Assignment #2 Clincal Assessment Tools

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  • 8/6/2019 Assignment #2 Clincal Assessment Tools


    Canadian Health Care Academy

    Clinical Assessment Tool

    Riaz Jiwa

    Professor Shelie Pool

    Due December 16, 2010

  • 8/6/2019 Assignment #2 Clincal Assessment Tools


    1. Demonstration of assessment and relationship of this tool to the client

    My client is resident of the Buchanon Lodge in New Westminster B.C, he has been

    diagnosed with progressive dementia. The assessment tool that was used was the Risk

    Assessment & Interventions tools (RAIT). Along with RAIT, the Morse Fall Scale was also

    used to determine my clients fall risk score. There are three sections in which the RAIT is

    divided up in: Assessment, Non Restraint Interventions and Referrals initiated. This

    assessment tool is further broken down into different categories. These categories include:

    cognition, mobility, bowel, bladder, other physiological factors, psychological factors and

    medication. The RAIT also analyzes non restraint interventions. Within each category of the

    assessment, there are subcategories which aid in giving a more precise assessment of a client.

    The reason why I used this tool is because I found it to be meticulous enough when making

    an assessment on my client. It enabled me to get an overall evaluation on my client which

    only made my focus assessment a lot easier. It also narrowed down some of the most

    important problems of my client allowing me to manage my time more efficiently based on

    my clients needs.

    2. Analysis of this toolExplain and demonstrate your understanding of the results.

    To successfully understand and comprehend the results of this assessment tool, I had to go

    back and review each section that was used when making an assessment on my client. Based

    on my assessment of my clients cognition, he forgets his limitations and has poor safety

    awareness. My client also demonstrated cognitive impairment. The non restraint intervention

    that can be used to evaluate my clients cognition is giving him a Mini-Mental Status Exam

    (MMSE). When assessing my clients mobility, it was noticeably apparent and depicted in

  • 8/6/2019 Assignment #2 Clincal Assessment Tools


    my assessment tool that my client had poor sitting posture. The non restraint intervention

    that can help my clients posture is to assess his seating as well as putting in a referral to see

    a physical therapist. When assessing my clients bowel and bladder patterns, I was able to

    place my client under the category of being constipated. The non restraint intervention for

    this is bowel protocol. My client also suffers with urinary incontinence. For this, my client

    can be assisted to the toilet every 2-3 hours.

    Other physiological factors that were used to assess my client and see which of the categories

    applied to my client were pain. A non restraint intervention that fits my client in this area is

    adequate positioning, which would allow optimal comfort as well as administering regular

    analgesics. Psychological factors that I used with RAIT to help myself identify areas that

    were appropriate for my client were that I found him to have a depressed mood and would

    tend to wander and pace around. When looking at the options I had under the non restraint

    interventions category, I found that encouraging socialization and activities, monitoring

    appetite, energy level, weight, mood and allowing familiar possessions/frequent reassurance

    could help with the psychological factors my client is displays. This was the second time I

    was able to check off a section for a referral initiated section. For this client, I suggested

    that he see a psychiatrist.

    For further completion of my assessment, I used the Morse fall scale which determined what

    risk level my client is at for falls. This assessment is broken down into six categories used

    for evaluation. These categories include: history of falling, secondary diagnosis, ambulatory

    aids, intravenous therapy, gait and mental status. Each of these sections is given a yes or

    no. Based on how you respond, each item is given a point value. To successfully give a

    client a score, all the points are added up. A score between 0-64 is a low-moderate risk.

  • 8/6/2019 Assignment #2 Clincal Assessment Tools


    Anything above 65 puts a client at high risk. My client received a score of 76 categorizing

    him as a high risk client.

    3. Incorporating and relating the results of this tool to your nursing practice and

    health promotion. How do the results affect LPN practice?

    I find that using any type of assessment tool when evaluating a client is of immense

    importance for the client and his/her overall well being. Without assessment tools, I believe

    that the scope of nursing practice whether it be for an LNP or RN, would be much more

    difficult. Doing an assessment, allows an LNP to have a somewhat of a baseline of their

    client; allowing him/her to have a foundation of what they will be dealing with when caring

    for certain clients. Not only does it make things easier for an LNP, it also allows better care

    that will be provided for each client; which in the end, leads to better health promotion and

    maintenance. I strongly believe that without assessment tools, LNPs would spend more time

    when evaluating a client and may not be as efficient as when using an assessment tool. In the

    future, I look forward to using various types of assessment tools when evaluating clients. It

    will only allow me to become more familiar for what is out there.