AINEES

• Assessment or standardized tools are an efficient and effective way to collect and organize data from the assessment of an older adult
• Assessment tools provide a means for tracking data over time and identify changing conditions that will assist the nurse planning care
• Functional assessment is an integral component of holistic assessment. It measures the person’s ability to fulfill responsibilities and perform self-care tasks such as ADLs and IADLs
• ADLs are activities of daily living. They include eating, toileting, ambulation, bathing, dressing and grooming
• iADLs are instrumental activities of daily living. They include cleaning, shopping, yard work, managing a budget, using the phone and preparing meals
• AINEES: autonomy, integument, nutrition, elimination, evaluate mental status and behaviors, sleep
• Autonomy includes mobilization and functioning
• Mobilization (autonomy) includes the decreased ability to perform ADLs, challenges to collect data, hygiene and sense of responsibility, assistance for those with cognitive deficits
• Strategies to promote autonomy are rising the bed rails, having a clear flood and lowering the bed all the way down. It is important to have a safe and secure environment
• The Morse Fall Scale is used to test for mobilization (autonomy)
• Nursing implications for mobilization:

  • Assessing the use or potential use of adeptive and assistive devices
  • Actual or potential use of mobility aids and adaptive equipment (grab bars and elevated toilet seat)
  • Consult physical, occupational and rehabilitation therapists
• Functioning (autonomy) includes screening for decline in ADLs and IADLs, barriers to collect data, lifestyle and hygiene choices
• Strategies for functioning (autonomy) are encourage mobilization, walking and other movements
• The Barthel index and Katz index of independence in ADLs are used to assess functioning (autonomy)
• Nursing implications for functioning

  • Determine the level of assistance needed
  • Measure changes over time
  • Identify factors that influence functional abilities
  • Provide a basis for planning care
• Integument is the risk of pressure injuries and skin tears since older adults have more fragile skin. It includes screening for risk of wounds, assessment of anatomical areas of risk, repositioning and exercices
• Interventions are necessary for those with a score of less than 18 on the Braden Scale
• The assessment for integuments is the Braden Scale
• Nursing implications for integuments:

  • assess tissue viability
  • identify patients at risk
  • determine the degree of risk of developing a pressure ulcer and apply preventive measures (eg: therapeutic surface)
  • reposition at risk sites every 8h
  • assess wounds and create treatment plan
• Nutrition and hydration include the BMI, assistance needed to eat and drink, ability to chew, swallow and complete oral hygiene, amount of supplements, eating habits, fluid restrictions, loss of appetite, availability of food and snacks
• The nutritional assessment consists of an interview, physical examination, anthropometrical measurements and biochemical analysis (blood and urine test)
• It is important to consider the risk of dehydration when assessing nutrition due to a decreased thirst sensation, decreased mobility, certain medications and a decreased kidney function
• A mini nutritional assessment is used to assess nutrition
• Elimination is an umbrella term for bowel movement and urine elimination
• For bowel movements, assess frequency and characteristics of stool, ability to use the toilet, incontinence, food and liquid intake, mobilization, positioning, laxatives and access to toilet or assistive devices
• For urine elimination, assess frequency, intake and output, UTI, BPH, use of briefs or catheter, autonomy and movement, availability of toilet
• Interventions for elimination are bladder training and promotion or a schedule for pts unaware of a need to urinate
• Elimination: Older adults are more at risk for incontinence, bladder distention, constipation or fecaloma
• Nursing implications for elimination

  • document patient’s bowel movements and daily living habits
  • bathroom schedule
  • promote and maintain continence and independence
• Screening for delirium is done every 4-8h in acute care or post op or every 24h for general patients
• For delirium, assess pre-hospital state, past history of cognitive problems, meds or cerebral accidents as well as potential physical causes
• Interventions for delirium: maintain an approach that favors orientation ans security, basic needs to look after and objects to reorient to keep a calm, safe and secure area
• Nursing pan for delirium or agitation

  • Ensure glasses and hearing aids are worn
  • Reorient patient to time, place and person
  • Encourage presence and participation of loved ones
  • Coordinate care to facilitate sleep
  • Minimize noise and light
• Use the confusion assessment method instrument (CAM) to evaluate for mental behaviors
• For sleep, assess regular sleep patterns and rest times, sleep aids, satisfaction, disorders (nocturia, orthopnea, sleep apnea, anxiety, incontinence)
• To improve sleep, organize nursing care, decrease fluids before bed, attend to basic needs and limit noise and light