NCM-114-rle-prelim.docx

**NCM 114-RLE** Techniques in Conducting an Assessment\ Techniques in conducting an interview with an older person - Assessment is usually composed of: *history-taking and physical assessment.* - ***[History taking]*** entails an interview on certain aspects of health such as: ADLs, n...

**NCM 114-RLE** Techniques in Conducting an Assessment\ Techniques in conducting an interview with an older person - Assessment is usually composed of: *history-taking and physical assessment.* - ***[History taking]*** entails an interview on certain aspects of health such as: ADLs, nutrition, and specific health concerns. - Matters affecting the interview: orientation to time, person and place, memory state, and understanding of questions. - \- ***[Physical assessment]*** is the process of examining the body for signs and symptoms of disease and other health problems, done through: *inspection, palpation, percussion and auscultation.* - ***[The setting]:** privacy and comfort* - Assessment should take place in a room where privacy, safety, and comfort can be quaranteed. - Provide an atmosphere of confidentiality. - Setting must be well-lighted, not too bright or glaring. - Place must be relatively quiet to facilitate good conversation. - Unnecessary clutter must also be removed from the room to minimize visual distractions , which can cause disorientation. - ***[Establishing rapport]***: *trust and respect* - Establishing good rapport begins with respect. - Trust will be gained once respect is shown towards the older person. - The interviewer should always begin by introducing himself/herself by name and title. - He/she should explain the purpose for meeting with the older person and what will be done during the interview and assessment. - Respect can be shown by addressing the older person formally, and once rapport is established, permission may be asked to use the older person's first name. - The family and significant others should also be part of the plan for establishing rapport. - Certain questions to the older person sometimes need validation from the family and other companions. - Very important to ensure that data gathered are correct and not affected by misunderstanding or confusion. **[Communication Techniques]** - Good communication is at the heart of assessment: it entails understanding of what is said, what is felt and what could help the other person. - An atmosphere of mutual trust and respect should be established before the conduct of assessment. - Factors that may affect communication should be identified at the start of the meeting: presence of sensory and cognitive impairment. **[Communicating With Older Persons With Sensory Impairment]** - At the beginning of the session: - Ask if he/she wears eyeglasses or a hearing aid and request that these be worn during assessment. - Older persons with poor eyesight must be assisted in answering written forms or when moving about the room. - Older persons with hearing impairment, provide non-verbal cues during face-to-face communication. - Some non-verbal cues include the speaker's head movements (acknowledgment, agreement); mouth movements (vowels, consonants); and eye movements (attention, turn-taking). - The person talking to the older person is facing the light, so that non-verbal cues are seen. Guidelines For Communicating With a Hearing Impaired Person 1. Get the older person's attention before speaking. 2. Face him/her directly to provide visual cues like lip-reading, facial expressions and gestures. 3. Speak slowly and clearly in a normal tone of voice, slightly louder but not shouting. 4. Turn off background noise from radio, TV, etc. 5. If the older person does not understand what you are saying, rephrase message rather than repeat word for word. 6. 6\. Signify changes in topic by pausing long enough before proceeding. 7. 7\. Avoid movements while talking. 8. 8\. End the session properly by saying it is ended. 9. 9\. Say "thank you" for his/her time that has spent with you. **Communicating With Older persons With Cognitive Impairment** - Cognitive impairment may be in the form of confusion or dementia. - Confused persons will have difficulty focusing and are likely to be disoriented. - Dementia is marked by memory impairment. - Very important that some questions be verified through the family or significant others. **Guidelines On Communicating With A Confused and/or Demented Person** 1. Invest time in establishing rapport. 2. Always stress who you are and what your job is. 3. Remain pleasant, calm and supportive. 4. Minimize other sounds in the background like clocks, TV, radio, etc. 5. Get the person's attention, by smiling or touching the person's hand. 6. 6\. Maintain physical and eye contact. 7. 7\. Ask the person to do one task at a time, breaking down complicated steps into simpler ones. 8. 8\. Speak slowly and wait for the person to respond. 