This scenario presents a common challenge in gerontological nursing: identifying and addressing potential mental health concerns in older adults, particularly when cognitive changes may complicate the assessment process. The professional challenge lies in accurately differentiating between normal age-related cognitive shifts, treatable mental health conditions, and the effects of underlying medical issues, all while respecting the patient’s autonomy and dignity. Careful judgment is required to select assessment tools that are both sensitive to the nuances of aging and appropriate for the individual’s presentation. The best approach involves utilizing a validated screening tool specifically designed for older adults and their potential mental health issues, such as depression or anxiety, while also considering the individual’s cognitive status. This aligns with best practices in gerontological care, which emphasize person-centered assessment and the use of evidence-based tools. For example, the Geriatric Depression Scale (GDS) is widely recognized and validated for assessing depression in older populations, and its different versions can accommodate varying levels of cognitive function. Incorporating a brief cognitive screen, like the Mini-Cog or the Montreal Cognitive Assessment (MoCA), alongside a mental health screen, allows for a more comprehensive understanding of the patient’s overall status and helps to rule out or account for cognitive impairment that might affect the interpretation of mental health screening results. This multi-faceted approach ensures that the assessment is thorough, accurate, and tailored to the older adult’s unique needs, promoting early identification and intervention for mental health conditions. An incorrect approach would be to solely rely on informal observation and conversation without the use of standardized tools. While observation is crucial, it lacks the systematic and objective measurement provided by validated instruments. This can lead to subjective biases and missed diagnoses, failing to meet the standard of care expected in professional gerontological nursing. Another incorrect approach would be to administer a general mental health screening tool not validated for older adults or one that does not account for potential cognitive impairment. Such tools may yield inaccurate results due to language complexity, cultural insensitivity, or an inability to differentiate between cognitive decline and mood symptoms, potentially leading to misdiagnosis or delayed appropriate care. Finally, administering a complex cognitive assessment without first considering the patient’s mental health status could overlook treatable mood disorders that are impacting cognitive function, thus delaying necessary psychiatric or psychological interventions. Professional decision-making in such situations should involve a systematic process: 1) Recognize the potential for mental health issues in older adults, considering age-related changes and common comorbidities. 2) Select assessment tools that are evidence-based, validated for the geriatric population, and appropriate for the individual’s presentation, including consideration of cognitive status. 3) Conduct a comprehensive assessment that integrates findings from both mental health and cognitive screenings. 4) Interpret findings within the context of the individual’s overall health, social support, and life circumstances. 5) Develop a care plan that addresses identified mental health needs, involving interdisciplinary collaboration as necessary.

Scenario Analysis: This scenario is professionally challenging due to the complex interplay of patient autonomy, the nurse’s role in advocacy and education, and the potential for differing interpretations of “quality of life” among the patient, family, and healthcare team. The nurse must navigate these sensitive dynamics while ensuring adherence to ethical principles and professional standards of care for older adults with chronic conditions. Correct Approach Analysis: The best professional approach involves facilitating a comprehensive, interdisciplinary discussion that prioritizes the patient’s expressed wishes and values. This approach acknowledges the patient’s right to self-determination and involves gathering input from all relevant parties to create a shared understanding of goals of care. It aligns with gerontological nursing standards that emphasize person-centered care, respect for autonomy, and the importance of advance care planning. Ethically, this respects the patient’s dignity and right to make informed decisions about their health and well-being, even when those decisions may differ from what others might choose. Incorrect Approaches Analysis: One incorrect approach involves solely relying on the family’s interpretation of the patient’s wishes without direct, recent confirmation from the patient. This fails to uphold the principle of patient autonomy, as the patient’s voice is superseded by that of their family, potentially leading to care that does not align with their actual desires or values. This can also create ethical distress for the patient if they are aware of decisions being made against their will. Another incorrect approach is to proceed with aggressive, life-prolonging treatments without a thorough re-evaluation of the patient’s current goals of care and quality of life. This disregards the potential for suffering and may not align with the patient’s preferences for comfort and dignity in their advanced age. Gerontological nursing emphasizes a holistic view of aging, which includes considering the patient’s overall well-being and preferences for end-of-life care, not just the biological continuation of life. A third incorrect approach is to defer all decision-making to the physician without actively engaging the patient and family in the discussion. While the physician has a critical role, the nurse’s role as an advocate and educator is essential in ensuring that the patient’s and family’s concerns are heard and understood. This approach neglects the nurse’s responsibility to facilitate communication and support informed decision-making for the patient. Professional Reasoning: Professionals should employ a decision-making framework that begins with assessing the patient’s current capacity and understanding. This is followed by open communication with the patient to ascertain their current wishes and values regarding their chronic illness management and quality of life. Simultaneously, engaging the family and the interdisciplinary team is crucial to gather perspectives and ensure a holistic understanding. The framework emphasizes shared decision-making, where all parties work collaboratively to establish goals of care that are aligned with the patient’s best interests and expressed preferences, respecting their autonomy and dignity throughout the process.

