Expert Answer:Patient Medical History Assessment Tool By Confusi

  

Solved by verified expert:Older Adult Simulation Scenarios. In order to get the most out of the experience, please make sure to read all of the scenarios so that you are familiar with the patients that you will be caring for.Please write out your responses and submit to the simulation faculty at the start of the simulation experience:
What considerations from the patient’s history could have an impact in the plan of care for these patients?

Consider the assessment tools that you learned about in the classroom; which would be applicable in the scenarios and explain why? Review SPICES, PAIN AD and the Confusion Assessment Method (CAM) tools.
Background for Scenario 1: Lucy is an 80 year old female admitted three days ago after sustaining a left femoral neck hip fracture from a fall at home. She lives alone and reported that she was going outside to grab the mail when her legs gave out. Neighbors witnessed the fall and called 911. Upon arrival to the Emergency Department she was in a lot of pain and unable to bear weight on the left side. During the fall she also sustained an abrasion to the left elbow and forearm. She was admitted under Dr. Spencer from Orthopaedic surgery who repaired the hip with a total hip arthroplasty two days ago. Lucy has a medical history of HTN, CAD, HF, Osteoarthritis and early onset dementia. She is 5’3’’ and weighed 145 pounds on admission. She has an allergy to Penicillin and Morphine Background for Scenario 2Harold is a 73 year old male admitted two days ago with hyperglycemia; his blood sugar was 480mg/dl on arrival. He lives alone, but was complaining to a family member over the phone that he felt lightheaded and weak, so they called 911. Paramedics brought him to the closest ED, but since his primary care provider is not associated with our hospital, his admitting physician is Dr. Shah. He was initially admitted to the ICU and put on an insulin drip, but has been transitioned to subcutaneous insulin and transferred to our medical surgical floor yesterday afternoon. Harold has a medical history of Type II DM, retinopathy, peripheral neuropathy, HTN, osteoarthritis and an appendectomy when he was 23. He is 5’9’’ and weighed 215 pounds yesterday. He has no allergies to medication..Background for Scenario 3Emily is an 80-year-old female being admitted thru the emergency department with a diagnosis of rule out urinary tract infection.She lives at home with her son who called 911 because the patient had become more lethargic and confused over the past 2 days.Emily has a history of a left –sided mastectomy with left axillary node dissection 10 years ago and lymphedema to her left arm.She also has a history of dementia with episodes of delirium during past hospitalizations.Emily is 5’6” tall and weighs 102 pounds.She is alert to person but is disoriented to place and time.Her lungs sounds were clear and she cannot remember the last time she had a bowel movement.
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general assessment series
Best Practices in Nursing
Care to Older Adults
From The Hartford Institute for Geriatric Nursing, New York University, College of Nursing
Issue Number 1, Revised 2012
Editor-in-Chief: Sherry A. Greenberg, PhD(c), MSN, GNP-BC
New York University College of Nursing
Fulmer SPICES: An Overall Assessment Tool for Older Adults
By: Terry Fulmer, PhD, APRN, GNP, FAAN, Bouve College of Health Sciences, Northeastern University
and Meredith Wallace, PhD, APRN, CS, Fairfield University School of Nursing
WHY: Normal aging brings about inevitable and irreversible changes. These normal aging changes are partially responsible
for the increased risk of developing health-related problems within the elderly population. Prevalent problems experienced
by older adults include: sleep disorders, problems with eating or feeding, incontinence, confusion, evidence of falls, and skin
breakdown. Familiarity with these commonly-occurring disorders helps the nurse prevent unnecessary iatrogenesis and
promote optimal function of the aging patient. Flagging conditions for further assessment allows the nurse to implement
preventative and therapeutic interventions (Fulmer, 1991; Fulmer, 1991).
BEST TOOL: Fulmer SPICES is an efficient and effective instrument for obtaining the information necessary to prevent
health alterations in the older adult patient (Fulmer, 1991; Fulmer, 1991; Fulmer, 2001). SPICES is an acronym for the
common syndromes of the elderly requiring nursing intervention:
S is for Sleep Disorders
P is for Problems with Eating or Feeding
I is for Incontinence
C is for Confusion
E is for Evidence of Falls
S is for Skin Breakdown
TARGET POPULATION: The problems assessed through SPICES occur commonly among the entire older adult population.
