Comprehensive

Assessment
The Keys to Unlocking
the Mystery of
Assessment

Objective
s:

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.

Assessme
nt of nursing home
Assessments

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

Medication
s
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 WellBeing

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/Le
gal

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

Financi
al
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/relievin
g 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

comprehensiv
e assessment
is the key to
developing
effective,
individualized
resident care