9. 9\. Keep the meeting short and gauge the response you get. 10. 10\. Expect slight suspicion or being thought of as family member or relative. HEALTH EXAMINATION FOR OLDER ADULTS COMMUNICATION IN OLDER ADULTS - **[Communication ]** - Behavioral skill that allows one to survive in and interact with the world **Communication strategies for older adults:** 1. Introduce yourself 2. Address patient with last name 3. Face the patient directly 4. Sit in front of the patient at eye level 5. Speak slowly 6. Ask open ended question 7. Accommodate patient's needs **Accommodate patient's needs:** 1. Inquire on hearing difficulty 2. Write questions In large font 3. Allow ample time for patient to answer **History taking in older adults** - Three fold purpose of history interview: 1. Establish a trusting and supporting relationship 2. To gather information 3. To offer information RULES IN HISTORY INTERVIEW 1. **[Record chief complaint]** - Old persons report reliable signs and symptoms. They report contains more information than reports of family and other sources. 2. Start assessment with **[open ended questions]** that encourage patient to talk about his state of health 3. Older persons may be **[reluctant]** to report signs and symptoms and may over estimate their healthiness - Due to embarrassment or fear - To avoid medical expenses or discomfort of treatment 4. Use simple sentence to elicit information a. adopt a more direct questions b. For patients with more severe cognitive impairment **confirm** key signs and symptoms with family members or caregivers in the **presence and consent** of the patient. c. Assess for ability for self care, degree of dependence or independence on others. 5. Ask patient's capacity to prefer activity of daily living (ADL) then move to assessing instrumental activities of daily living (IADL). 6. Get a **medication history** for each drug. - Medication's name - Dose - Frequency - Indication - Explore possible polypharmacy - Current use of multiple drugs - Underuse/inappropriate use/non-adherence - Over the counter meds - Vitamins and nutrition supplement and mood altering drugs - Assess medication for drug interactions and interactions 7. Check for probable synergism among multiple risk factors (geriatric syndrome) 8. Ask for smoking and alcohol drinking - Advice patient to quit at each visit - Assess for alcohol drinking ask the following(CAGE): 1. Have you felt the need to **[CUT]** down drinking? 2. Have you ever felt **[ANNOYED]** by the criticism of drinking? 3. Have you ever felt **[GUITLY]** about drinking? 4. Have you ever taken a drink first thing in the morning as **[EYE OPENER]** or to get rid hang over or steady your nerves? 9. Enable the older person about past; reminiscence of previous experience. - Listen to the process of life review to get important insight and support patient as they work through painful feelings and recapture the joys of accomplishment. 10. Talk about wishes on end of life decision. - Older persons may like their health care provider to initiate this discussion before threatening situation develop. Discussion of end of life decision: - Provide information - Explore the patient's preference - Identify decision maker - Convey empathy and support. **COMMUNICATION** - lines of communication must be clear to develop appropriate NCP. - [80% of communication is nonverbal] 1. Do not yell or speak loudly to an older person 2. Try to be at eye level with the patient 3. Minimize background noise 4. Monitor patient's reaction. 5. Touch patient if appropriate or acceptable 6. Supplement verbal interaction with written instructions 7. Keep instructions simple 8. Ask the patient how he/she would like to be addressed. 9. Practice active listening 10. Ask open ended questions 11. Encouraging reminiscing is fruitful since it gives reassurance that they can talk about better times, share personal life history and survival skills. **Barriers to proper communication with the Elderly** 1. Fear of one's own aging 2. Fear of sharing emotion 3. Professional distance 4. Overworked, overscheduled, Lack of proper time to communicate. 5. Unresolved issues in nurses' family about aging relatives leading to insensitivity. **Collaborative Care in older adults** 1. Older adults face a multitude of complex problems 2. Collaborative care enhance problem solving **Factors that affect symptom reporting** 1\. **[Co-morbid illnesses]** - Atypical symptom presentation in the elderly - Disease interaction - Effects of cognitive ability or mood, e.g. symptomatology in patient's with dementia - Stigma or burden associated with certain diseases, e.g. leprosy, tuberculosis or even erectile dysfunction 2\. **[Educational attainment]** - Ability to verbalize or describe any health problems - Ability to identify any changes to one's self as "not normal" - Health perceptions that may modify the symptom presentation 