Therefore, the instrument may be used for both healthy and frail older adults.
VALIDITY AND RELIABILITY: The instrument has been used extensively to assess older adults in the hospital setting, to
prevent and detect the most common complications (Fulmer, 2001; Lopez et al., 2002; Pfaff, 2002; Turner, J. et al., 2001;
NICHE). Psychometric testing has not been done.
STRENGTHS AND LIMITATIONS: The SPICES acronym is easily remembered and may be used to recall the common
problems of the elderly population in all clinical settings. It provides a simple system for flagging areas in need of further
assessment and provides a basis for standardizing quality of care around certain parameters. SPICES is an alert system and
refers to only the most frequently-occurring health problems of older adults. Through this initial screen, more complete
assessments are triggered. It should not be used as a replacement for a complete nursing assessment.
Permission is hereby granted to reproduce, post, download, and/or distribute, this material in its entirety only for not-for-profit educational purposes only, provided that
The Hartford Institute for Geriatric Nursing, New York University, College of Nursing is cited as the source. This material may be downloaded and/or distributed in electronic format,
including PDA format. Available on the internet at www.hartfordign.org and/or www.ConsultGeriRN.org. E-mail notification of usage to: hartford.ign@nyu.edu.
MORE ON THE TOPIC:
Best practice information on care of older adults: www.ConsultGeriRN.org.
Fulmer, T. (2007). How to try this: Fulmer SPICES. AJN, 107(10), 40-48.
Fulmer, T. (1991). The Geriatric Nurse Specialist Role: A New Model. Nursing Management, 22(3), 91- 93.
Fulmer, T. (1991). Grow Your Own Experts in Hospital Elder Care. Geriatric Nursing, March/April 1991, 64-66.
Fulmer, T. (2001). The geriatric resource nurse: A model of caring for older patients. American Journal of Nursing, 102, 62.
Kagan, S.H. (2010). Geriatric syndromes in practice: Delirium is not the only thing. Geriatric Nursing, 31(4), 299-304.
Lopez, M., Delmore, B., Ake, J., Kim, Y., Golden, P., Bier, J., & Fulmer, T. (2002). Implementing a Geriatric Resource Nurse
Model. Journal of Nursing Administration, 32(11), 577-585.
Nurses Improving Care for Healthsystem Elders (NICHE) Program at the Hartford Institute for Geriatric Nursing,
http://www.nicheprogram.org/.
Pfaff, J. (2002). The Geriatric Resource Nurse Model: A culture change. Geriatric Nursing, 23(3), 140-144.
Turner, J. T., Lee, V., Fletcher, K., Hudson, K., & Barton, D. (2001). Measuring quality of care with an inpatient elderly
population: The geriatric resource nurse model. Journal of Gerontological Nursing, 27(3), 8-18.
Fulmer SPICES: An Overall Assessment Tool for Older Adults
Patient Name:
Date:
SPICES
EVIDENCE
Yes
No
Sleep Disorders
Problems with Eating or Feeding
Incontinence
Confusion
Evidence of Falls
Skin Breakdown
Adapted from Fulmer, T. (1991). The Geriatric Nurse Specialist Role: A New Model. Nursing Management, 22(3), 91- 93.
© Copyright Lippincott Williams & Wilkins, http://lww.com.
general assessment series
Best Practices in Nursing
Care to Older Adults
A series provided by The Hartford Institute for Geriatric Nursing,
New York University, College of Nursing
EMAIL
hartford.ign@nyu.edu HARTFORD INSTITUTE WEBSITE www.hartfordign.org
www.ConsultGeriRN.org
CLINICAL NURSING WEBSITE
general assessment series
Best Practices in Nursing
Care to Older Adults
From The Hartford Institute for Geriatric Nursing, New York University, College of Nursing
Issue Number 13, Revised 2012
Editor-in-Chief: Sherry A. Greenberg, PhD(c) MSN, GNP-BC
New York University College of Nursing
The Confusion Assessment Method (CAM)
By: Christine M. Waszynski, MSN, APRN, BC, Hartford Hospital
WHY: Delirium is present in 10%-31% of older medical inpatients upon hospital admission and 11%-42% of older adults
develop delirium during hospitalization (Siddiqi, House, & Holmes, 2006; Tullmann, Fletcher, & Foreman, 2012). Delirium is
associated with negative consequences including prolonged hospitalization, functional decline, increased use of chemical and
physical restraints, prolonged delirium post hospitalization, and increased mortality. Delirium may also have lasting negative
effects including the development of dementia within two years (Ehlenbach et al., 2010) and the need for long term nursing
home care (Inouye, 2006). Predisposing risk factors for delirium include older age, dementia, severe illness, multiple comorbidities, alcoholism, vision impairment, hearing impairment, and a history of delirium. Precipitating risk factors include
acute illness, surgery, pain, dehydration, sepsis, electrolyte disturbance, urinary retention, fecal impaction, and exposure to high
risk medications. Delirium is often unrecognized and undocumented by clinicians. Early recognition and treatment can improve
outcomes. Therefore, patients should be assessed frequently using a standardized tool to facilitate prompt identification and
management of delirium and underlying etiology.