This scenario is professionally challenging because it requires the nurse to balance the resident’s expressed desire for independence with the potential risks associated with their cognitive changes and the facility’s duty of care. The nurse must navigate the complexities of maintaining resident autonomy while ensuring safety and preventing harm, a core ethical and professional responsibility in gerontological nursing. Careful judgment is required to avoid paternalism while still intervening appropriately. The best professional approach involves a comprehensive, individualized assessment and collaborative care planning. This entails gathering detailed information about the resident’s current functional abilities, cognitive status, understanding of risks, and personal preferences. It requires open communication with the resident, their family (with consent), and the interdisciplinary team to develop a plan that supports the resident’s desire for independence as much as safely possible. This approach aligns with ethical principles of autonomy, beneficence, and non-maleficence, and is supported by professional nursing standards that emphasize person-centered care and individualized care plans. It respects the resident’s right to make choices about their life while ensuring their well-being is prioritized through a structured, evidence-based process. An incorrect approach would be to immediately restrict the resident’s access to the community garden based solely on the observed confusion and the facility’s general policy without further assessment. This fails to uphold the resident’s right to autonomy and may lead to unnecessary loss of engagement and quality of life. It also bypasses the crucial step of individualized assessment and care planning, which is fundamental to ethical gerontological nursing practice. Another incorrect approach would be to allow the resident unrestricted access to the garden without any modifications or increased supervision, despite the observed confusion. This neglects the nurse’s duty of care and the principle of non-maleficence, potentially exposing the resident to preventable risks of falls, disorientation, or other safety hazards. It fails to implement appropriate risk mitigation strategies. Finally, an incorrect approach would be to delegate the decision-making entirely to the family without involving the resident in the discussion or conducting an independent nursing assessment. While family input is valuable, the primary responsibility for assessing the resident’s capacity and developing a safe care plan rests with the nursing professional, respecting the resident’s voice and agency. Professionals should use a decision-making framework that begins with a thorough assessment of the resident’s current situation, including cognitive status, physical capabilities, and understanding of risks. This should be followed by open communication with the resident to understand their wishes and preferences. Next, relevant stakeholders, such as family (with consent) and the interdisciplinary team, should be consulted. Based on this comprehensive information, a personalized care plan should be developed that aims to maximize the resident’s independence and quality of life while mitigating identified risks. This process is iterative and requires ongoing evaluation and adjustment.

Scenario Analysis: This scenario is professionally challenging because it requires a gerontological nurse to navigate the complex interplay between demographic shifts, resource allocation, and the ethical imperative to provide equitable care. The increasing prevalence of chronic conditions and the growing demand for specialized geriatric services, coupled with potential funding limitations and workforce shortages, create a high-stakes environment where decisions directly impact patient outcomes and the sustainability of care models. Careful judgment is required to balance population-level needs with individual patient care requirements, ensuring that interventions are both effective and ethically sound. Correct Approach Analysis: The best professional practice involves advocating for the development and implementation of evidence-based, person-centered care models that are specifically designed to address the multifaceted needs of an aging population. This approach prioritizes proactive strategies such as preventative care programs, integrated health and social support services, and the utilization of technology to enhance care delivery and monitoring. It aligns with the ethical principles of beneficence and justice by aiming to improve the quality of life for older adults and ensure that resources are distributed equitably to meet the growing demand. This proactive stance is crucial for addressing the demographic trends effectively and sustainably. Incorrect Approaches Analysis: One incorrect approach involves focusing solely on reactive interventions, such as increasing hospital bed capacity without addressing the underlying causes of increased demand or investing in community-based support. This fails to acknowledge the demographic trend of an aging population requiring long-term, chronic care management and can lead to inefficient resource utilization and patient dissatisfaction. It neglects the ethical responsibility to promote well-being and prevent avoidable hospitalizations. Another incorrect approach is to prioritize the care