Week Two Flashcards
What is an Assessment?
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.
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.
Why do we Assess People?
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
What Kind of Data do we 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
When to Collect Data?
Whenever possible collect the
data when the older person is at
their best
Focus on collecting priority data
How do we Collect Data?
- Observation
- Physical assessment
- Conversation
- Assessments will include quantitative and qualitative data
- Do not interpret data whilst collecting data
From who do we Collect the Data?
- Self-report
- Report by proxy
- Direct observation
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 Tool
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 Assessment Tool
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 Assessment
FANCAPES
- Fluids
- Aeration
- Nutrition
- Communication
- Activity
- Pain
- Elimination
- Socialisation
Inappropriate Medication in Older Adults
- Beers Assessment
Functional Assessment
Standardized Assessment
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
Performance Assessment
standarized assessment
Objective measurement of performance
* Grip strength, Shuttle test, timed walk, balance test
Mental Status Assessment
standardized assessment
Cognition: MMSE, Clock drawing test, Mini-Cog Delirium Index
Mood: geriatric depression scale