BEST TOOL: The Confusion Assessment Method (CAM) is a standardized evidence-based tool that enables non-psychiatrically
trained clinicians to identify and recognize delirium quickly and accurately in both clinical and research settings. The CAM
includes four features found to have the greatest ability to distinguish delirium from other types of cognitive impairment. There
is also a CAM-ICU version for use with non-verbal mechanically ventilated patients (See Try This:® CAM-ICU).
VALIDITY AND RELIABILITY: Both the CAM and the CAM–ICU have demonstrated sensitivity of 94-100%, specificity of
89-95% and high inter-rater reliability (Wei, Fearing, Eliezer, Sternberg, & Inouye, 2008). Several studies have been done to
validate clinical usefulness.
STRENGTHS AND LIMITATIONS: The CAM can be incorporated into routine assessment and has been translated into several
languages. The CAM was designed and validated to be scored based on observations made during brief but formal cognitive
testing, such as brief mental status evaluations. Training to administer and score the tool is necessary to obtain valid results.
The tool identifies the presence or absence of delirium but does not assess the severity of the condition, making it less useful to
detect clinical improvement or deterioration.
FOLLOW-UP: The presence of delirium warrants prompt intervention to identify and treat underlying causes and provide
supportive care. Vigilant efforts need to continue across the healthcare continuum to preserve and restore baseline mental status.
MORE ON THE TOPIC:
Best practice information on care of older adults: www.ConsultGeriRN.org.
The Hospital Elder Life Program (HELP), Yale University School of Medicine. Home Page: www.hospitalelderlifeprogram.org/
CAM Disclaimer: www.hospitalelderlifeprogram.org/private/cam-disclaimer.
Useful websites for clinicians including the CAM Training Manual:
www.hospitalelderlifeprogram.org/pdf/TheConfusionAssessmentMethodTrainingManual.pdf
Cole, M.G., Ciampi, A., Belzile, E., & Zhong, L. (2009). Persistent delirium in older hospital patients: A systematic review of frequency and prognosis. Age and
Ageing, 38(1), 19-26.
Ehlenbach, W.J., Hough, C.L., Crane, P.K., Haneuse, S.J.P.A., Carson, S.S., Randall Curtis, J., & Larson, E.B. (2010). Association between acute care and critical
illness hospitalization and cognitive function in older adults. JAMA, 303(8), 763-770.
Inouye, S.K. (2006). Delirium in older persons. NEJM, 354, 1157-65.
Inouye, S., van Dyck, C., Alessi, C., Balkin, S., Siegal, A. & Horwitz, R. (1990). Clarifying confusion: The confusion assessment method.
Annals of Internal Medicine, 113(12), 941-948.
Maldonado, J.R. (2008). Delirium in the acute care setting: Characteristics, diagnosis and treatment. Critical Care Clinics, 24(4), 657-722.
Rice, K.L., Bennett, M., Gomez, M., Theall, K.P., Knight, M., & Foreman, M.D. (2011, Nov/Dec). Nurses’ recognition of delirium in the hospitalized older adult.
Clinical Nurse Specialist, 25(6), 299-311.
Siddiqi, N., House, A.O., & Holmes, J.D. (2006). Occurrence and outcome of delirium in medical in-patients: A systematic literature review. Age and Aging, 35(4),
350-364.
Tullmann, D.F., Fletcher, K., & Foreman, M.D. (2012). Delirium. In M. Boltz, E. Capezuti, T.T. Fulmer, & D. Zwicker (Eds.), A. O’Meara (Managing Ed.), Evidencebased geriatric nursing protocols for best practice (4th ed., pp 186-199). NY: Springer Publishing Company, LLC.