needs of younger populations due to perceived higher economic productivity or shorter-term care requirements. This approach is ethically unsound as it violates the principle of justice, which demands fair distribution of resources and equitable access to care regardless of age. It fails to recognize the inherent value and rights of older adults and ignores the demographic reality of a growing elderly population. A third incorrect approach is to rely solely on traditional, unadapted care models that were not designed for the complexities of an aging population with multiple comorbidities. This can lead to fragmented care, missed diagnoses, and suboptimal outcomes, as these models may not adequately address issues like polypharmacy, cognitive impairment, or social isolation, which are prevalent in older adults. This approach is professionally deficient as it does not adapt to evolving patient needs driven by demographic shifts. Professional Reasoning: Professionals should employ a decision-making framework that begins with a thorough understanding of the demographic landscape and its implications for healthcare needs. This should be followed by an assessment of available resources and potential gaps. Ethical principles, particularly justice and beneficence, should guide the selection of interventions. A commitment to continuous learning and adaptation of care models to meet the evolving needs of the aging population is paramount. This involves advocating for policy changes, embracing innovation, and fostering interdisciplinary collaboration to ensure comprehensive and equitable care.

Scenario Analysis: This scenario is professionally challenging because it requires the gerontological nurse to navigate a complex ethical and legal landscape involving patient autonomy, family dynamics, and the potential for elder abuse or neglect, all within the context of a patient’s declining capacity. The nurse must balance the patient’s right to self-determination with the responsibility to ensure their safety and well-being, while also respecting the family’s involvement and concerns. This requires astute observation, clear communication, and a thorough understanding of professional obligations. Correct Approach Analysis: The best professional practice involves the gerontological nurse initiating a comprehensive assessment of the resident’s cognitive status and decision-making capacity. This assessment should be conducted by qualified healthcare professionals, potentially including a geriatrician or neuropsychologist, and should involve direct observation of the resident’s interactions and ability to understand information relevant to their care choices. If the resident is deemed to have capacity, their wishes regarding visitation should be respected and documented. If capacity is questionable or absent, the nurse must then engage in a structured process to determine the resident’s best interests, which may involve consulting with the healthcare team, reviewing advance directives, and involving the designated healthcare proxy or legal guardian, all while adhering to the facility’s policies and relevant state laws regarding patient rights and surrogate decision-making. This approach prioritizes the resident’s autonomy and legal rights while ensuring their safety and well-being are paramount. Incorrect Approaches Analysis: One incorrect approach would be to immediately defer to the family’s wishes without independently assessing the resident’s capacity. This fails to uphold the resident’s right to autonomy and could lead to the imposition of visitation restrictions against their will, potentially violating their personal liberty and privacy rights. It also neglects the nurse’s professional responsibility to advocate for the patient. Another incorrect approach would be to ignore the family’s concerns and proceed solely based on the resident’s stated preference without a thorough assessment of capacity. While patient autonomy is crucial, a complete lack of consideration for potential underlying issues like undue influence or a decline in judgment could inadvertently put the resident at risk or lead to decisions that are not in their best interest, especially if their capacity is compromised. A third incorrect approach would be to document the family’s request without taking any further action or initiating an assessment. This passive stance abdicates the nurse’s responsibility to investigate a potentially sensitive situation, ensure patient safety, and facilitate appropriate decision-making processes. It fails to address the core issue of the resident’s capacity and their right to make informed choices. Professional Reasoning: Professionals should employ a systematic approach that begins with a thorough assessment of the patient’s capacity to make decisions. This involves gathering information from multiple sources, including direct observation, patient interviews, and consultation with other healthcare professionals. When capacity is uncertain, a formal evaluation is necessary. The nurse must then weigh the patient’s expressed wishes against their best interests, considering any legal mandates or ethical guidelines. Open and honest communication with the patient, family, and healthcare team is essential throughout this process to ensure all perspectives are considered and that the final decision aligns with the patient’s rights and well-being.