3**[. Local Health beliefs]** - Traditional perception of health"balance" - local health practices modifying symptom reporting 4\. **[Self-perception]** - Need to maintain sense of control **[5. Financial status]** - Financial burden may affect degree of symptom reporting 6\. **[Religion and superstition]** - Fatalism associated with religiosity"bahala na ang Diyos" - Symptoms may actually be related to "kulam", "barang" or "na-nuno" 7**[. Language]** - Differences in perceived meaning of a particular symptom - "manhid" may mean pain or paresthesia or hypesthesia - "hilo" may be interpreted as with "naliliyo", "lumulutang" or "matutumba" - Chest pain may be described as "hirap huminga" or "mabigat ang dibdib" - Familiarity and comfort in using native languages to describe symptoms, e.g. some patients are more vocal when using Bisaya or Chavacano 8\. **[Family and friendship]** - Strength of the relationships within and outside the familycan go both ways (openness to describe symptoms vs. hesitancy) - Family's perception of patient's symptoms may go both ways - Perceived hierarchy of the patient in his current family structure Ways of improving accuracy of symptoms elicited **1. Establish good rapport** - Be respectful and formal - Avoid treating the patient like a child....even if cognitively impaired - Acknowledge the family 2**. Thorough and meticulous history taking/interviewing** - Consider atypical symptom presentation - Explore multiple interpretations of a particular symptom - Consider patient's background and co-morbidities when interviewing - Be wary of inconsistencies 3\. **Use aids in facilitating better communication** - Hearing aids - eyeglasses - Interpreters 4\. **Validate your findings with information from other sources** - Caregivers - Family - friends 5\. **Be wary of barriers hindering symptom reporting** - Language - educational level - family dynamics and financial situation - religion and superstition - patient's self-perception - Physician's own prejudices Potential difficulties in obtaining health information 1. Communication difficulties - Decreased hearing and vision, slow speech. 2\. Under reporting of symptoms - fear of being labeled as complainer, fear of serious illness. 3\. Vague non-specific complaint - Atypical presentation of disease, cognitive impairment 4\. Multiple complaint - Maybe a mask of depression - May mean presence of multiple chronic disease - May mean Social isolation, a crying for help **5. Lack of time** - at least one hour appointment - COMPLETE PHYSICAL ASSESSMENT - Functional Status - Nutrition - Vision - Hearing - Cognition **Important Aspects of Physical Assessment for Older Adults** 1. Focus on functional ability 2. Efficient sequence that minimize repositioning 3. Importance of primary comfort **Opportunities and challenges** a. Focus on healthy successful aging b. Understand and mobilize family and social support c. Determine skills directed to functional assessment (6^th^ vital sign) d. Promote the older persons long term health and safety **Physical assessment** 1. Consider the importance of comfort 2. PA is to be complete only in 40-45 min 3. Balance with patient's endurance and fatigue 4. Consider use of brief screening tools 5. The nurse can divide assessment time into two visits 6. Promote patient's personal comfort which enable taking useful information. **Adjustments to the examining room of an older person** 1. Make sure the room is neither too cool or too warm. - Older persons are sensitive to temperature variations 2. **Ensure brighter lighting.** - To enable patients to see gestures and facial expression of clinicians 3. Seat at patient's eye level and face the person direct. 4. Make sure the room is free of distractive noises 5. Keep pace slow and deliberate 6. Ensure comfort and relaxation because it assures successful physical exam - Minimize changes in position - Proper draping - Explain why you need to change position and **General Survey** - Patient is sitting or standing - Inspect the patient closely from head to toe to from an impression - Determine the patient's state of health, degree of vitality, mood, affect, hygiene and appearance - Note any shortening of height (trunk, flexion of hips and knees changes in posture) VITAL SIGNS - Blood pressure- **BLOOD PRESSURE** - **[Assess for orthostatic hypotension:]** - Let patient sit for 10 min measure BP then let patient stand for 3 minutes then measure BP standing. - A drop in systolic BP of [\>] 20 mmHg. - A drop in systolic BP of [\>]10 mmHg w/ in 3 minutes of standing - An increase in heart rate of 20 beats /min with in 3 minutes standing - Pulse- Apical pulse is most accurate - Elderly is likely to have abnormal rhythm or atrial or ventricular ectopy that may not be transmitted in radial pulse - Asymptomatic rhythm changes are generally benign like postural hypotension, however some arrhythmia