NSB103 Health Assessment Lecture Notes PDF

NSB103 Health Assessment Dr Jane O’Brien (UC) Lecture: Assessing the older adult Acknowledgement: Dr Pauline Gillan Dr Helen Donovan  Care of the Older Person: Contexts of Care Care takes place in: Primary Care (GP’s, allied health) Acute Care (hospital) Community Care (post acut...

NSB103 Health Assessment Dr Jane O’Brien (UC) Lecture: Assessing the older adult Acknowledgement: Dr Pauline Gillan Dr Helen Donovan  Care of the Older Person: Contexts of Care Care takes place in: Primary Care (GP’s, allied health) Acute Care (hospital) Community Care (post acute care; hospital in the home etc) Residential Aged Care Facilities (low level and high level care) https://www.evidentlycochrane.net/falls-prevention-older-people-what-can-nurses-do/  Older Adults in Acute Care “Hospitals are a high risk environment with significant risk of iatrogenic adverse events” (Creditor, 1993, cited in Koch, Hunter, & Nair, 2009, p.154). Adverse drug events (due to altered physiology, pharmacokinetics, pharmacodynamics and drug compliance/adherence, polypharmacy) Nutritional deficits (>40% of older patients in acute and subacute care are a high risk of malnutrition (Koch, et al, 2009, p.155). Deconditioning (inactivity, bedrest, medical illnesses, polypharmacy can result in loss of function in activities of daily living; decrease in muscle mass 5% per day) (Koch, et al, 2009, p.155). High risk of: Pressure injuries Skin tears Falls Other complications due to hospitalisation.  Aged Care Quality Standards Standard 1: Consumer dignity and choice Standard 2: Ongoing assessment and planning with consumers Standard 3: Personal care and clinical care Standard 4: Services and supports for daily living Standard 5: Organisation’s service environment Standard 6: Feedback and complaints Standard 7: Human resources Standard 8: Organisational governance https://www.agedcarequality.gov.au/providers/standards  Health Issues Experienced by Older Adults Impaired cognition- delirium, dementia, depression Falls Urinary incontinence Constipation and faecal incontinence Pain Skin compromise (skin tears, pressure injuries etc) Leading causes of burden of disease for older adults: Cardiovascular disease and Cancers (24%) Neurological conditions (11%) Musculoskeletal conditions (9%) Respiratory conditions (9%)  Burden of Disease https://www.aihw.gov.au/reports/older-people/older-australia-at-a-glance/contents/health-functioning/burden-of-disease  Person Centered Care (PCC) of the Older Adult “… the need for a recognition of and connection with the person, a focus on the person’s strengths and goals, an interdisciplinary approach, and recognition of the centrality of relationships” (Nay, et al., 2009, p. 109). Factors facilitative of PCC: Having skilled, knowledgeable and enthusiastic staff with good communication skills Opportunities for involvement of client, carer and family Opportunities for staff to reflect on their own values and beliefs Staff training and education Organisational support An environment of mutual respect and trust (Nay, et al., 2009, p. 117).  Comprehensive Assessment of the Older Adult Specific domains of health assessment: Medical health (concerned with symptom identification and any unmet health care needs) Physical function (in terms of everyday activities- e.g. self care, household tasks, mobility) Psychological function (primarily concerned with cognition and mood) Social function (includes ethnicity, spirituality, cultural background) (Davis, et al., 2009, p. 172-173) Sources of assessment information: Patients/clients (self report) Others who know the patient well (informant report) Observing the patient undertaking various activities of daily living (direct observation) Various sources of secondary written sources of information (hospital records, medical reports, investigation results) (Davis et al, 2009, p. 173)  General Approach to Older Adult Assessment; Nursing checklist (Estes et al, 