II. Assessment of older adult

protection

promotion of health service

prevention of illness

faci of healing

dx and ttt of human responses

advocacy

nursing acc to ANA 6

TENETS/CORE PRINCIPLES OF NURSING PRACTICE by ANA adopted by PNA

they guide or standardize our practice

1. Caring and Health are central to the practice of the registered nurse

2. Nursing is individualized to each patient

3. Nurses use the nursing process to plan and provide care.

4. Nurses coordinate care via partnerships

5. The work environment affects quality of care and outcomes.

5 CORE TENETS

caring

is the core of nursing, establishes trust and a therapeutic relationship.

assessment

The first and most important step in the Nursing Process ● It dictates all the processes that follow and tells us how good the diagnosis, planning, and interventions are

holistically, totality

A good assessment is when we look at the person — or as a whole; we look at the —of a person.

older adult’s ability to meet health and illness needs

GOAL OF ASSESSMENT

physical, emotional

give 3 wellness wheel

Functional Capability of the patient

general focus of assessment

identify strengths, identify limitations

2 focus assessment

. Acute Care Hospitals 2. Home Care 3. Long-Term Care/Nursing Homes

CARE SETTINGS FOR ASSESSMENT 3

acute care hospitals

Urgent needs, emergent symptoms, acute and sudden conditions

Sudden onset of illness ○ Post-surgery recovery ○ Acute exacerbation of chronic diseases

3 focus acute care hosp

Vital Signs ○ Wound Healing ○ Medication Response, Risk for delirium ○ Risk for falls ○ Mobility

6 priorities acute care

home care

Patients are generally well and are able to perform ADLs ● Nurses only go a few times per week ● More on Health Maintenance

Manage chronic illness ○ Maintain safety ○ Medication adherence of the patient

home care 3 focus

Long-Term Care/Nursing Homes

Patients admitted here have a limited level of independence or cannot perform ADLs anymore

Continuous monitoring for the decline of the patient ○ Prevent complications

2 focus nsg home

Risk for Injuries (Pressure Injuries) ○ Risk for Falls ○ Risk for Malnutrition

nsg home assessment priorities 3

health Promotion ○ Illness Prevention ○ Early Detection of problems

senior centers/community health 3 focus

Health Monitoring: Vital Signs, Vision and Hearing Screening

○ Lifestyle, Habits

○ Health Education Needs

senior centers assessment priorities 3 focus

Congregate or Assisted Living

Same with Nursing Home, but the patient still has independence

Monitoring of Independence ○ Ensure a safe environment ○ Supporting Social Needs

Congregate or Assisted Living 3 focus

Ability of the patient to manage ADLs and IADLs

○ Social Interaction & Quality of Life

○ Emotional Adjustment

assisted living 3 priorities

Depends on the patient’s problem

Independent/Group Nursing Practices priority

Hospice or Palliative Care

End of life care; the patient will surely die in the near future

Level of Comfort (Alleviation of suffering)

○ Symptom Control (especially pain)

○ Family support at end of life

Hospice or Palliative Care 3 focus

Pain ○ Shortness of Breath ○ Fatigue

hospice 3 assessment priorities

Broad Gerontologic Knowledge Base 2. Art of Assessment 3. Identifying Complexities

SKILLS NEEDED IN GERONTOLOGIC ASSESSMENT 3

biology of aging, psychosocial changes, cultural beliefs

3 under Broad Gerontologic Knowledge Base

normal physiologic changes and pathologic changes

biology of aging Distinguish between

geriatric depression

Bereavement and social isolation can be normal or abnormal can be a sign of

art of assessment

refers to incorporating human touch in the assessment process

Active Listening ● Empathy ● Patient ● Non-verbal communication ● Trust Building

art of assessment 5

Multiple comorbidities, polypharmacy, atypical illness presentation

3 under Identifying Complexities

Multiple comorbidities

Patients may have many illnesses with overlapping illnesses.

polypharmacy

Using multiple medications at the same time; there may be drug to drug interactions and adverse effects

Atypical illness presentation

Symptoms present atypically; unusual symptoms that differ in older and younger adults

1. Person-centered approach

2. Patients as Active Participants

3. Emphasis on Functional Ability

No matter what assessment tool you use, always follow these 3 principles:

