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Concepts in Gerontological Nursing > Assessment & Assessment Tools > Flashcards

Assessment & Assessment Tools Flashcards

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1
Q

What is an Assessment?

A
  • Assessment of the older person differs from a younger person as it is more complex, more detailed and will likely take longer to complete.
  • Signs and Symptoms of common conditions often present differently in older people compared to younger people.
  • Holistic assessment is the assessment of the whole person rather than focusing on disease/ functionality alone.
  • For older people in particular, we need to focus on social complexity.
    Comprehensive assessments should be interprofessional.
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2
Q

Why do we assess and what for?

A
  • Help nurses and other health care professionals to objectively and subjectively identify the needs and concerns of people and their families.
  • Timely and appropriate holistic nursing assessment is critical to patient safety.
  • CNO Nursing assessment as part of scope of practice
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3
Q

What kind of data do we collect?

A

Objective Data
- Vitals
- Labs

Subjective Data
- Pain assessment
- Cognitive data
- Discharge planning (starts the minute you assess them)

Collect data on
- Social support
- Info on their home

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4
Q

Comprehensive holistic assessment

A

Cultural
Psychological
Psychosocial
Physical
Environmental
Safety considerations
Higher risk for falls

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5
Q

When to collect the data?

A
  • Whenever possible collect the data when the older person is at their best
  • Focus on collecting priority data
    Collect info when they are at their best
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6
Q

How do we collect data?

A
  • Verbally
  • Interview / ask questions
  • Observation
  • Physical assessment
  • Conversation
  • Assessments will include quantitative and qualitative data
    *Do not interpret data whilst collecting data
  • Risk of making assumptions
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7
Q

From whom do we collect the data?

A
  • Self-report
  • Report by proxy: Going to only represent the view of the proxy
  • Direct observation
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8
Q

Is an assessment tool the same as a screening tool?

A

No it is not the same tool.

Screening tool:
- is a process for evaluating the possible presence (ie risk) of a particular problem.
- The outcome is normally a simple yes or no to identify those in need of further evaluation.
- Generally brief and narrow in scope.
- Example of screening tools: PHQ-9 - Depression and SI
- Fall Risk Assessment Tool
- COVID-19 assessment tool

Assessment tool:
- Is a more comprehensive process for defining the nature of that problem, determining a diagnosis, and developing specific treatment recommendations/ care plan for addressing the problem or diagnosis.

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9
Q

Types of Assessments and Tools

A

Health history
- Physical assessment
- Comprehensive assessments
- Social support assessments
- Standardized Assessments

Performance Assessment:
- Mental Status Assessment:
- Social Support Assessment:

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10
Q

Health history

A

Marks the beginning of the nurse-patient/ client relationship, requires excellent relational skills
- Profile
- Past medical history
- Review of systems and symptoms
- Medication history
- Family history
- Social history

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11
Q

Physical assessment

A

Prioritize assessment
- Vital signs
- Mobility - falls
- Lab results

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12
Q

Comprehensive assessments

A

“FANCAPES”
- Fluids
- Aeration
- Nutrition
- Communication
- Activity
- Pain
- Elimination
- Socialization

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13
Q

Social support assessments

A

Beers assessment

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14
Q
  • Standardized Assessments
A

Functional assessment:
- Activities of Daily Living (Katz index)
- Toileting
- Eating
- Ambulation
- Bathing
- Dressing
- Grooming
Instrumental Activities of Daily Living (IADLs)
- Cleaning
- Yard work
- Shopping
- Money management

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15
Q
  • Performance Assessment:
A

Objective measurement of performance
- Grip strength - Reduced muscle mass
- Shuttle test - Rehabilitation
- Timed walk - Rehabilitation
- Balance test - Falls

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16
Q
  • Mental Status Assessment:
A

Cognition
- MMSE
- Clock drawing test
- Mini-Cog Delirium Index

Mood
- Geriatric depression scale

17
Q

Social Support Assessment:

A

Caregiver Strain Index
- Assessing the Caregiver and the burden and strain.

