Assignment #2 Clincal Assessment Tools

8/6/2019 Assignment #2 Clincal Assessment Tools

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Canadian Health Care Academy

Clinical Assessment Tool

Riaz Jiwa

Professor Shelie Pool

Due December 16, 2010



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 tool…Explain 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 client’s 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 client’s cognition is giving him a Mini-Mental Status Exam

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



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

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

a physical therapist. When assessing my client’s 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.



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.

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Assignment #2 Clincal Assessment Tools