Ch 7 Older Adult health assessment
a thorough functional assessment will help the gerontological nurse work toward healthy aging by accomplishing the following:
- identifying the specific areas in which help is needed or not needed -identify changes in abilities from one period of time to another -determining the need of a specific service(s) -providing info that may be useful in assessing the safety of a particular living situation
Barthel Index (BI) and Functional Independence Measure (FIM)
2 tools commonly used in the rehab center to assess a person's need for assistance with ADL's. Data is used both inpatient and postdischarge planning relative to the amount of physical assistance required. BI ranks functional status as either independent or dependent and then allows for further classification. FIM includes to measure ADLs of mobility, cognition, and social functioning. It is widely used and is the most comprehensive functional tool for rehab setting.
What are the activities of daily living? and what tool is used to measure ADL's?
Activities such as bathing, dressing, toileting, continence,transferring, and feeding. dressing and bathing require higher cognitive function than the others. ADL's can be measured using the Kats Index: -It measures the amount of dependence/ independence you have measures bathing, dressing, toileting, transferring, continence, feeding). A score of a 4 indicates moderate impairment and a score of 2 is severe impairment. 6= high independence 0= very dependent
assessment of mood:
Additional screening tools are necessary to assess mood. This is bc of the high rate of depression among older adults; it may be a side effect of a medication or highly associated with some health conditions such as stroke or parkinson's disease. Person's with untreated depression are more functionally impaired and will have prolonged hospital stays, lower quality of life, increased morbidity overall, and reduced longevity. MOOD MEASURES: Beck and Zung have been used, geriatric scale most used the Geriatric Depression Scale (table 7-11): is administered as a self-report by the older adult, however it does not contain a question to evaluate for suicide potential. A 30 item tool developed specifically for screening older adults and has been tested extensively in a number of settings. IT deemphasizes physical complaints, libido, and appetite.
There are 2 tools used for a basic overall assessment of older adults which uses a framework that focuses on function at the most basic level and the extent to which assistance is necessary, when alterations are found, then a focus of that specific area is needed.
FANCAPES AND fulmer SPICES. -The FANCAPES assessment tool focuses on the older adult's physical functioning and evaluates the individuals ability to meet his or her own needs and how much assistance is needed to meet the needs. Need to know what is normal and what is not FANCAPES evaluates physical functioning. The Fulmer SPICES assess six syndromes that are common to the older adults and require nursing interventions Anything that is identified with a problem involves a more in-depth assessment. Similar to the assessment performed in the HER, where a person complains of problems breathing, then a MORE detailed history is obtained.
FANCAPES
Fluids: client's state of hydration and those physiological, situational, and mental factors that contribute to the maintenance of adequate hydration. attention is directed as the ability of the person to obtain adequate fluids independently, to express thirst, to swallow effectively, and evaluate meds. Aeration: adequacy of oxygen exchange. Observations include respiratory rate and depth at rest and during activity; talking, walking, and situations requiring added exertion; the presence or absence of edema in the extremities or abdomen. At a minimum, breath sounds should be evaluated and meds reviewed to evaluate their effects on aeration. Also determining oxygen saturation level is essential anytime that respiratory compromise is suspected, such as potential of pneumonia. Nutrition: includes mechanical and psychological factors in addition to the type and amount of food consumed; ability to bite, chew, and swallow; fit dentures and condition of gums and teeth. Alterations in diet related to culture, medical restrictions, available economic resources, and living conditions should be included. If the person has a special diet- get to know who prepares the meals for the elder. A persons visual and neurological impairment interferes with the person's ability to prepare a meal or feed himself. Functional economic status is also important to determine the person's ability to obtain groceries. Communication: includes sending and receiving verbal and nonverbal info. Assessment of communicative ability includes the determination of sight and sound acuity; voice quality; and adequate function of the tongue, teeth, pharynx, and larynx. Appraisals of the person's ability to read, write, and understand the spoken language of the nurse should be ascertained. undetected limitation of these skills can lead to erroneous conclusions or to the patient's inability to follow directions. Activity: more than just the ability to ambulate and exercise. The nurse assess's the person;s ability to eat, toilet, dress, and groom; to prepare meals; to use the phone; and to move about with or without assistive devices. Coordination and balance, finger dexterity, grip strength, and other abilities necessary in daily life should also be assessed. Pain: physical, mental, and spiritual pain is considered.The presence and absence of pressure and discomfort are key aspects of pain assessment. information about recent losses or visible symptoms of anxiety may help identify persons in pain. The manner by which the client customarily attains relief from pain or discomfort will provide further information. Elimination: bladder and bowel elimination are assessed and include evidence of urinary dribbling or incontinence, use of protective garments or devices and medications that affect voiding and intestinal peristalis. Nurse and patient must come to an understanding of common bowel sound words to be able to create full communication and understanding. Socialization and social skills: assessment of socialization and skills include the individual's ability to negotiate in society, to give and receive love, friendship, and to feel self worth. It focuses on the person's ability to deal with loss and to interact with other people in give and take situations.