18
Q

Integrated Assessment Tools

A

Older American’s Resources and Services (OARS)
- Fulmer SPICES

19
Q

Older American’s Resources and Services (OARS)

A

Evaluates the (dis)ability and capacity level at which the person is able to function.
- Includes five sub-scales:
1. Social Resources
2. Economic Resources
3. Physical Health
4. Mental health
5. Ability to perform ADLs

20
Q

Fulmer SPICES

A

Stands for six common syndromes of the older person that require nursing interventions:
“SPICES”
- Sleep disorders
- Problems with eating or feeding
- Incontinence
- Confusion
- Evidence of falls
- Skin breakdown
- Several of these domains can be further assessed using more specific tools once noted.

21
Q

Environmental & Safety Assessments

A

Intrinsic safety issues
- Mobility concerns
- Vision and hearing impairment
- Cognition

Extrinsic safety assessment
- Fire hazards
- Poisoning
- Medication (Beers)
- Fall hazards
- Temperature regulation
- Crime and abuse

22
Q

Comprehensive Geriatric Assessment

A
  • Gold standard in best practice for managing frailty in older adults
  • Used in diverse practice settings – Geriatric Emergency Medicine (GEM), geriatric outreach, family health teams, GAIN clinics
  • CGA is conducted by an interdisciplinary team, RNs are often team leaders
    • Triage referrals
    • Perform initial CGA
    • Make recommendations to physicians/NPs
    • Health promotion strategies
  • Coordinate community services and system navigation
    • Perform follow-up
23
Q

Approach to CGA

A
  1. Screening
    - Medical and Surgical History
    - Medications*
    - Allergies
    - Immunizations
    - Social History
    - Functional History (iADLs and ADLs)
  2. Assessment
    - Conduct a geriatric review of systems
    - Data collected during the review of systems will inform the physical assessments performed that relate to specific geriatric syndromes
    - Special attention should be given to:
    - Sensory impairments (vision, hearing, proprioception)
    - Cardiovascular
    - Neurological
    - Genitourinary systems
  3. Creation of a Problem List
    - Planning Goal-Directed Interventions
24
Q

Goal of CGA

A
  • To optimize health and well-being in older adults – a holistic approach
  • Your assessment and interventions will be tailored to the individual’s needs and goals - patient and family-centered
25
Q

Geriatric Review of Systems

A
  • Falls
  • Cognition
  • Sleep
  • Pain
  • Polypharmacy*
  • Mood / Mental Health
  • Nutrition
  • Continence
26
Q

What do you need to consider when assessing older people and using assessment tools?

A
  • Focus on all skills required for assessment, including relational, observational and physical assessment skills
  • Integrate cultural considerations in the assessment
  • Choose the right tool for the right purpose – make sure you understand how to use the tool correctly
  • Consider the limitations of tools
  • Consider the older person’s capacity and ability to participate in assessment
  • Consider who else to include in a comprehensive assessment
  • Always place the person at the center of the assessment
27
Q

Why are assessments of older people different than younger people?
a. It is more complex and detailed and therefore takes longer
b. We have to consider social complexities
c. Symptoms often present differently
D. All of the above

A

D

28
Q

What is considered a gold standard of collection data for an older person?
a. Only using standardized assessments we know we can rely on them
b. Use of a comprehensive/holistic assessment approach
c. Do not ask the patient, they might encounter problems
d. Only focus on functional assessments that are important

A

B

29
Q

Whenever possible, collect data when and older person is at their best?
a. True
b. False

A

A

30
Q

Elements of CGA:
a. Screen
b. Assessment
c. Creation prob list
d. Plan interventions

A

A, B, C, D

31
Q

Which of these is an intrinsic safety concern for older people?
a. Fire hazard
b. Medications
c. Mobility concerns
d. Environmental temperatures

A

C

32
Q

I should interpret data as I collect them during an assessment
a. True
b. False

A

B

Concepts in Gerontological Nursing (6 decks)

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