may cause syncope. - Respiration-Respiration is unchanged - Temperature - Changes in environmental temperature make patient susceptible to hypothermia - Pain (5^th^ v/s)- Ask for pain: - Right now - Last week - Distinguish pain from chronic pain and acute pain and determine the cause. - functional ability (6^th^ v/s)- Ability to perform tasks and fulfill social roles associated with daily living - Employ performance based assessment use geriatric assessment tools. - Physical function - Cognitive function - Psychological function - Urinary continence - Assess risk for fall - Details about how the fall occurred especially from witnesses - Identify risk for fall - Medical co-morbidities - Functional status - Environmental risk 1. Katz index : - ADL : walking, bathing, dressing, transferring, toileting, feeding, grooming (essential or basic function) - Instrumental Activities of Daily Living (IADLs) - Using telephone - Managing finances - Doing laundry - Doing homework - Preparing meals - Shopping - Managing transportation **2. Timed "get up and go" test** - Have patient sit then walk 10 feet. Normal if done in 20 sec. or less. - Observe the gait, balance ability and transfer 3\. **Gait Speed** (most important test for physical function) - This test is the strongest predictor of future disability and death - Walk in the hallway 50 feet ( should be done in \0.8meters /sec) 4. Life Space 1. How large the patient's space is? 1. Is he confined in the room? 2. Go beyond the block? 3. Assess the level of mobility SKIN AND HEENT - Patient is sitting - Skin : thinning, loss of elasticity, turgor, wrinkling, paleness, opaque or transparent, fragile, presence of purple macules - Due to decrease in vascularization - Nails - Loss of luster, yellowish, thickened - Check for nevi and scars - Check for skin cancer (ABCD test) - Asymmetry - Boarder that are irregular - Color variations - Diameter \> than 6mm - Elevation Refer patient to derma if positive in any of the ABCDE CRITERIA for further evaluation - For bedbound check for decubitus ulcer (erythema, bruising, skin irritation) SCALP/FACE - Check hair and texture - Hair: loses pigment, normal hairloss on trunk, pubic hair, axilla and limbs. - FACE: - Palpate for sinus tenderness - Frontal - maxillary - Cornea, iris, lens. - Conjunctiva, sclera - Check for ptosis - Check lower lids - Note yellowing of sclera - Arcus senilis - Reaction to light and accommodation - Check lens for opacities - Near vision is blurred - Check nasal surface - Check the ear canal - Mouth (check the floor of mouth, side and undersurface of the tongue) Vision test - Ask : difficulty in driving, reading, watching tv - Ask patient to read newspaper, magazine, Snellen chart or jaeger chart - Newspaper : read headline and first line of the newspaper - \>20/40 needs referral Hearing tests - Impairment in hearing is associated with : - Depression - Social withdrawal - Assess for cerumen impaction - Hearing loss : high frequency hearing is affected first (presbycusis) - Refer to formal audiometry when positive of any of the following: - Acknowledge hearing loss when asked. - Unable to perceive what was whispered in a distance of two feet. NECK - Palpate lymph nodes of the antero-cervical area at the clavicle - Palpate the posteror cervical chain - Normally cervical nodes are not palpable but submandibular gland become easier to feel. - Trachea - Palpate the sternal notch and check position of trachea. - Palpate also the thyroid gland BACK, POSTERIOR THORAX AND LUNGS - Note kyphosis - Percuss the lungs and posterior thorax - Assess respiratory excursion - Ascultate posterior thorax and observe: - Rate - Rhythm - Depth - Effort of breathing - Listen to adventitious sounds MUSCULO-SKELETAL, EXTREMITIES, NERVOUS SYSTEM - Still sitting - Examine the temporomandibular joint, neck joint, hand joints, wrist joints, elbows, (inspect, palpate joints and check for ROM) - Shoulder (external and internal rotation) Nutritional status check 1. Visual inspection ( check for muscle wasting of the thighs/shoulder girdle) 2. BMI = 3. Watch for unintentional weight loss greater than 5% in 6 mos. NERVOUS SYSTEM - CRANAL NERVES - UPPER EXTREMITIES MOTOR FUNCTION - Assess for muscle bulk - Check for muscle tone - Assess strength of bicep and tricep muscles and hand grip - Check for pronator rift - Fine motor coordination ANTERIOR THORAC LUNGS AND CVS - Supine - Anterior thorax - Check for COPD (note changes in pulmonary function) 1. Increase in anteroposterior diameter of the chest 2. Pursed lip breathing 3. Dyspnea with talking and minimal exertion - Carotid pulse (palpate and listen for bruits) - Inspect and palpate the anterior chest for heaves, lifts and thrills - Feel the peristernal and epigastric area - Note for the PMI - Auscultate for S1 and S2 and listen is there is an S3 or S4 - Listen for : timing, location, pitch, quality of detected