Scenario Analysis: This scenario is professionally challenging because it involves a common yet complex presentation in older adults where subtle changes can indicate significant underlying issues. The nurse must differentiate between normal aging, a treatable medical condition, and a potential side effect of medication, all while respecting the patient’s autonomy and cognitive status. The risk of misdiagnosis or delayed treatment is high, impacting the patient’s quality of life and safety. Careful judgment is required to gather comprehensive data, consider multiple differential diagnoses, and involve the patient and their family appropriately. Correct Approach Analysis: The best professional practice involves a comprehensive geriatric assessment that begins with a thorough, multi-faceted approach. This includes a detailed history of present illness, a review of systems, a thorough medication reconciliation, and a functional assessment. Crucially, it necessitates a cognitive assessment to understand the patient’s baseline and current mental status, as well as an assessment of their social support system and living environment. This holistic approach, aligned with gerontological nursing standards of practice and ethical principles of beneficence and non-maleficence, ensures all potential contributing factors are considered before formulating a diagnosis and treatment plan. It prioritizes understanding the older adult as a whole person within their unique context. Incorrect Approaches Analysis: One incorrect approach would be to solely focus on the reported fatigue and assume it is a normal consequence of aging without further investigation. This fails to uphold the ethical principle of beneficence, as it risks overlooking a treatable condition that could significantly improve the patient’s well-being. It also neglects the professional responsibility to conduct a thorough assessment as outlined by gerontological nursing guidelines. Another incorrect approach would be to immediately attribute the fatigue to a recent medication change without a broader assessment. While medication side effects are a possibility, this narrow focus ignores other potential causes, such as underlying medical conditions or psychosocial factors, which are common in older adults. This approach violates the principle of thoroughness in assessment and could lead to inappropriate treatment or a missed diagnosis. A third incorrect approach would be to rely solely on the family’s report of the patient’s symptoms without directly engaging the patient in the assessment process, especially if the patient has some capacity for communication. This could be ethically problematic if it undermines the patient’s autonomy and right to participate in their own care, and it may also lead to incomplete or biased information, as the patient’s subjective experience is paramount. Professional Reasoning: Professionals should employ a systematic, patient-centered approach. This involves starting with open-ended questions to understand the patient’s chief complaint and then proceeding with a structured, yet flexible, assessment that considers the unique physiological, psychological, and social aspects of aging. Always prioritize direct patient assessment, but judiciously incorporate caregiver input when appropriate and with patient consent. Maintain a broad differential diagnosis and systematically rule out or confirm possibilities. Document all findings meticulously and involve interdisciplinary team members as needed.

Scenario Analysis: This scenario is professionally challenging because it involves a sensitive situation where a patient’s cognitive decline may impact their ability to provide informed consent for a procedure. The nurse must balance the patient’s autonomy with the need to ensure their safety and well-being, while also adhering to ethical and legal standards of care. The urgency of the situation, coupled with the potential for misinterpretation of the patient’s wishes, necessitates careful judgment and a structured approach. Correct Approach Analysis: The best professional practice involves a comprehensive cognitive assessment using a validated tool like the Mini-Mental State Examination (MMSE) or the Montreal Cognitive Assessment (MoCA) to objectively evaluate the patient’s cognitive status. This approach is correct because it provides objective data to inform the decision-making process regarding the patient’s capacity to consent. Regulatory frameworks and ethical guidelines, such as those emphasized by gerontological nursing standards, mandate that healthcare providers assess a patient’s capacity to make decisions, especially when there are concerns about cognitive impairment. This assessment allows for a determination of whether the patient can understand the information, appreciate the consequences of their decisions, and communicate their choice. If the assessment indicates a lack of capacity, the nurse then follows established protocols for surrogate decision-making, which respects the patient’s previously expressed wishes or best interests. Incorrect Approaches Analysis: One incorrect approach involves proceeding with the procedure based solely on the family’s assertion that the patient would want it. This fails to uphold the principle of patient autonomy and the requirement for informed consent. Ethically and legally, a patient’s wishes must be ascertained directly or through legally recognized means, not presumed by family members without a formal assessment of capacity. Another incorrect approach is to delay the procedure indefinitely until a formal psychiatric evaluation is completed, even if the patient appears to be experiencing an acute, reversible condition that requires immediate intervention. While a formal evaluation might be necessary in some cases, an immediate, comprehensive cognitive assessment by the nurse can often provide sufficient information to guide urgent decision-making, and delaying necessary care based on a potentially lengthy process could be detrimental to the patient’s health. A third incorrect approach is to interpret the patient’s silence or lack of verbal objection as consent. Silence or a lack of objection does not equate to informed consent, particularly in individuals with suspected cognitive impairment. Consent must be an affirmative and informed agreement, which requires the patient to understand the nature of the procedure, its risks, benefits, and alternatives. Professional Reasoning: Professionals should employ a systematic approach when assessing a patient’s capacity to consent. This begins with recognizing potential indicators of cognitive impairment. Next, a validated cognitive assessment tool should be utilized to gather objective data. This data then informs a determination of the patient’s capacity. If capacity is present, informed consent is obtained directly from the patient. If capacity is lacking, the professional must identify and engage the appropriate surrogate decision-maker according to legal and ethical guidelines, ensuring that the patient’s best interests and previously expressed wishes are prioritized.