2020, p. 817-818) 1. Ensure a warm, comfortable and welcoming environment 2. Always address questions to the older adult (not caregiver) 3. Use bright indirect light to enhance ability to function (quiet environment; minimal background noise) 4. Minimise interruptions 5. Allow adequate time (and rest periods as needed) 6.Allow person to maintain independence 7. Ask prior to assisting if assistance is needed for examination 8. Instruct removal of all items of clothing for examination- always provide gown, respect modesty 9. Provide warmer temperature- provide blankets if needed 10. Check hearing aids and clean glasses; validate all information provided 11. Ask if person would like caregiver to remain present during examination 12. Allow person to choose own position for comfort 13. Maximise visual cues 14. Use open ended questions 15. At end of interview illicit essential subjective information related to close ended questions 16. Use evidence based tools specific to the older person 17. Conclude by asking if there are other concerns or if any questions Special Considerations for Assessing an Older Adult Calleja, et al., 2020, p. 812  Assessment of the Older Adult Special assessments: Developmental assessment Cultural and spiritual assessment Nutritional assessment Pain assessment (Calleja, et al., 2020, p. 813-814 ) Physical Examination: Functional testing Cognition Vital signs Height and weight Skin, hair, nails, head and neck, eyes, ears, nose etc (and body systems)  Assessment of the Older Adult: Vital Signs Respirations Pulse Temperature BP (Estes et al, 2020, pp. 819) https://www.rnpedia.com/nursing-notes/fundamentals-in-nursing-notes/vital-signs/ Assessment Tools: Nutrition Assessment Tools: Pain Assessment Assessment Tools: Falls Risks Assessment Tools: Pressure Injury WATERLOW PRESSURE ULCER PREVENTION/TREATMENT POLICY Risk Assessment Ring scores in table, add total. More than one score/category can be used. BUILD/WEIGHT SKIN TYPE SEX MALNUTRITION SCREENING TOOL (MST) FOR HEIGHT VISUAL RISK AGE (Nutrition vol.15, no.6 1999—Australia) AREAS MALE 1 A - HAS PATIENT LOST WEIGHT RECENTLY B - WEIGHT LOSS SCORE AVERAGE HEALTHY 0 FEMALE 2 YES - GO TO B 0.5 - 5 KG = 1 BMI = 20-24.9 0 TISSUE PAPER 1 14 - 49 1 NO - GO TO C 5 - 10KG = 2 ABOVE AVERAGE DRY 1 50 - 64 2 UNSURE - GO TO C AND SCORE 2 10 - 15 KG = 3 BMI = 25-29.9 1 OEDEMATOUS 1 65 - 74 3 > 15KG = 4 OBESE CLAMMY, PYREXIA 1 75 - 80 4 UNSURE =2 BMI > 30 2 DISCOLOURED 81 + 5 BELOW AVERAGE GRADE 1 2 C - PATIENT EATING POORLY OR LACK OF APPETITE ‘NO’ NUTRITION SCORE BMI < 20 3 BROKEN/SPOTS = 0, ‘YES’ = 1 IF > 2 REFER FOR NUTRITION ASSESSMENT/ BMI=WT(KG)/HT (m2) GRADE 2-4 3 INTERVENTION. CONTINENCE MOBILITY SPECIAL RISKS COMPLETE/ FULLY 0 TISSUE MALNUTRITION NEUROLOGICAL DEFICIT CATHETERISED 0 RESTLESS/FIDGETY 1 URINE INCONT. 1 APATHETIC 2 TERMINAL CACHEXIA 8 DIABETES , MS, CVA 4-6 FAECAL INCONT. 2 RESTRICTED 3 MULTIPLE ORGAN FAILURE 8 MOTOR/SENSORY 4-6 URINARY + FAECAL BEDBOUND SINGLE ORGAN FAILURE PARAPLEGIA (MAX OF 6) 4-6 INCONTINENCE 3 e.g. TRACTION 4 (RESP, RENAL, CARDIAC) 5 CHAIRBOUND PERIPHERAL VASCULAR e.g. WHEELCHAIR 5 DISEASE 5 MAJOR SURGERY OR TRAUMA ANAEMIA (HB < 8) 2 ORTHOPAEDIC /SPINAL 5 SMOKING 1 ON TABLE > 2 HR# 5 ON TABLE > 6 HR# 8 MEDICATION—CYTOTOXICS, LONG TERM /HIGH DOSE STEROIDS, ANTI-INFLAMMATORY—MAX OF 4 SCORE # Scores can be discounted after 48 hours, provided patient is recovering normally. 10 + AT RISK 15 + HIGH RISK 20 + VERY HIGH RISK © J. Waterlow 1985, revised 2005* Obtainable from the Nook, Stoke Road, Henlade TAUNTON TA2 5LX * The 2005 revision incorporates the research undertaken by Queensland Health. www.judy-waterlow.co.uk Assessment Tools: Skin Tear Grading and Pressure Injury Grading Assessment of the Person with Dementia: Pain Assessment Abbey Pain Scale For measurement of pain in people with dementia who cannot verbalise. How to use scale: While observing the resident, score questions 1 to 6 Name of resident: ………………………………………………………………………... Name and designation of person completing the s cale: …………………………. Date: ….