murmurs. - Turn patient to the left lateral decubitus position to listen for S3 or systolic murmurs or mitral stenosis - Let the patient sit and lean forward. Listen at left sternal boarder at the apex to any aortic insufficiency. BREAST, ABDOMEN, PERIPHERAL VASCULAR AND NEUROLOGICAL - BREAST ; Must not be omitted in male patients - Note: size and shape of the breast ( decrease in size, may be flaccid, pendulus - Inspect nipple and areola - Palpate for lumps or mass (do not forget the tail of spence - Palpate the nipple - Other breast - ABDOMEN: - Fat tend to accumulate at lower abdomen near the hips - Inspect the abdominal contour - Listen to bruits - Percuss for tympany and dullness - Deep and light palpation and check patient's expression for tenderness. - Palpate for aortic pulsations in the midline - NORMAL PHYSIOLOGIC CHANGES IN OLDER ADULTS    Cultural sensitive care 1. Always address patients, support people and other health personnel by their last name until you are given permission to use other names. 2. When meeting a person for the first time, introduce your name and your role. 3. Be authentic with people 4. Do not make assumptions about patients, always tactfully ask about what don't understand. 5. Respect ethno-cultural values beliefs and practices even if they differ from your own. 6. 6\. Show respect to the patient's support people. 7. 7\. Make an effort to obtain the trust of patients and co-workers. *Acculturation* is defined as the degree to which individuals have moved from their original system of cultural values and beliefs toward a new system. *ethnogerontology* is the study of the causes, processes, and consequences of race, national origin, culture, minority group status, and ethnic group status on individual and population aging in the three broad areas of biological, psychological, and social aging. - Cultural competence refers to the ability of nurses to understand and accept the cultural backgrounds of clients and provide care that best meets the client's needs. - Examples of cultural competence - nurse's ability to discuss appropriate foods associated with healing with a hospitalized older adult and procure those foods to aide in the healing process. - sharing in prayer with an older adult. - Questioning older adults about their ability to pay for their medications or health care also shows an increased integration of mind, body, and spirit and is an example of cultural competence Characteristics of a culturally competent nurse: 1. Consistently recognizes the great cultural diversity in the population and approaches care of older adults with an open and accepting attitude toward diverse health care practices. 2. Increased respect for culture is evident during assessments, and information is gathered regarding cultural beliefs and practices. 3. A greater integration of mind, body, and spirit as well as the use of alternative and complementary therapies is practiced, and great respect toward the special needs of culturally diverse clients at the end of life is paid. 4. Conducting cultural assessments, utilizing translator services in facilities, and providing culturally competent care are integral components to developing culturally competent institutions and ultimately improving care of older adults. 5. Two common issues in the care of older adults from various cultural backgrounds have to do with the following: 1. use of complementary and alternative therapy (CAM) and 2. end-of-life care. **ASSESSING SPIRITUALITY AND RELIGIOUS PRACTICES** **HOLISTIC CARE** - **Tri-part being: intimate connection of body, mind and spirit:** **1. Physical or Biological dimension** which relates to the world around us; **2. Psychosocial dimension** which relates to self and others and involves our emotions, moral sense, intellect and will; **3. Spiritual dimension** which transcends physical and psychosocial and capacity to relate to a higher being. - **Is spirituality parallel to religiosity?** - **Spirituality means......Part of being human that seeks meaningfulness through intra-, inter-, and transpersonal connection (Reed, 1991).** - **Involves a belief in a relationship with some higher power, creative force, divine being, or infinite source of energy. (God).** **Origin of our Spirituality** - "And the Lord God formed man of the dust of the ground, and breathed into his nostrils the breath of life; and man became a living being." **Genesis 2:7(NKJV)** **Religiosity means.......