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Thorough assessments are essential for building individualised care plans.

When performing a head to toe assessment, a person-centred approach encourages greater communication between nurse and the person being assessed.

A head to toe assessment is a systematic review of a person’s health status and is the subject of an Aged Care Channel program, Assessment: Head to Toe.

“When conducting an assessment, the over-riding principle is to examine and observe closely, using a systematic approach. You’ll always be looking for signs of abnormality, infection or disease,” says Lesa Sutherland, a registered nurse and education support manager, who will introduce the program.

It is called systematic because it starts at the head and progresses to the feet in a very rudimentary way, integrating different body system assessments within each region. This clustering of assessment helps reduce the number of times the person has to change position during the examination.

Despite its systematic approach, the collection of both objective and subjective data is critical. The experts encourage staff to involve family and carers who are familiar to the person with dementia. They’re often the key to making the assessment a success.

Subjective data refers to information that comes directly from the older person and includes how they’re feeling or what kind of pain they are experiencing. Asking open-ended questions can help to obtain this information.

Information that is observed and measured by staff such as temperature, heart rate or respiratory patterns provides necessary objective data, contributing to an overall picture of health.

“As you assess the person, note perceived needs, goals, lifestyle and expectations as well as their health status. Taken together, these elements will help us build the best individualised care plan for them,” says Tamara Macleod, a nurse practitioner with UnitingCare Ageing, who demonstrates key steps.

Starting an assessment in the morning when the older person’s energy levels are higher, may improve the overall ease of the examination.

Conducting an assessment utilises the broad spectrum of human senses, says associate professor Paul Middleton.

“It utilises a range of techniques which include inspection, which is a visual look for abnormalities; palpation, which is feeling for swelling, lumps and texture; percussion, or tapping to get a sense of density and resonance within the body; and auscultation, or listening to sounds produced within the body.”

There are three kinds of scenarios when a complete assessment is necessary. These include assessment on admission, a non-scheduled assessment following a change in behaviour, and a routinely scheduled assessment determined by a person’s overall health.

Assessment on admission is critical because it gives staff baseline data, which they can use to measure any future decline in health.

“In all three cases, we analyse the data that’s gathered and decide whether the older person’s care or medication plan needs to be revised. We might also use the data to support ACFI claims that help pay for their care.”

BOLD: Preparing for a head to toe assessment

Prior to completing an assessment, it is essential to obtain the person’s informed consent. This means explaining the assessment process to them so they know exactly what to expect.

The program advises seeking consent from family or a guardian if someone’s incapable of giving consent.

Confidentiality is also important. Personal data can only be discussed on a need to know basis with other members of the care team.

Once consent is obtained, staff will need to access any pre-admission documents, including any personal, social or medical histories, medical discharge summaries, X-rays, medications and their aged care client record. This information will help ensure an assessment covers all aspects of a person’s health status, including allergies and special care requirements.

There are several strategies staff can employ to offer a more person-centred approach.

The first is conducting the examination in a quiet, private room that is free from distraction. Comfortable lighting and temperature can also put people at ease. If a person wears glasses or a hearing aid, make sure they wear them.

“For those with pain, begin approximately 30 to 60 minutes after their medication, when they are most able to follow your instructions. Use the same principal for those with Parkinson’s disease when they are most alert and comfortable,” says Macleod.

“Also try to work at the older person’s eye level if possible. This will help you keep eye contact – if that’s culturally appropriate – and show you’re interested in what they’re saying.” McCleod adds that it also helps people with sight or hearing impairment.

As older people tire easily, the assessment can also be carried over two or more sessions.

The program encourages staff to use an interpreter who can explain medical terminology, rather than a family member.

Be mindful of the person’s modesty. “Drape the parts of their body that you’re not assessing at the time. And consult the care plan for cultural sensitivities and preferences. Some cultures prohibit men touching women and vice-versa,” says Macleod.

BOLD: Conducting the assessment

“Remember to wash your hands before starting any kind of examination. Always follow organisational procedures regarding infection control and manual handling,” says Macleod. Protective gloves should also be worn when appropriate.

It is important to note the person’s posture, co-ordination and clarity of speech. A urinalysis should also be conducted, along with recordings of their height, weight and glucose levels.

Observe for any injuries requiring immediate attention and note any lack of body symmetry or obvious abnormalities that might indicate an underlying physical or cognitive impairment, says Middleton.

BOLD: Vital signs assessment

Staff should assess the person’s vital signs including their radial pulse, temperature, blood pressure and respiration rate.

Beginning with the person’s skin and scalp, their body systems must then be examined in greater detail.

Observe the range of motion in the person’s neck, their oral health and as well as their ears and eyes for neurological and physical abnormalities or disease. The person’s visual fields, visual acuity and extraocular muscles should also be tested.

“Asking the person to clench their teeth together and puff out their cheeks will assess the motor portions of the facial and trigeminal nerves. Facial muscles should move symmetrically and smoothly. If not, there may be a neurological deficit that requires further investigation,” says Macleod.

Check the cranium and jaw for tenderness or inflammation. The program suggests carrying out a focus assessment if the person reports pain in any part of the body.

Abdominal obstruction, poor circulation and co-ordination are significant warning signs. Examine the person’s limbs and extremities by assessing the mobility and strength of their arms and legs.

Lastly, review the findings with the person’s care team to determine what further action is needed. The individual’s care plan may require alterations to accommodate their changing health status.

END INFO: For more information on this program go to www.agedcarechannel.com.au

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