………………………………………Time: ……………………………………… Latest pain relief given was…………………………..…………..….….at ………..hrs. Q1. Vocalisation eg. whimpering, groaning, crying Q1 Absent 0 Mild 1 Moderate 2 Severe 3 Q2. Facial expression eg: looking tense, frowning grimacing, looking frightened Q2 Absent 0 Mild 1 Moderate 2 Severe 3 Q3. Change in body language eg: fidgeting, rocking, guarding part of body, withdrawn Q3 Absent 0 Mild 1 Moderate 2 Severe 3 Q4. Behavioural Change eg: increased confusion, refusing to eat, alteration in usual Q4 patterns Absent 0 Mild 1 Moderate 2 Severe 3 Q5. Physiological change eg: temperature, pulse or blood pr essure outside normal Q5 limits, perspiring, flushing or pallor Absent 0 Mild 1 Moderate 2 Severe 3 Q6. Physical changes eg: skin tears, pressure areas, arthritis, contr actures, Q6 https://www.ncbi.nlm.nih.gov/books/NBK557444/figure/article-20337.image.f1/ previous injuries. Absent 0 Mild 1 Moderate 2 Severe 3 Add scores for 1 – 6 and record here Total Pain Score Now tick the box that matches the Total Pain Score 0–2 3–7 8 – 13 14+ No pain Mild Moderate Severe Finally, tick the box which matches Chronic Acute Acute on the type of pain Chronic Dementia Care Australia Pty Ltd Website: www.dementiacareaustralia.com Abbey, J; De Bellis, A; Piller, N; Esterman, A; Giles, L; Parker, D and Lowcay, B. Funded by the JH & JD Gunn Medical Research Foundation 1998 – 2002 (This document may be reproduced with this acknowledgment retained) www.WongBakerFACES.org Assessing Cognitive Status of the Older Person (MMSE) https://oxfordmedicaleducation.com/geriatrics/mini-mental-state-examination-mmse/ Screening for Delirium in the Older Adult Reference: Inouye SK, Van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI (1990) Clarifying confusion: the Confusion Assessment Method. Annals of Internal Medicine 113: 941-8  Assessment of the Person with a Disability Disability is an umbrella term for impairments, activity limitation and participation restrictions (AIHW, 2020). The Australian Bureau of Statistics (2015) includes a list of 17 key disabilities that are likely to last for https://www.pngkit.com/view/u2e6y3a9o0a9o0w7_disabled-friend-illustrations-people-with-disability-cartoon/ at least 6 months and restrict everyday activities  ABS Survey of Definition of Disability Loss of sight not corrected by glasses or contact lenses Loss of hearing when communication is restricted (or when an aid to assist or substitute hearing is required) Speech difficulties Shortness of breath or breathing difficulties causing restriction Chronic or recurrent pain or discomfort causing restrictions Blackouts, fits or loss of consciousness Difficulty learning or understanding Incomplete use of arms or fingers Difficulty holding or gripping things Incomplete use of legs or feet Nervous or emotional condition causing restriction Restriction in physical activities or in doing physical work Disfigurement or deformity Mental illness or condition requiring help or supervision Long term effects of head injury, stroke or other brain damage causing restriction Receiving treatment or medication for any other long-term conditions or ailments causing restriction Any other long term conditions causing restriction  Prevalence of Disabilities The WHO (2011) estimates the global disability rates among the adult population to be between 15.6% and 19.4% (approx 785-975 million persons aged 15 years or older) (WHO 2011) In Australia 1 in 6 people or 18% of the population are estimated to be living with a disability (about 4.4 million people) (AIHW, 2019). A higher rate of disability occurs in females than males (likely to be the result of females being over-represented in the older age group). The prevalence of disability increases with age. Around 1 in 8 (12%) people aged under 65 have some level of disability, rising to 1 in 2 (50%) for those aged 65 and over. This means