Vasilevskis, E.E., Morandi, A., Boehm, L., Pandharipande, P.P., Girard, T.D., Jackson, J.C., Thompson, J.L., Shintani, A., Gordon, S.M., Pun, B.T., & Ely, E.W. (2011).
Delirium and sedation recognition using validated instruments: Reliability of bedside intensive care unit nursing assessments from 2007 to 2010. JAGS,
59(Supplement s2), S249-S255.
Wei, L.A., Fearing, M.A., Eliezer, J., Sternberg, E.J., & Inouye, S.K. (2008). The confusion assessment method (CAM): A systematic review of current usage. JAGS,
56(5), 823-830.
Permission is hereby granted to reproduce, post, download, and/or distribute, this material in its entirety only for not-for-profit educational purposes only, provided that
The Hartford Institute for Geriatric Nursing, New York University, College of Nursing is cited as the source. This material may be downloaded and/or distributed in electronic format,
including PDA format. Available on the internet at www.hartfordign.org and/or www.ConsultGeriRN.org. E-mail notification of usage to: hartford.ign@nyu.edu.
The Confusion Assessment Method Instrument:
1. [Acute Onset] Is there evidence of an acute change in mental status from the patient’s baseline?
2A. [Inattention] Did the patient have difficulty focusing attention, for example, being easily distractible, or having
difficulty keeping track of what was being said?
2B. (If present or abnormal) Did this behavior fluctuate during the interview, that is, tend to come and go or increase
and decrease in severity?
3. 
[Disorganized thinking] Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant
conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?
4. 
[Altered level of consciousness] Overall, how would you rate this patient’s level of consciousness? (Alert [normal];
Vigilant [hyperalert, overly sensitive to environmental stimuli, startled very easily], Lethargic [drowsy, easily aroused];
Stupor [difficult to arouse]; Coma; [unarousable]; Uncertain)
5. 
[Disorientation] Was the patient disoriented at any time during the interview, such as thinking that he or she was
somewhere other than the hospital, using the wrong bed, or misjudging the time of day?
6. [Memory impairment] Did the patient demonstrate any memory problems during the interview, such as inability to
remember events in the hospital or difficulty remembering instructions?
7. [Perceptual disturbances] Did the patient have any evidence of perceptual disturbances, for example, hallucinations,
illusions or misinterpretations (such as thinking something was moving when it was not)?
8A. [Psychomotor agitation] At any time during the interview did the patient have an unusually increased level of motor
activity such as restlessness, picking at bedclothes, tapping fingers or making frequent sudden changes of position?
8B. [Psychomotor retardation] At any time during the interview did the patient have an unusually decreased level of motor
activity such as sluggishness, staring into space, staying in one position for a long time or moving very slowly?
9. [ Altered sleep-wake cycle] Did the patient have evidence of disturbance of the sleep-wake cycle, such as excessive
daytime sleepiness with insomnia at night?
The Confusion Assessment Method (CAM) Diagnostic Algorithm
Feature 1: Acute Onset or Fluctuating Course
This feature is usually obtained from a family member or nurse and is shown by positive responses to the following
questions: Is there evidence of an acute change in mental status from the patient’s baseline? Did the (abnormal) behavior
fluctuate during the day, that is, tend to come and go, or increase and decrease in severity?
Feature 2: Inattention
This feature is shown by a positive response to the following question: Did the patient have difficulty focusing attention,
for example, being easily distractible, or having difficulty keeping track of what was being said?
Feature 3: Disorganized thinking
This feature is shown by a positive response to the following question: Was the patient’s thinking disorganized or
incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from
subject to subject?
Feature 4: Altered Level of consciousness
This feature is shown by any answer other than “alert” to the following question: Overall, how would you rate this patient’s
level of consciousness? (alert [normal]), vigilant [hyperalert], lethargic [drowsy, easily aroused], stupor [difficult to arouse],
or coma [unarousable])
The diagnosis of delirium by CAM requires the presence of features 1 and 2 and either 3 or 4.