** - **Religious orientations and involvement**; includes experiential, ritualistic, ideological, intellectual, consequential, creedal, communal, doctrinal, moral, and cultural dimensions. - **Religious practices** related to life events as birth, transition from childhood to adulthood, marriage, illness and death. - **Religious rules of conduct** influenced by culture such as dress, food, social interaction, menstruation and sexual relationship. - **Nightingale** instilled ***spirituality*** as the very heart of human nature -- **FUNDAMENTAL to HEALING**. **Spiritual Health or Spiritual Well-Being** - It is manifested by a feeling of being "**generally alive**, **purposeful,** and **fulfilled**." (Ellison, 1983) - A **way of living**, a lifestyle that views and lives life as purposeful and pleasurable, that seeks out life-sustaining and life-enriching options to be chosen freely at every opportunity, and that sinks its roots deeply into spiritual values and /or specific religious beliefs." According to Pilch (1988) **Characteristics Indicative of Spiritual Well-Being:** - \- Sense of inner peace - \- Compassion for others - \- Reverence for life - \- Gratitude - -Appreciation of both unity and diversity - \- Humor - \- Wisdom - \- Generosity - \- Ability to transcend the self - \- Capacity for unconditional love **Spiritual Distress** - A challenge to the spiritual well-being or to the belief system that provides strength, hope, and meaning to life: - **Physiologic problems**: medical diagnosis of a terminal or debilitating disease, experiencing pain, experiencing the loss of a body part or function, or miscarriage or stillbirth; - **Treatment-related concerns**: blood transfusion, abortion, surgery, dietary restrictions, amputation of a body part, or isolation; - **Situational factors**: death or illness of a significant other, inability to practice one's spiritual rituals, or feelings of embarrassment when practicing them (Carpenito, 2002). **NANDA International (2003): Characteristics of Spiritual Distress:** - -Expresses lack of hope, meaning and purpose in life, forgiveness of self - \- Expresses being abandoned by or having anger toward God - \- Refuses interaction with friends, family - \- Sudden changes in spiritual practices - \- Requests to see a religious leader - \- No interest in nature, reading spiritual literature **SPIRITUAL NEEDS** - **QUESTIONS:** 1\. Who are those individuals with spiritual needs? 2\. Are all clients have spiritual needs? 3\. Why nurses need to identify indications of clients' spiritual needs? - **All clients have needs that reflect their spirituality:** - Need for love - Need for hope - Need for trust - Need for forgiveness - Need to be respected and valued - Need for dignity - Need for meaning to the fullness of life - Need for values - Need for creativity - Need to connect with a God or Higher Power or a Being greater than oneself - Need to belong to a community **FRAMEWORK: NURSING PROCESS** - ASSESSING- Data about client's general history (religious preferences or orientation); through nursing history; and clinical observations of the behaviour, verbalizations, mood, and so on. - **NOTE**: Nurses should never assume that a client follows all practices of the client's stated religion. - **General Questions -- all clients:** **Assessment Interview Guides** 1\. Are there any particular religious practices important to you? If so, could you please tell me about them? 2\. How will being here interfere with your religious practices? 3\. How is your faith helpful to you? In what ways is it important to you right now? 4\. In what ways can I support your spiritual needs? For example, would you like me to read your prayer book/bible to you? **5.** Would you like a visit from your spiritual counsellor or the hospital chaplain? What are your hopes and source of strength right now? What comforts you during hard times? **CLINICAL ASSESSMENT** **1. ENVIRONMENT**. Does the client have a bible, other prayer book, devotional literature, religious symbols, or religious get well card? Does church send altar flowers or Sunday bulletins? **2. BEHAVIOUR.** Does client appear to pray before meals or at other times or read religious literature? Does client have nightmares or sleep disturbances or express anger at religious representatives? **3.** **VERBALIZATION**. Does client mention God or a higher power, prayer, power, faith, the church or religious leader or religious topics? Does client ask for a visit from clergy? Does client express fear of death, concern with the meaning of life or inner conflict? **4**. **RELIGIOUS** beliefs, concerns about a relationship with the deity, questions about the meaning of existence or the meaning of suffering, or about moral or ethical implications of therapy? **5.** **AFFECT AND ATTITUDE**. Does client appear lonely, depressed, angry, anxious, agitated, apathetic, or pre-occupied? **6.** **INTERPERSONAL RELATIONSHIPS**. Who visits? How does client respond to visitors? Does a minister come? How does client relate to other clients and nursing personnel? - DIAGNOSING - The **North American Nursing Diagnosis Association** (**NANDA International, 2003**) recognizes three diagnoses related to spirituality: **1**. **SPIRITUAL DISTRESS** is impaired ability to experience and integrate meaning and purpose in life through a person's connectedness with self, others, art, music, literature, nature, or a power greater than oneself. **2.