Week 2 Flashcards
How are assessment’s different in older adults
Assessment of the older person differs from a younger person as it is more complex, more
detailed and will likely take longer to complete.
Symptoms and signs of common conditions often present differently in older people
compared to younger people. (think about the link between UT and delirium)
Holistic assessment is the assessment of the whole person rather than focusing on disease/
functionality alone.
Main focus of assessment in older adults
Focus on social complexity.
Comprehensive assessments should be interprofessional
What kind of data can assessments collect?
- Health history
- Observation
- Standardised measures/ scores
- Functional assessment
- Mental status assessment
- Assessment of social support
- Comprehensive holistic assessment includes cultural,
psychological, psychosocial, physical, environmental and safety
considerations
Considerations for when we collect data
Whenever possible collect the
data when the older person is at
their best
Think about medication/time/mental circumstances
How to collect data
- Observation
- Physical assessment
- Conversation
- Assessments will include quantitative and qualitative data
- **Do not interpret data whilst collecting data*
From whom do we collect the data?
- Self-report
- Report by proxy
- Direct observation
Is an assessment tool the same as a screening tool?
Screening 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.
Assessment 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.
Health history assesment
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
Physical assessment
Prioritise assessment
- Vital signs
- Mobility
- Lab results
Comprehensive assessments: FANCAPES
- Fluids
- Aeration
- Nutrition
- Communication
- Activity
- Pain
- Elimination
- Socialisation
Polypharmacy assesment
BEERS
Types of standardized functional assessments
Activities of Daily Living (Katz index)
* toileting, eating, ambulation, bathing, dressing, and grooming
Instrumental Activities of Daily Living (IADLs)
* cleaning, yard work, shopping, and money management
What are performance assessment’s
- Objective measurement of performance
- Grip strength, Shuttle test, timed walk, balance test
Mental status assessment (cognition, mood assessments)
Cognition: MMSE, Clock drawing test, Mini-Cog Delirium Index
Mood: geriatric depression scale
Social support assessment
Caregiver stain index
Older American’s Resources and Services (OARS)
Evaluates the (dis)ability and capacity level at which the person is able to function. Includes five
sub-scales: Social & economic resources; physical and mental health and ability to perform ADLs
Fulmer SPICES
SPICES stands for six common syndromes of the older person that require nursing interventions:
Sleep disorders
Problems with eating or feeding
Incontinence
Confusion
Evidence of falls
Skin breakdown
Examples of intrinsic safety issues (part of enviorment/safety assesment)
Mobility concerns
Vision and hearing impairment
Cognition
Examples of extrinsic safety assessment (part of enviorment/safety assesment)
Fire hazards
Poisoning
Medication (Beers)
Fall hazards
Temperature regulation
Crime and abuse
Gold standard in best practice for managing frailty in older adults
Comprehensive Geriatric Assessment
Who completes a CGA?
interdisciplinary team
4 step approach of GCA
- Screening
- Assessment
- Creation of a Problem List
- Planning Goal-Directed Interventions
Goal of CGA
optimize health and well-being in older
adults – a holistic approach
Screening for CGA
- Medical and Surgical History
- Medications*
- Allergies
- Immunizations
- Social History
- Functional History (iADLs and
ADLs)
Assessment for CGA
- 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,
and genitourinary systems
Geriatric Review of Systems
- Falls
- Cognition
- Sleep
- Pain
- Polypharmacy*
- Mood / Mental Health
- Nutrition
- Continence
