NSE 121 CLINICAL ASSESSMENT TOOL (CAT)

Student Name: Priyanshi Kataria Date: 17th March, 2024

Client Initials: MK Room#: 222 Age:88 Code Status: allow natural death
Date of Hospitalization: 07/18/2023 focused on comfort and do
not attempt CPR
Allergies: Penicillins Date of surgery (if Level of education:
applicable): NA Anesthesiologist
Allergy precautions in place: Thorough
Documentation, Alert Tags

Religious and/or cultural considerations: NA

Spoken language? English

Purpose of admission: Admitted from acute care hospital, for delirium and to have better quality of life

Primary medical and/or surgical diagnosis (explain)

Primary medical concern for visit to acute care was in the context of urinary tract infection and
acute kidney injury
He has completed a course of antibiotics for urinary tract infection likely for long term care application.
It was believed that he was probably at his baseline level of disorientation due to a history of dementia becau
was eating well and had regular bowel movements.

Surgery or invasive procedures while in hospital if applicable (explain): NA

Past medical Hx & co-morbid health problems/ complications

History of depression with suicide attempt, sexually inappropriate behaviour in retirement home.
He had a mild acute kidney injury.

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Medical consultations:

1. Hypotension-induced temporary loss of consciousness in the circumstances of a urinary tract infection wit
potential autonomic dysfunction. No arrhythmia was found during work-up.There is no suspicion for epilept
activity on history of throughout his admission.
2. Urinary tract infection
His urinalysis was suggestive of infection and his urine culture grew E. Coli that was pansensitive.
3. Multifactorial hypoactive delirium probably occurred in the setting of underlying cognitive impairment.
Electrolyte supplementation was used as needed to optimize the resident. He was started on laxatives for bow
regimen.

Goal(s) of care:

1. Reduce High-Risk Behaviors: Aimig for fewer episodes of socially/sexually inappropriate behaviors and r
care by
the next review date.
2. Minimize Impact of Responsive Behaviors: Working towards ensuring the resident's responsive behaviors
less impact on themselves or others by the next review date.
3. Support ADLs and Improve ADL Abilities
4. Support Coping with Functional Changes: Facilitating a supportive environment where the resident feels a
coping with changes in functional abilities.
5. Enhance Confidence in Mobility: Through interventions and support, help the resident express improved
confidence regarding their mobility.
6. Reduce Modifiable Fall Risk Factors (e.g., blood sugar control, improved balance, muscle strength)
7. Improve Urinary Continence: Seting a goal to improve the resident's level of urinary continence from freq
incontinent to occasionally incontinent.

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Treatments and procedures; nursing interventions from Kardex/care plan/pathway (e.g. include isolation
precautions and safety precautions; IV therapy; wound care; oxygen; postop care; etc.):
⦁ Antibiotic Therapy:Administered IV ceftriaxone from July 10, 2023.
Stepped down to oral cephalexin until July 19, 2023.
⦁ Isolation Precautions:
Implemented due to COVID-19 positivity in January 2024.
Follow standard and droplet precautions; use PPE appropriately.
⦁ Fall Precautions:
High-risk fall precautions due to mobility issues.
Use non-slip socks, ensure call bell within reach, and maintain a clutter-free environment.
⦁ Behavioral Precautions:
Monitor for signs of agitation, delirium, and inappropriate behaviors.
Employ de-escalation techniques and provide a calm, safe environment.
⦁ Incontinence Management:
Incontinent of both bladder and bowel.
Implement scheduled toileting, use absorbent products, and maintain skin integrity through regular cl
and barrier creams.

(Client narrative): Interprofessional interventions (e.g. Physiotherapy,

Client’s illness experience and perception of Occupational Therapy, Speech Language Pathologist,
reason for hospitalization Social Worker, Chaplaincy)
Greatest fear as reported by SDM is poor Quality Appointments (if any)
of life of the resident
The percieved reason of hospitalization by the Creative arts therapy, music therapy, horticulture therap
daughter is to treat pain, and therefore agrees to and recreation
treatments such as antibiotics, if it will improve Reason for referral
his QOL but no treatments to prolong life 1. Improve ADL
i.e the resident is under do not resuscitate/do not 2. cognitive impairment communication
intubate (DNR/DNI) status 3. lift the mood
goals of care is investigations may be considered if 4. behavioural eg: wandering and non compliance
benefit to quality of life and comfort is anticipated 5. improve social relationships
6. pain supportive resources and palliative care
supportive resources