** **READINESS FOR ENHANCED SPIRITUAL WELL-BEING.** It recognizes that spiritual well being is the ability to experience and integrate meaning and purpose in life through a person's connectedness with self, others, art, music, literature, nature, or a power greater than oneself. \- Some people respond to adversity with an increased sensitivity to spirituality or spiritual maturation. **3. RISK FOR SPIRITUAL DISTRESS: By NANDA** (2003) as being " at risk for an altered sense of harmonious connectedness with all of life in the universe in which dimensions that transcend and empower the self may be disrupted." \- This diagnosis may be appropriate for a client who presently shows no indication of this disruption, yet a nurse may fail to intervene. - PLANNING - Identify interventions to help the client achieve the overall goal of maintaining or restoring spiritual well-being so that spiritual strength, serenity, and satisfaction are realized. 1\. Help client fulfill religious obligations. 2\. Help client draw on and use inner resources more effectively to meet the present situation. 3\. Help client maintain or establish a dynamic, personal relationship with a supreme being in the face of unpleasant circumstances. **4.** Help client find meaning in existence and the present situation. **5**. Promote a sense of hope. **6.** Provide spiritual resources. - IMPLEMENTING - Nursing actions to help clients meet their spiritual needs: **1. PROVIDING PRESENCE** - **PRESENCING** -- being present, being there, or just being with client. - Frederiksson, noted, that presencing is a "**gift of self**" given by the nurse who maintains an attitude of attentiveness toward the client. Thus, nurses who listen attentively to client yet fail to give of self diminish their effectiveness. **FEATURES of PRESENCING**: a\. Giving of self in the present moment. b\. Being available with all of the self. c\. Listening, with full awareness of the privilege of doing so. d\. Being there in a way that is meaningful to another person. **Levels of Presencing, (Osterman and Schwatz-Barcott)** **Four ways of being present for clients:** **1. PRESENCE** ( when a nurse is physically present but not focused on the client). **2. PARTIAL PRESENCE** (when a nurse is physically present and attending to some tasks on the client's behalf but not relating to the client on any but the most superficial level). **3.** **FULL PRESENCE** ( when a nurse is mentally, emotionally and physically present intentionally focusing on the client) **4.** **TRANSCENDENT PRESENCE** (when a nurse is physically, mentally, emotionally and spiritually present for a client; involves a transpersonal and transforming experience) - **PRESENCING** is often the best and sometimes the only intervention to support client who suffers under circumstances that medical interventions cannot address. It can be most beneficial. Rather than worrying about saying or doing "the right thing" nurses should focus on being fully present (Taylor, 2002). **2.** **SUPPORTING RELIGIOUS PRACTICES** - Nurses need to consider specific religious practices that will affect nursing care, such as client's beliefs about birth, death, dress, diet, prayer, sacred symbols, sacred writings, and holy days. **3**. **ASSISTING CLIENT WITH PRAYER** \- **Prayer** involves a sense of love and connection, (Dossey) as well as a reaching out. - **Prayer** offers a means for someone to talk to, a mechanism for expressing care, and a sense of serenity and connection with something greater. (as cited in O'Brien, 2011). - Hence, it has many health benefits and healing properties. - Private or group prayer - Nurse ensures quiet environment and privacy. **4**. **REFERRING CLIENTS FOR SPIRITUAL COUNSELLING** - \- One situation the nurse may encounter is client refusal of necessary medical intervention because of religious tenets. - EVALUATING - Using the measurable desired outcomes developed during the planning stage, the nurse collects data needed to judge whether client goals and outcomes have been achieved. Functional Status - Ability of the older person to perform ADLs necessary for self-care. There are three levels of ADLs- from basic to advanced. - *Basic level* is known as **Physical ADLs** which involve personal care tasks: feeding, grooming, being continent (bowel/urinary), transferring, toileting, dressing and bathing. - *Intermediate level* refers to the **Instrumental ADLS,** include tasks necessary for independent functioning in the community: cooking, cleaning, doing laundry, shopping, using the telephone and means of transportation, taking medicines and managing money. - *Advanced ADLs*, refers to social, occupational or recreational activities, that greatly affect the older person's quality of life such as volunteering in church activities or community organizations, involvement in livelihood projects, minding grandchildren, or playing board games or bingo. Rationale for Functional Assessment - Assessment of the older person's level of function is used as ***basis for the plan of care**.