What is the physical/functional assessment?
Functional Assessment: Evaluation of person's ability to carry out basic tasks for self-care and tasks needed to support independent living Numerous tools available that describe, screen, assess, monitor, and predict functional ability Tools used determine the individual's ability to perform tasks needed for self-care: -Activities of Daily Living (ADL's)-Katz tool It measures the amount of dependence/ independence you have.(measures bathing, dressing, toileting, transferring, continence, feeding) -Barthel Index (BI) and Functional Independence Measure (FIM) -IADL's:are tasks needed for independent living such as cleaning, yard work, shopping and money management, performance of these IADL's require a higher level of cognitive and physical functioning.
Implications for Gerontological Nursing
Goal of assessment is always to assist patient in improving quality of life Gerontological nurse challenged to provide highest level of excellence in assessment of elderly without burdening person
What does the health history consist of ?
Marks the beginning of the nurse-client relationship. Elements of the assessment include: Patient profile: orientation ( time, place, & date) Past medical history: see if they remember Review of symptoms and systems Medication history: ask to see medications Family history: history of diseases or conditions that run commonly in the family Social history:needs to include the current living arrangements, economic resources to deal with current health resources, amt of family support and community resources
Integrated Assessment
Older American's Resources and Service (OARS) : -Social resources: evaluates the social skills and ability to negotiate and make friends (# of times friends are seen and phone conversations). The ability to ask things from friends. -Economic resources: data about monthly income and sources( social security, supplemental security income, pensions, income generated from capital) are needed to determine the adequacy of income compared with the cost of living and food, shelter, clothing, medications, and small luxury items. This can provide insight into the elder's standards of living and point out areas of need that might be alleviated by the sue of additional resources. -Mental health: consideration is given to intellectual function, the presence or absence of psychiatric symptoms, and the amount of enjoyment and interaction the person gets from life. -Physical health: includes the diagnosis of major and common diseases of the type prescribed and OTC meds the person is taking, and the person's perception of his or her health status. -Activities of daily living: are walking, getting into and out of bed, bathing, combing hair, shaving, dressing, eating, and getting to the bathroom on time by oneself. The IADLs measured include tasks like dialing a phone, driving a car, hanging up clothes, obtaining groceries, and taking meds and having correct knowledge of their dosages. OARS tool is designed so that each component can be used individually, designed to evaluate ability, disability, and the capacity level at which a person is able to function
It assesses the 6 common syndromes in older adults
SPICES: had been readily used with older adults as an overall assessment tool regardless of health status or setting. the acronym refers to the 6 common syndromes of the elderly that require nursing interventions and they are: Sleep disorders Problems with eating or feeding Incontinence Confusion Evidence of falls Skin breakdown Like FANCAPES, anything that indicates a problem in 1 of the categories warns the nurse that more in depth assessment is needed. It is a system for alerting the nurse to the most common problems that interfere with the health and well being of older adults, particularly those who have 1 or more medical conditions.
