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
Social Support Assessment
caregiver strain index
Integrated Assessment Tools
Older Americans Resources and Services (OARS)
Fulmer SPICES
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
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
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
Comprehensive Geriatric Assessment
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
Approach to CGA
- Screening
- Assessment
- Creation of a Problem List
- Planning Goal-Directed Interventions
Remember the goal of CGA is 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
What matters most to the individual?
Screening
Medical and Surgical History
* Medications*
* Allergies
* Immunizations
* Social History
* Functional History (iADLs and
ADLs)
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,
and genitourinary systems
Geriatric Review of systems
- Falls
- Cognition
- Sleep
- Pain
- Polypharmacy*
- Mood / Mental Health
- Nutrition
- Continence
What do you need to consider when assessing older people and using assessment tools?
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 centre of the assessment
