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L2 Falls and PAIN assessment.docx

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Dalhousie University
NURS 2200
Cynthia Barkhouse Mckeen

Falls Assessment and Medication Reconciliation Objectives 1. Demonstrate knowledge of interviewing skills private, quiet, comfortable setting introduce self, state goals for interview pose open-ended & direct questions listen to patient in attentive, nonjudgmental manner; choose appropriate vocabulary. 2. Demonstrate knowledge of components of health history record reason for seeking care in person’s own words elicit critical characteristics to describe patient’s symptom(s) gather pertinent data for past history, family history, & systems review identify self-care behaviors & risk factors from functional assessment. 3. Record data accurately & as a reflection of what the patient believes the true health state to be. 4. Develop skills needed to work in teams, improving outcomes in clinical practice: communication, negotiation, leadership & collaboration. 5. Collaborate to research drug information & complete a medication review/reconciliation form, using the case study to collect information and generate list of options for addressing any gaps in information. 6. Develop prioritized list of interventions/action plan (e.g. contact prescriber/physician to discuss concerns regarding medication – identify specific concerns). 7. Assess risk for falls, complete the Morse Assessment tool using the clinical case study. Medication Reconciliation  A process of assessing a patient’s medication list and comparing it with the prescriber’s admission/transfer/discharge list of medications  Discrepancies are identified and addressed, if appropriate  Documentation is essential, providing rationale for changes  Medication Reconciliation  Evidence indicates inaccurate communication of information at transition points responsible 50% of med errors & 30% of adverse drug events  Implementation of Med Rec policies improves patient safety & reduces potential for error  Team effort involving patient, family, prescribers & pharmacists (hospital & community), nurse Falls Prevention: Fall Categories: 1. Accidental Falls  14% of falls  Caused by environmental hazards  Prevention interventions designed to ensure environment is free from hazards 2. Unanticipated Falls  8% of all falls  E.g. of causes of these falls: fainting, seizures, pathological factors such as pain or fracture  Likelihood of this occurring again  Interventions aimed at reducing the risk of the fall if event reoccurs (i.e. teach how to rise from lying to sitting to standing if orthostatic hypotension cause of fall) 3. Anticipated Physiological Fall  78% of all falls  6 factors contribute to these falls 1. Comorbidities/Polypharmacy 2. Previous fall (in past 12 months) 3. Weak or impaired gait 4. Lack of realistic assessment of own abilities 5. IV or saline lock 6. Use of ambulatory aids Morse Fall Risk Assessment  Completed on all patients admitted to CDHA facilities  Collaborative, interdisciplinary approach is used  Regular reassessment of patient’s fall risk, and with changes in patient condition Falls Prevention  Evidence indicates that an interdisciplinary approach to assessment of risk for falls is best practice  Nsg diagnosis: high risk for injury related to history of falls, use of psychotropic meds, unsteady gait, lower extremity weakness, cognitive impairment  Goal is to have no injuries related to falls while in hospital  Interventions are on back of Morse Assessment tool  Include interventions for all patients, more for those at moderate risk  Additional interventions for those at high risk  Bring internet access/texts/library access for clinical practice guidelines to IPHE Health History Categories: 1. Biographical data 2. Reason for seeking care 3. Present health or history of present illness 4. Past history 5. Family history 6. Review of systems 7. Functional assessment (include independent living skills (ILS)) Purpose of the Health History  Provides subjective data base  Identifies clients’ strengths  Identifies clients’ actual & potential health problems (80% of diagnosis from physical assessment comes from correct data collected in health history)  Purpose of the Health History  Identifies support systems  Identifies learning needs  Identifies discharge needs  Identifies referral needs Types of Health Histories Complete: ambulatory care, follow-up, admission to acute care Focused: acute care, inpatient change in condition Method used depends on: 1. Client’s condition 2. Amount of time Medical & Nursing History Medical: Focuses on diagnosis & treatment of illness Nursing: Focuses on diagnosis and treatment of human responses to health problems Biographical