© 2003 Sharon K. Inouye, MD, MPH
Inouye, S., van Dyck, C., Alessi, C., Balkin, S., Siegal, A. & Horwitz, R. (1990). Clarifying confusion: The confusion assessment
method. Annals of Internal Medicine, 113(12), 941-948.
general assessment series
Best Practices in Nursing
Care to Older Adults
A series provided by The Hartford Institute for Geriatric Nursing,
New York University, College of Nursing
EMAIL
hartford.ign@nyu.edu HARTFORD INSTITUTE WEBSITE www.hartfordign.org
www.ConsultGeriRN.org
CLINICAL NURSING WEBSITE
dementia series
Best Practices in Nursing
Care to Older Adults
with dementia
From The Hartford Institute for Geriatric Nursing, New York University, College of Nursing,
and the Alzheimer’s Association
Issue Number D2, Revised 2012
Editor-in-Chief: Sherry A. Greenberg, PhD(c) MSN, GNP-BC
New York University College of Nursing
Assessing Pain in Older Adults with Dementia
By: Ann L. Horgas, RN, PhD, FGSA, FAAN, University of Florida College of Nursing
WHY: Pain in older adults is very often undertreated, and it may be especially so in older adults with severe dementia. Changes in a patient’s ability
to communicate verbally present special challenges in treating pain, since self-report is considered the gold standard of pain assessment.
As with all older adults, those with dementia are at risk for multiple sources and types of pain, including chronic pain from conditions such as
osteoarthritis and acute pain from surgery, injury, and infection. Untreated pain in cognitively impaired older adults can delay healing, disturb sleep
and activity patterns, reduce function, reduce quality of life, and prolong hospitalization.
BEST TOOLS: Several tools are available to measure pain in older adults with dementia. Each has strengths and limitations (Herr, Decker, & Bjoro,
2006). The American Medical Directors Association has endorsed the Pain Assessment in Advanced Dementia Scale (PAINAD) (Warden, Hurley, &
Volicer, 2003).
The American Society for Pain Management Nursing’s Task Force on Pain Assessment in the Nonverbal Patient recommends a comprehensive,
hierarchical approach to pain assessment that incorporates the following steps:
• Ask older adults with dementia about their pain. Even older adults with mild to moderate dementia can respond to simple questions about
their pain.
• Use a standardized tool to assess pain intensity, such as the numerical rating scale (NRS) (0-10) or a verbal descriptor scale (VDS) (Herr, Coyne,
et al., 2006). The VDS asks participants to select a word that best describes their present pain (e.g., no pain to worst pain imaginable) and may
be more reliable than the NRS in older adults with dementia.
• Use an observational tool (e.g., PAINAD) to measure the presence of pain in older adults with dementia.
• Ask family or usual caregivers as to whether the patient’s current behavior (e.g., crying out, restlessness) is different from their customary
behavior. This change in behavior may signal pain.
• If pain is suspected, consider a time-limited trial of an appropriate type and dose of an analgesic agent. Thoroughly investigate behavior
changes to rule out other causes. Use self report and observational pain measures to evaluate the pain before and after administering the
analgesic.
TARGET POPULATION: Older adults with cognitive impairment who cannot be assessed for pain using standardized pain assessment instruments.
Pain assessment in older adults with cognitive impairment is essential for both planned or emergent hospitalization.
VALIDITY AND RELIABILITY: The PAINAD has an internal consistency reliability ranging from .50 (for behavior assessed at rest) to .67 (for
behaviors assessed during unpleasant caregiving activities). Interrater reliability is high (r = .82 – .97). The PAINAD scale is reported to have
moderate to high concurrent validity, depending on whether the patient was at rest or involved in pleasant or unpleasant activities (r = .76 – .95).
STRENGTHS AND LIMITATIONS: Pain is a subjective experience and there are no definitive, universal tests for pain. For patients with dementia, it
is particularly important to know the patient and to consult with family and usual caregivers.
BARRIERS to PAIN MANAGEMENT in OLDER ADULTS with DEMENTIA: There are many barriers to effective pain management in this
population. Some common myths are: pain is a normal part of aging; if a person doesn’t verbalize that they have pain, they must not be
experiencing it; and that strong analgesics (e.g., opioids) must be avoided.
There are also some barriers to using the PAINAD to assess pain in this population. First, the PAINAD has not been evaluated for use in people with
mild to moderate dementia. Second, some of the PAINAD scale behaviors, such as breathing, may be difficult to assess. Third, some studies have
reported that the brevity of the PAINAD (only 5 items) makes it easy to complete, but limits its utility by restr …
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