Scenario Analysis: This scenario is professionally challenging because it requires the nurse to navigate the complex interplay of biological, psychological, and sociological factors influencing an older adult’s well-being, while also respecting their autonomy and promoting their quality of life. The nurse must move beyond a purely medical model to understand the holistic needs of the patient, which is a core tenet of gerontological nursing. Careful judgment is required to select interventions that are not only clinically appropriate but also align with the patient’s values and social context. Correct Approach Analysis: The best professional approach involves a comprehensive assessment that integrates biological changes associated with aging, the individual’s psychological state (including cognitive function, emotional well-being, and coping mechanisms), and their social environment (family support, community engagement, and cultural background). This holistic perspective is directly supported by established aging theories, such as the Disengagement Theory (sociological), which suggests a mutual withdrawal between the aging person and society, and the Activity Theory (sociological), which posits that successful aging occurs when older adults remain active and engaged. Psychologically, theories like Erikson’s stages of psychosocial development, specifically the stage of Ego Integrity vs. Despair, are relevant. Biologically, understanding cellular aging theories or wear-and-tear theories helps explain physical decline. By considering all these dimensions, the nurse can develop a personalized care plan that addresses the multifaceted needs of the older adult, promoting their sense of self-worth and continued engagement with life, thereby enhancing their quality of life. This approach aligns with ethical principles of beneficence, non-maleficence, and respect for autonomy, as it prioritizes the patient’s overall well-being and their right to self-determination. Incorrect Approaches Analysis: Focusing solely on the biological manifestations of aging, such as prescribing medication for perceived physical ailments without exploring underlying psychological distress or social isolation, fails to acknowledge the interconnectedness of aging factors. This approach neglects sociological theories that highlight the importance of social roles and relationships in maintaining well-being and psychological theories that emphasize the impact of life satisfaction and coping strategies. Another incorrect approach would be to assume that the patient’s withdrawal from social activities is a natural and inevitable consequence of aging, as suggested by a simplistic interpretation of disengagement theory, without exploring the potential underlying causes such as depression, fear, or lack of accessible opportunities. This overlooks the psychological and sociological factors that might be driving the behavior and misses opportunities for intervention. Lastly, prioritizing interventions based solely on the family’s wishes without a thorough assessment of the older adult’s own preferences and psychological state would violate the principle of autonomy and could lead to a care plan that is not truly beneficial or acceptable to the patient. Professional Reasoning: Professionals should employ a systematic, patient-centered approach. This involves beginning with a broad, holistic assessment that considers biological, psychological, and sociological domains. Utilize established aging theories as a framework for understanding observed phenomena. Prioritize patient self-report and preferences, integrating them with clinical findings. Collaborate with the patient, family (with patient consent), and other healthcare professionals to develop a comprehensive and individualized care plan. Regularly re-evaluate the plan based on the patient’s evolving needs and responses, ensuring it remains aligned with their goals and values.