that the longer we live, the more likely we are to experience some form of disability (AIHW, 2020). The Older Adult and Disabilities https://www.aihw.gov.au/reports/older-people/older-australia-at-a-glance/contents/health-functioning/health-disability-status  Mechanisms of Disability Physiological: Congenital disorders (occur prenatally or during birth) Trauma (the leading cause of disability)- e.g. motor vehicle related trauma (major cause of spinal and brain injury); others include sport, work and violence. Chronic diseases- caused by physiological disruption related to specific diseases (e.g. multiple sclerosis, myasthenia gravis, Guillian-Barre syndrome; poorly controlled diabetes, atherosclerosis) Ageing- normal physiological changes of ageing e.g. sensory impairments; reduced cardiac output and increased systolic BP, loss of balance, decreased muscle mass and strength- restricting physical activity  Mechanisms of Disability con’t Psychological: Include: Nervous or emotional conditions which cause restrictions in everyday activities that have lasted or are expected to last for 6 months or more A mental illness for which help or supervision is required (for 6 months or more) A brain injury, including stroke, which results in a mental illness or nervous and emotional condition which causes restrictions in everyday activities (ABS 2015). Social: Include spoken language, body language, social interaction, values and beliefs, power relationships and culture. Biopsychosocial: Combination of psychological, physiological and social mechanisms Person-Centered Approach for the Person with a Disability The central tenet for person-centered care is respect for and integration of individual differences when delivering patient care. Critical characteristics of PCC:  Understanding the patient as a unique person presenting with individual characteristics, needs, values, beliefs and preferences  Responding flexibly to individual needs and preferences by selecting and delivering interventions responsive to patients needs and preferences (Crisp et al, 2021, p. 1298-99).  References Australian Government Aged Care Quality and Safety Commission (2021). Quality Standards. https://www.agedcarequality.gov.au/providers/standards Australian Institute of Health and Welfare (2019). Disability: an overview. https://www.aihw.gov.au/reports-data/health- conditions-disability-deaths/disability/overview Australian Institute of Health and Welfare (2020). People with a disability in Australia. https://www.aihw.gov.au/reports/disability/people-with-disability-in-australia/contents/about Australian Institute of Health and Welfare (2018). Older Australians. Retrieved from https://www.aihw.gov.au/reports/older-people/older-australia-at-a-glance/contents/summary Australian Institute of Health and Welfare (2018). Older Australia at a Glance. Retrieved from https://www.aihw.gov.au/reports/older-people/older-australia-at-a-glance/contents/health-functioning/burden-of- disease Calleja, P., Theobald, K. & Harvey, T. (2020). Estes Health Assessment and Physical Examination, Australian and New Zealand 3rd edition, Cengage. Sydney. Crisp, J., Douglas, C., Rebeiro, G. & Water, D. (2021). Potter and Perry’s Fundamentals of Nursing, Australian and New Zealand edition (6e), Elsevier, Chatswood. Davis, S., Dorevitch, M. & Garratt, S. (2009). Person-centred comprehensive geriatric assessment. In R. Nay & S. Garratt (Eds), Older people: Issues and innovations in care, 3rd edition. Elsevier, Chatswood. Koch, S., Hunter, P. & Nair, K. (2009). Older people in acute care. In R. Nay & S. Garratt (Eds), Older people: Issues and innovations in care, 3rd edition. Elsevier, Chatswood. Marieb, E. N. & Hoehn, K. N. (2014). Human anatomy and physiology, 9th edition. Pearson, Essex. Nay, R., Bird, M., Edvardsson, D., Fleming, R. & Hill, K. (2009). Person-centred care. In R. Nay & S. Garratt (Eds), Older people: Issues and innovations in care, 3rd edition. Elsevier, Chatswood.