Impact of illness on self (Self concept, Role,

Family):
Weakened social relationships, unable to perform
activities of daily living by self, has a behavioural
impact

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Primary Survey Approach
1. Airway
⦁ Can the client speak? yes
⦁ Can the client breath? yes
⦁ Are they coughing? no
⦁ Are they choking? no

2. Breathing
⦁ What is the client's respiratory rate? High, low or normal for the client?
Respiratory rate:16 breaths/min ; which is normal
⦁ What is the oxygen saturation? High, low or normal for the client?
O2 Sat: 96% ; which is normal
⦁ Is the client having any difficulty with breathing?
Client is regularly monitored for respiratory distress while feeding
⦁ What is the client's chest movement like?

3. Circulation
⦁ What are the client's vital signs? High, low or normal for the client?
The clients vitals have been observed to be in a normal range.
⦁ What is the capillary refill?
The clolour returned in 3 seconds which is normal fnding.
⦁ Is the skin warm or cool to touch?
The client's skin is warm to touch.
⦁ What is the client's urine output like?
The client's urine output is unmeasured due to incontinence of both bladder and bowel.
4. Disability
⦁ Is the client alert?
Not completely alerted. tends to fall off to sleep
⦁ Is the client confused?slightly
⦁ Is the client able to respond appropriately to questions?
Responds with a nod to " Dr. krewstow", is able to nod in order to say yes to a question.
⦁ Can the client be clearly understood?
The client has lost understanding ability due to dementia.
⦁ Is the client experiencing any pain?
The client is not experiencing any pain.

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5. Exposure
⦁ What is the client's temperature? High, low or normal for the client?
The client's temperature is equal bilaterally. It was measured to be 35.6°C Tympanically which is norm
⦁ Does the client have any signs of trauma or bleeding?no
⦁ Is the client’s skin intact?
The client's skin is not fully intact, as there are abrasions and bruises observed. Additionally, there is a n
proper lotioning to moisturize dry skin.
⦁ If the client has any dressings, are they dry and intact?no
⦁ Does the client have any tubes (oxygen, intravenous, urinary catheter) and are they in place?no

Systems
Assessment Data
Overall well- ADL
being/needs Eating: supervision needed, diet regular
Personal hygiene: extensive assistance required
Oral care: daily cleaning of teeth or dentures by staff
need assistance for bath prefers showers Wednesday
Dressing, transfers: extensive assistance required
prefers street clothes
no special equipment
Presence of pain No pain

Vital signs Weight : 69.2 Kg

Blood Pressure: 100/55 mmHg
Temperature: 35.6°C
Pulse: 62 bpm
Respirations: 16 breaths/min
02 Sat: 96.0%
Height: 152.0 cm
Pain Level: 0

Neurological/mental The resident is not oriented to place time, but responds with a nod to " Dr.
health / musculoskeletal krewstow"
Daughter stated that her father was primarily bedridden, although he was not
aware of the time or place

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Cardiovascular s1 s2 heard properly, no murmurs

Peripheral vascular and no concern

skin some abrassions and bruises observed, need proper lotioning to moisturize the dry
skin

Respiratory no crackles no wheeze

POSITIONed and MAINTAIN head with chin tilted slightly towards chest when
providing meals and medications.
Provided more time for resident to chew. Observed for full rise/fall of neck before
offering another bite to ensure open airways and no choking.

Gastrointestinal abdo soft non tender no masses

(abdomen; bowel
elimination)

Genitourinary deferred

Activity/rest drowsy, asleep in bed, opened eyes to voice but not answering questions

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Other things to check if ⦁ memory problems
applicable (tubes, ⦁ vision: adequate no glasses
assistive devices,
⦁ hearing: minimal difficulty when not in quiet setting no hearing aid used
nutrition, etc)
⦁ Oral care: no dentures
⦁ clear speech no communication impairment
⦁ Assisted device: Wheelchair used
⦁ Resident needs side rails for safety at night only