Quality of Life (QoL)- direct

Risk of Hospitalization- indirect

Nursing Home Admission- indirect

mortality- indirect

FUNCTIONAL ASSESSMENT 4 and rel to level of dependence

Detecting subtle changes ● Timely interventions ● Prevention of Complications

Early Recognition of Decline 3

Health Perception

○ Nutritional-Metabolic

○ Elimination

○ Activity-Exercise

○ Sleep-Rest

○ Cognitive-Perceptual

○ Self-Perception/Self-Concept

○ Role-Relationship

○ Sexuality-Reproductive

Gordon’s Functional Health Problems 11

structured, person-centered approach to understanding the whole patient,

Gordon’s Functional Health Problems focus

a. Encourages pattern recognition ○ Systematic ○ Applicable across settings

b. Time consuming ○ Advance Skill Level ○ Lesser Focus on Function

gordon adv and diadv

Evaluates basic self-care functions that are essential for independent-living

Katz Index of Independence in ADLs focus

Bathing ○ Dressing ○ Toileting ○ Transferring ○ Continence ○ Feeding

6 Activities for Judging (ADLs): KATZ

a. Fast ○ Clear and Objective ○ Useful for care of planning

b. Limited scope ○ Scoring is all or nothing ○ Does not consider context

katz adva and diadv

Evaluates more complex daily tasks that are necessary for living independently

Lawton’s Instrumental Activities of Daily Living (IADL) focus

Cooking, Cleaning, Managing Finances, Grocery Shopping, and Managing Medications

IADLs: lawton 6

a. Early detection of decline ○ Quick and Easy ○ Widely used & validated

b. Not gender neutral ○ Cultural expectations ○ Limited scope

adv and diadv lawton

ok

familliarize

Assesses global cognitive function

Mini-Mental State Exam (MMSE) focus

○ Max = 30 points

○ 25-30 = Normal ‘

○ 21-24 = Mild Impairment

○ 10-20 = Moderate

○ <10 = Severe

Mini-Mental State Exam (MMSE) scoring

Screens for cognitive impairment ○ Establishes baseline ○ Allows tracking of the patient’s cognitive function

Mini-Mental State Exam (MMSE) importance 3

○ Orientation ○ Registration ○ Attention ○ Language ○ Copying

mmse things to judge 5

5- what is the yr

5- where are we now

give 2 mmse question and points

assess depressive symptoms of Older Adults

Geriatric Depression Scale focus

are basically satisfied w ur life

have u dropped many of ur activities and interests

do u feel ur life is empty

give 3 qs from geriatric depression scale

identify malnutrition or risk for malnutrition

Mini-Nutritional Assessment (MNA) focus

Normal: 12-14 '

○ At risk for Malnutrition: 8-11

○ Malnourished: 0-7

Mini-Nutritional Assessment (MNA) scoring

mobility, neuropsychological prob, bmi

give 3 MNA screening

View older adults as a whole ○ Take note of the environmental stressors

What should nurses do? 2

a. (illness, frailty, chronic diagnosis

b. loss, depression, isolation

c. (safety, hospital stress, missing aids

Interrelationship of:

a. physical

b. psychosocial

c. env

Aging does not cause disability

Age-related changes ● Core Idea:

Age-related physiologic changes + chronic disease

Disability=

mobility, vision, nutrition

give 3 aspects under age related changes

Delayed recognition ○ Functional Decline ○ Hospitalizations

Atypical presentation of illness: Effects on Function: 3

Always suspect illness ○ Compare to baseline, holistic monitoring

Nursing Implications 3

Physiologic changes of aging ○ Comorbidities and Polypharmacy ○ Cognitive and Sensory impairment

Why do atypical presentations occur? 3

Confusion, delirium, incontinence

uti ss

syncope, fatigue, confusion

mi ss

confusion, anorexia, tachypnea

pneumonia ss

Anorexia, agitation, weakness

hf ss

Changes in condition may reflect disease

cognitive assessment core idea

a. sudden, reversible

b. chronic, irreversible

a. delirium

b. dementia

Assessment Setting

Environmental Modification

time and pacing

focus on abilities

source of info

nurse pt interaction

TAILORING THE NURSING ASSESSMENT TO THE OLDER PERSON 6

Patient comfort ○ Convenience ○ Patient Privacy

Environmental Modification 3

Manner of communication

influences accuracy of data

collect objective data

APPROACHES TO PHYSICAL ASSESSMENT purpose

Identify strengths ○ Identify Limitations ○ Verify Subjective Findings ○ Gather new data

APPROACHES TO PHYSICAL ASSESSMENT steps 4

head to Toe ○ Left to Right

APPROACHES TO PHYSICAL ASSESSMENT methods

a. acute issues

b. mobility fall risk

c. skin integrity

settings priority

a. hosp

b. home

c. long term

SPICES Tool- Sleep Disorders ○ Problems with Eating or Feeding ○ Incontinence ○ Confusion , Evidence of Falls ○ Skin Breakdown

Tells us that there is a needed intervention for the patient ● Not disorders but a cluster of symptoms

Confirmatory ○ Detection of Hidden problems ○ Monitoring of treatments

LABORATORY DATA ● Purpose: 3

○ Decreased organ function ○ Medications ○ Silent Diseases

labs special cons in older adults 3

Correlate labs with functional changes ○ Avoid assumptions ○ Recognize slight deviations

labs Nursing Implications 3