* - The ***objective*** of the care plan is either to ***improve** or **maintain*** the ***functional status*** of the older person. An older person with arthritic fingers will hope to regain ability to perform basic self-care tasks such as feeding and grooming. A functional assessment before intervention helps establish a ***baseline*** on which to gauge improvement. Standardized Functional Assessment Tests - ***Katz Index Of Independence in Activities of Daily Living*** - Most ***appropriate instrument*** to assess ***functional status*** as a ***measurement** of the **patient's ability to perform ADLs independently.*** - Tool to ***detect problems in performing ADLs and to plan care accordingly.*** - The index ***ranks adequacy of performance*** in the ***six functions*** of: ***bathing***, ***dressing, toileting, transferring, continence and feeding.*** - A ***scoring scheme-*** a score of ***6*** indicates ***full function***, ***4*** indicates ***moderate impairment and 2 or less indicates severe functional impairment.*** - The tool is used extensively as a ***flag*** signaling functional capabilities of older adults in clinical and home environment. Barthel Activities of Daily Living Index - Consists of ***10 items*** that ***measure*** a ***person's daily functioning specifically the activities of daily living and mobility.*** - *Ten items are*: - Feeding - Grooming - Bathing - Dressing - Continence of bowel - moving from wheelchair to bed and return \- transferring to and from a toilet - walking on level surface - going up and down the stairs \- continence of bladder Uses: - [Determine a baseline level of functioning.] - [Monitor improvement in activities of daily living over time.] Scoring Scheme: - The person receives a score based on ***whether*** they ***have received help while doing the task.*** - The ***scores*** for each of the items ***are summed to create a total score***. - The ***higher the score*** the ***more "independent***" the person***. Independence*** means that the ***person needs no assistance at any part of the task.*** - If a person does about ***50% independently***, then the "***middle***" score would apply. The Barthel ADL Index: Guidelines 1. The index should be used as a record of *what a patient does*, *not* as a record of *what a patient could do.* 2. The *main aim* is to establish degree of independence from any help, physical or verbal, however minor and for whatever reason. 3. 3\. The *need for supervision* renders the patient *not* independent. 4. 4\. Patient's performance should be established using the best available evidence: a)asking the patient, friends/relatives and nurses are the usual sources; b) direct observation and common sense are also important. However, *direct testing is not needed*. 5. 5\. Usually, the patient's performance over the processing 24-48 hours is important, but occasionally longer periods will be relevant. 6. 6\. Middle categories imply that the patient supplies over *50%* of the effort. 7. 7\. Use of aids to be independent is allowed.  Instrumental Activities of Daily Living (IADL) - Using Telephone - Traveling - Shopping - Preparing Meals - Housework - Taking Medicine - Managing Money  Psychological Function - *Psychological function* involves assessment of *cognitive* and *affective* status. \- ***Cognitive status*** is evaluated through assessment of: attention, memory, orientation,, calculation, language, visual-spatial ability, concentration, abstraction , and judgment. - *Affective status* is assessed by determining whether there is: sadness, loneliness, anxiety, or depression. - A common standardized tool in assessing cognitive status is: *Folstein Mini-Mental State Examination (MMSE).* - A standardized tool on depression is: *Geriatric Depression Scale (Short Form).* Geriatric Depression Scale (Short Form)  Social Function Assessment - *Social function* is measured by the: a)social network, and b) social support of the older person. - *Social network* refers to the web of relationships that the person has around him/her, including family, relatives and friends who give support in various moments. - *Social support* includes the emotional, instrumental, or financial aid obtained from the social network. Social Functioning Scale - *Social Functioning scale* is a measure of social function among older persons. - Studies reveal that a low level of social interaction is associated with poor mental functioning and health problems. - Maintaining some level of social contact is an important determinant of health. - file:///C:/Users/Dell/Downloads/social-functioning-scale.pdf