instruments for assessing cognition and mood
Several instruments used to assess for cognitive status and depression in the older adult, altered cognition in the OA is commonly attributed to: dementia, delirium or depression Mini mental status exam-30-point-item assessment used to screen and monitor cognitive fxn; tests orientation, short-term memory and attention, calculation ability, language and construction (see sample). Can't be given to people who can't see , write or don't know English. A score of 30 suggests no impairment. A score of 26 or less suggests potential dementia; however adjustments are needed for educational level. it is most useful for ruling out dementia than for diagnosis. Mini Cog- test found to be equivalent to the MMSE, less bias, easier to administer, and more sensitive to dementia, assess short-term memory and executive fxn (See Sample). Has been the standard tool for screening of mental status/cognitive status. It assesses short term memory and executive function. Although it does require the ability to hear, hold a pencil,and write numbers, it is brief and highly sensitive and specific for dementia. Clock-drawing test- reported to be 2nd only to MMSE across the world, useful for screening and diagnosis of dementia . Although it is useful for the screening and diagnosis of dementia, it can't be used to identify those with MCI.Some level of manual dexterity and visual acuity is required and therefore is not appropriate for use with individuals who are blind or who have severe arthritis., Parkinson's disease, or stroke that affects their dominant hand. A person is presented with a piece of paper and is asked to draw the face of a clock with a certain time.
Cultural Rules and Etiquette
Social organization and expectations (roles of family members and friends) Communication style, especially in health care setting Use of personal space and eye contact General health orientation related to time (past, present, future) Appropriate wording of greetings Appropriate use of names Appropriateness of touch, especially between genders
Different assessment tests when assessing functional status and cognition abilities:
When assessing both functional status and cognitive abilities slightly different tools are indicated. These tools incorporate both memory, recall, finding way.These tools are especially useful in determining cognitive and functional stages. The tests that assess function and cognition are the following: Blessed Dementia Score: is a 22 item tool that incorporates aspects of ADL's, IADLs, memory, recalling events and finding one's way outdoors.The higher the score the greater degree of dementia assessed. Clinical Dementia Rating Scale and Global Deterioration Scale also assess both cognitive and functional abilities and are used to stage dementia including those with mild cognitive impairment. The deterioration scale and several other tools have been found sensitive enough to show therapeutic changes, such as those related to medication adjustments.
what special abilities does the assessment of an older adult require?
ability to listen patiently, allow for pauses, ask questions not often asked, observe minute details, obtain data from all available sources, and recognize normal changes associated with late life that may be considered abnormal in one who is younger.
Instrumental Activities of daily living
are tasks needed for independent living such as cleaning, yard work, shopping and money management, performance of these IADL's require a higher level of cognitive and physical functioning
What does the health assessment provide?
info critical to the development of a plan of care that can enhance personal health status, decrease the potential for or the severity of chronic conditions, and encourage self efficacy and empowerment for self care.
How is the process of assessment different in older adults?
it is more detailed even when problem oriented. If a complete and comprehensive assessment is needed it is done by a group of professionals and led by a nurse.
Mental Status Assessment
older adults are at greater risk impairments in mental capacity. Cognitive ability is easily threatened by any disturbance in health or homeostasis which can rapidly lead to delirium.Altered mental status may be the 1st sign of anything from a heart attack to a UTI. In a general assessment it is helpful to have baseline measures of cognition and mood and is especially important if there are any indications of potential problems present. These are best administered when the person is comfortable, rested and free of pain.
What does a comprehensive assessment include?
psychological parameters such as cognitive and emotional well being; caregiver stress or burden; the individual's self perception of health and patterns of health and health care, education, family structure, plans for retirement, and living environment.
What are the outcomes for chapter 7?
• List the essential components of the comprehensive health assessment of an older adult • Describe the purpose of the inclusion of functional assessment when caring for an older adult • Discuss the various tools used in screening the older adult.