Data  Name  Ethno-cultural background:Primary language  Address/phone  Contact  Religion  Age, birth date  Marital status  Birthplace  Education  Gender  Occupation  Source of history & reliability Reason for Seeking Care, Present Health, Hx present illness Reason for seeking health care:  Ask person with many concerns to focus on what prompted them to seek help now  Record in patient’s own words, use quotations  Avoid medical diagnosis, record descriptive symptom e.g. ―chest pain for past 2 hrs‖ Present Health /Hx of Present Illness Well person: short statement about general health Ill person:  Chronologic record of reason for seeking care from first symptom  Do not bias data with comments, collect all data first  PQRSTU (pg. 73 in text) – to record critical characteristics of any symptom  Provocative or palliative; quality or quantity; region or radiation; severity scale; timing; understand patient’s perception Past Health History  Childhood illnesses  Hospitalizations & surgeries  Serious injuries  Chronic illnesses  Allergies  Medications  Recent travel  Immunizations Family History  Heart disease  High BP  Stroke  Diabetes  Blood disorders  Arthritis  Cancers  Allergies  Obesity  Substance abuse  Mental illness  Kidney disease  Infectious diseases Interviewing Older Adults  Assume competent unless mental status previously established  Interview alone, then with family if older adult requests  Glasses, hearing aids  Decrease background noise  Increase lighting  Address by Mr. Mrs. Miss & last name – more informal with permission as rapport is established Review of Systems General Health Status: LISTEN, direct & open-ended  Fatigue  Night sweats  Weakness  ILS (ADL)  Exercise intolerance  Unexplained fevers  Present weight  # colds/illnesses per yr Integument  Skin diseases  Change in mole  Pruritis  Lesion changes  ―itching‖  Hair texture  Excessive bruising  Any changes  Excessive dryness or moisture  baldness  Pigment/color changes  Nail changes  Rashes Head & Neck  Headaches  Swollen glands  Injury/surgery  Lumps & scars  Syncope/vertigo  Concussion/LOC  ―Dizzy spells‖  Pain with movement  ―fainting‖  Nodes/masses  Stiff neck Eyes  Corrective wear  Last eye exam  Itching/tearing  Eye injury  Eye Pain  Drainage/floaters  Blurred vision  Halos  Loss of vision  Redness, swelling, discharge  Blind spots  Flashing lights  Light sensitivity  Cataracts/glaucoma Ears  Last hearing test  Ear pain  Sensitivity to sounds  Tinnitus  Ear infections  ―Ringing‖  Fullness in ears  Drainage  Vertigo  characteristics  Use of hearing aids  Ear wax problems  Hearing Nose & Sinuses  Epistaxis (nosebleeds)  characteristics  Postnasal drip  Snoring  Sneezing/allergies  Nasal obstruction  Illicit drug use  Polyps, fracture, deviated septum  Rhinitis (―Runny‖ nose)  Sinus pain  Frequent colds  Anosmia  Any discharge Mouth & Throat  Sore throat  Last dental exam  Bleeding gums  Tonsillectomy  Hoarseness  Mouth pain  Lesion  Toothache  Difficulty chewing  Change in voice  Dysphagia  Change in taste  Difficulty swallowing  Dental health  Dentures/bridges Respiratory  Difficult breathing  SOB  History of disease: asthma, bronchitis, emphysema, TB, pneumonia  History of smoking  Cough/sputum  Noisy respirations  Last chest x-ray Cardiovascular  Chest pain  Palpitations  Murmurs  Skipped beats  Hypertension  Dizzy spells  Cold/numb extremities  Swelling  Hair loss on legs  Sores  Results of ECG Breasts, Female/Male Reproductive Health Covered elsewhere in curriculum Gastrointestinal  Loss of appetite  Indigestion  Food intolerance  Use of antacids  Pyrosis (―heartburn‖)  Nausea/vomiting  Dysphagia  Hematemesis  Liver/gallbladder disease  Flatulence  Regular BM  Jaundice  Weight changes  Colour of stool  Diarrhea/constipation  Hemorrhoids or fistula  Use of laxatives Genitourinary  Pain on urination  Kidney stones  Urgency, nocturia  Burning/frequency  Hesitancy  Incontinence  Urine colour  History of UTIs  hematuria  Kidney diseases  Kidney infections Musculoskeletal  Fractures/sprains  (independent livingskills/activitiesof  Weakness daily living)  Limited ROM  Muscle cramps  Back pain  Joint swelling, pain, stiffness  Osteoporosis  Joint deformity  ILS/ADL problems  Arthritis/gout Neurological  Any Hx of seizure, stroke, fainting, blackouts?  Any weakness, tic, tremor, paralysis or coordination problems?  Any numbness/tingling?  Any memory problems, confusion or disorientation?  Any anxiety, mood changes, Hx of depression, hallucinations or mental illness? Endocrine  Endocrine disorders  Hair/skin changes  Diabetes  Weight changes  Polyuria, polydipsia, polyphagia  Goiter  Increased thirst  Hormones  Heat/cold intolerance Immune/Hematologic  Anemia  Recurrent infections  Cancer
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