This scenario is professionally challenging due to the inherent vulnerability of older adults and the potential for serious harm from falls. The nurse must balance the need for comprehensive assessment with the resident’s comfort and autonomy, while adhering to best practices and regulatory expectations for elder care. Careful judgment is required to select the most appropriate and effective assessment tools and interventions. The best approach involves a multi-faceted assessment that integrates objective measures with subjective patient input and considers the resident’s functional status in their usual environment. This approach is correct because it aligns with the principles of person-centered care, which emphasizes understanding the individual’s unique needs, preferences, and capabilities. Regulatory frameworks for gerontological nursing, such as those promoted by the Gerontological Nursing Certification Board (GERO-BC) and implied by best practice guidelines in elder care, advocate for holistic assessments that go beyond simple checklists. This includes observing the resident during activities of daily living, inquiring about their perceived balance and confidence, and utilizing validated tools like the Timed Up and Go (TUG) test to objectively measure mobility and fall risk. This comprehensive strategy allows for the identification of specific risk factors and the development of tailored, evidence-based interventions. An approach that relies solely on a single, generic fall risk screening tool without further investigation is professionally unacceptable. While screening tools are valuable, they are often a starting point. Failing to conduct a more in-depth assessment, including functional observation and patient self-report, can lead to missed risk factors and ineffective interventions. This overlooks the complexity of fall etiology in older adults, which can be multifactorial and influenced by environmental, physiological, and psychological factors not captured by a single score. Another professionally unacceptable approach is to administer a detailed assessment without considering the resident’s current physical or emotional state. Forcing a comprehensive assessment on a fatigued or distressed resident can yield inaccurate results and compromise the therapeutic relationship. Ethical considerations dictate that patient comfort and dignity are paramount, and assessments should be conducted in a manner that respects these principles. Finally, an approach that focuses exclusively on environmental modifications without a thorough individual assessment of the resident’s mobility and intrinsic risk factors is also flawed. While environmental safety is crucial, it is only one component of fall prevention. Without understanding the resident’s specific gait, balance, strength, and cognitive status, interventions may be misdirected or insufficient to address the primary causes of their fall risk. Professionals should employ a decision-making framework that begins with recognizing the resident’s vulnerability and the potential for falls. This involves a systematic process of gathering information through observation, patient interview, and validated assessment tools. The data collected should then be synthesized to identify specific risk factors. Based on this comprehensive understanding, individualized interventions can be developed and implemented, with ongoing evaluation to ensure their effectiveness and to adapt to changes in the resident’s condition.

Scenario Analysis: This scenario is professionally challenging because it requires the nurse to synthesize information from multiple sources (patient report, family input, and direct observation) to accurately assess the patient’s functional status. The challenge lies in balancing the patient’s subjective experience with objective findings and family perceptions, while ensuring the chosen assessment tool is appropriate for the clinical context and the patient’s specific needs. Ethical considerations include respecting patient autonomy, ensuring accurate documentation for care planning, and avoiding assumptions based on age or perceived frailty. Correct Approach Analysis: The best professional practice involves selecting a validated functional assessment tool that is appropriate for the patient’s cognitive and physical status, and then systematically applying it using a combination of direct observation, patient self-report, and, where appropriate and with consent, input from reliable family members or caregivers. This approach ensures a comprehensive and objective evaluation, aligning with the principles of person-centered care and accurate clinical documentation mandated by professional nursing standards. Utilizing a tool like the Katz Index, which focuses on basic ADLs, or the Barthel Index, which includes both ADLs and mobility, allows for standardized measurement of functional abilities, facilitating effective care planning and monitoring of changes over time. Incorrect Approaches Analysis: One incorrect approach would be to rely solely on the patient’s self-report without objective verification. This fails to account for potential cognitive impairments, memory deficits, or a desire to present a more independent image, leading to an inaccurate assessment and potentially inappropriate care plans. It also neglects the professional responsibility to conduct a thorough and objective evaluation. Another incorrect approach is to exclusively use family input without direct patient assessment or validation. While family members can provide valuable insights, their perceptions may be influenced by their own experiences, biases, or a desire to over- or under-estimate the patient’s capabilities. This approach risks misrepresenting the patient’s actual functional status and can undermine patient autonomy. A third incorrect approach is to choose a functional assessment tool without considering the patient’s specific condition or the purpose of the assessment. For example, using a tool designed for acute care in a long-term care setting without modification, or selecting a tool that is too complex for a patient with significant cognitive impairment, would lead to an unreliable and potentially misleading assessment. This demonstrates a lack of critical thinking and professional judgment in tool selection. Professional Reasoning: Professionals should employ a systematic decision-making process that begins with understanding the purpose of the assessment. This involves identifying the patient’s current clinical presentation and potential limitations. Next, the nurse should select the most appropriate validated assessment tool based on the patient’s condition, cognitive status, and the specific functional domains to be evaluated. The assessment should then be conducted using a multi-modal approach, integrating direct observation, patient self-report, and, when necessary and consented to, input from caregivers. Finally, the findings should be documented accurately and used to inform individualized care planning and ongoing evaluation.