats $ ser)ings &r less &' pr&tein 8meat &r dairy pr&ducts; per day( Ta/es 'luids p&&rly( 4&es n&t ta/e a li*uid dietary supplement <R is NP< andG&r maintained &n clear li*uids &r IJIs '&r m&re than = days

$1 Pro#a#ly Inade!uate Rarely eats a c&mplete meal and generally eats &nly a%&ut $ &' any '&&d &''ered( Pr&tein inta/e includes &nly " ser)ings &' meat &r dairy pr&ducts per day( <ccasi&nally -ill ta/e a dietary supplement( <R recei)es less than &ptimum am&unt

'1 Ade!uate Eats &)er hal' &' m&st meals( Eats a t&tal &' # ser)ings &' pr&tein 8meat, dairy pr&ducts per day( <ccasi&nally -ill re'use a meal, %ut -ill usually ta/e a supplement -hen &''ered <R is &n a tu%e 'eeding

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1B GERIATRIC ANALYSIS PAPER


&' li*uid diet &r tu%e 'eeding &r TPN regimen -hich pr&%a%ly meets m&st &' nutriti&nal needs '1 No Apparent Pro#lem @&)es in %ed and in chair independently and has su''icient muscle strength t& li't up c&mpletely during m&)e( @aintains g&&d p&siti&n in %ed &r chair( n&t re*uire supplementati &n(

FRIC+I/N 8 S9"AR

&1 Pro#lem Re*uires m&derate t& ma+imum assistance in m&)ing( C&mplete li'ting -ith&ut sliding against sheets is imp&ssi%le( 3re*uently slides d&-n in %ed &r chair, re*uiring 're*uent rep&siti&ning -ith ma+imum assistance( Spasticity, c&ntractures &r agitati&n leads t& alm&st c&nstant 'ricti&n

$1 Potential Pro#lem @&)es 'ee%ly &r re*uires minimum assistance( 4uring a m&)e s/in pr&%a%ly slides t& s&me e+tent against sheets, chair, restraints &r &ther de)ices( @aintains relati)ely g&&d p&siti&n in chair &r %ed m&st &' the time %ut &ccasi&nally slides d&-n

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