[Aidy]

I need help with the order of this assessment. I have a 75 y/o male in rehab following a series of falls, loss appetite, more confused, reduced mobility, nocturia. I have to perform an assessment on him but I'm confused to what order I should priortize his assessments as everything interrelates. The isses I'm assessing are:

1. Communication.
2. Alzheimers (Mental assessment & depression).
3. Physical assessment (Temp, Pulse, BP etc).
4. Mobility fall risk/Braden scale.
5. Activites of daily living.
6. Incontinence/Nocturia.
7. Appetite/nutrition.
8. Social need.
9. Home needs.

Any advice appreciated - as far as I can see Alzheimers can affect all, incontinence could cause falls due to lack of sleep and reduced appetite due to daytime naping. Lack of appetite can reduce lean tissue mass which could also cause his falls. Incontincence could make pressure sores more likely. Round and round I go - Any help plz!!!

Kind regards
Aidy

[Aidy]

I can't believe that not one person has replied, or is it you all don't have a clue?


Kind Regards

[mom and nurse]

Hi Ady - First of all welcome to allnurses. If your Alzheimer's patient is in a rehab hospital, there will probably be an admission package with the areas you mentioned to assess. Ask if one of the nurses at the hospital can give you a copy. It's a group of papers with the questions you need to ask on an initial assessment of a patient.

I recommend you start of with the usual vital signs. Temperature, pulse, Blood pressure, respiration, (check his pulsox....is he on Room air?)

Is his breathing normal or abnormal? Are his lungs clear?

Does he know his name? does he know where he is? Can he tell you the year? Can he respond to your questions? Can he follow a simple command?

Do a skin assessment based on the Braden Scale, especially check his sacral area and heels for ulcers if he is not mobile.

Check his heart rate, pedal pulses, capillary refill

Is he continent or incontinent of urine and bladder. Does he have bowel sounds?

In the United States we use "FIM scores" to rate the activities of daily living on a scale of 1 - 7 with 7 being totally independent.

Can he transfer from a bed to a wheelchair and vice versa or is he bed bound?

If you can get ahold of the admission package for your rehabilitation hospital it should have standard questions to ask the patient and the family and give you a guide to follow.

These are just a few things to check. Others may want to add on. But remember to ask the hospital where you are working for their admission package which should give you a guide to follow. Hope this helps.

mom and nurse

[Aidy]

I am actually a student at a university in Ireland (woo) and this is an assignment not a placement. I now have most of the things you have stated but everything seems intertwined and its just confusing on what to assess first. I started with the Glasgow Coma Scale which assess the CNS and all major obs. I moved onto to communication which is at the heart of assessment - and diagnosed that the client is unable to give consent to his wife did so. I then looked at the person alzheimers who is in mid stages. I then assessed mobility, Morse fall risk and Braden scale as he was in as a result of falls. Incontinence of urine was next as he might not be getting a good nights sleep, hence the falling. Appetite was next which could be a result of him napping during the day or forgetting that he's hungry due to the alzheimers. I then moved on to social and home assessment needs - PHEW!

I think thats sort of right but any more advice is always welcome

xo