The nurse is conducting a functional assessment on an older patient who has lost five pounds (2.27 Kg) since the last visit 12 weeks ago and reports a decrease in energy and appetite.
Which action should the nurse include during the assessment?
A.
Ask the patient how often episodes of sundowning are experienced.
B.
Inquire about the frequency of falls in recent months.
C.
Request the patient to lie as still as possible for the assessment.
D.
Assist the patient with clarifying values about end-of-life care options.
The correct answer and Explanation is :
The correct action the nurse should include during the functional assessment is:
B. Inquire about the frequency of falls in recent months.
Explanation:
A functional assessment of an older patient involves evaluating their ability to perform daily activities and maintain independence. Given that the patient has lost weight and reports decreased energy and appetite, this could signal various health concerns such as malnutrition, depression, chronic disease exacerbation, or even early frailty syndrome. Weight loss and a decrease in energy are common warning signs of functional decline, which can increase the risk of falls. Therefore, asking about the frequency of falls is critical.
Falls are a significant health risk for older adults, leading to injuries, hospitalization, and loss of independence. Many older adults experience muscle weakness, balance issues, or cognitive decline, all of which contribute to the risk of falls. Identifying whether falls have occurred can help the nurse assess the patient’s mobility, strength, and balance, which are essential aspects of functional assessment.
Why the other options are less relevant:
- A. Ask the patient how often episodes of sundowning are experienced: Sundowning refers to confusion and agitation that worsens in the evening, often seen in patients with dementia. While this could be relevant in assessing cognitive function, there is no indication from the given scenario that the patient is experiencing cognitive issues like confusion or dementia.
- C. Request the patient to lie as still as possible for the assessment: This is typically done during specific diagnostic procedures like imaging studies or when measuring vital signs such as blood pressure. It is not relevant to a functional assessment focusing on daily living activities.
- D. Assist the patient with clarifying values about end-of-life care options: While discussing end-of-life care is important, it’s not directly related to the immediate functional assessment for weight loss and decreased energy.