NCM114: Care of Older Adults Lecture 6 - Comprehensive Geriatric Assessment PDF

Trinity University of Asia - St. Luke’s College of Nursing Batch 2026 - Luminaris NCM114: CARE OF OLDER ADULTS LECTURE 06: COMPREHENSIVE GERIATRIC ASSESSMENT AY 2024-2025 | FIRST SEMESTER | Prof. Robert Matthew Marquez | Adapted from: Book/Lecture PPT...

Trinity University of Asia - St. Luke’s College of Nursing Batch 2026 - Luminaris NCM114: CARE OF OLDER ADULTS LECTURE 06: COMPREHENSIVE GERIATRIC ASSESSMENT AY 2024-2025 | FIRST SEMESTER | Prof. Robert Matthew Marquez | Adapted from: Book/Lecture PPT FOCUS: PREVENT FUNCTIONAL DECLINE OUTLINE I. COMPREHENSIVE GERIATRIC ASSESSMENT A. THREE UNDERLYING PRINCIPLES II. TOOLS USED IN THE CGA A. PHYSICAL B. FUNCTIONAL C. SOCIOECONOMIC D. MEDICAL E. PSYCHOLOGICAL F. ENVIRONMENTAL (FROM THE BOOK) III. INTRODUCTION IV. SPECIAL CONSIDERATIONS AFFECTING ASSESSMENT “Multidimensional interdisciplinary diagnostic A. INTERRELATIONSHIP BETWEEN diagnostic process focused on determining a frail PHYSICAL AND PSYCHOSOCIAL older person’s medical, psychological and functional ASPECTS OF AGING capability in order to develop a coordinated and B. NATURE OF DISEASE AND integrated plan for treatment and long term DISABILITY AND THEIR EFFECTS follow up” ON FUNCTIONAL STATUS It is both a diagnostic and therapeutic process. It C. AGE-RELATED CHANGES seeks to ensure that problems are identified, D. Atypical Presentation of Illness quantified, and managed appropriately. E. Cognitive assessment Should be carried out: F. Tailoring the Nursing Assessment ○ After hospitalization for an acute illness to the Older Person ○ On nursing home placement or change V. The Health History in living status VI. Atypical Presentation of illness in Older ○ After any abrupt changes in physical, Adult social, or psychological function VII. The interviewer ○ When the older person or family would like VIII. Electronic Health Records a second opinion regarding an A. Strategies to Mitigate Issues intervention or treatment protocol B. Positive Aspects of EHR Use recommended by the primary care IX. Health History Format provider X. Description of a Typical Day Research-based, clinical outcomes of CGA: XI. Present Health Status ○ Reduced hospitalization XII. Drugs ○ Reduced mortality rates XIII. Immunization and Health Screening Status ○ Improved mental status XIV. Allergies ○ Lower healthcare costs XV. Nutrition ○ Improved functional ability XVI. Previous Health Status ○ Lower hospital readmissions A. Family History B. Preview of systems THREE UNDERLYING PRINCIPLES OF XVII. Approach to Physical Assessment COMPREHENSIVE GERIATRIC ASSESSMENT XVIII. General Guidelines Physical, psychological, and socioeconomic factors. XIX. Equipment and Skill Comprehensive evaluation of an older person’s XX. Additional Assessment Measures health status requires an assessment in each of A. Functional Status Assessment these domains. B. Cognitive Affective Assessment Functional abilities should be a central focus of the XXI. Social Assessment comprehensive evaluation. XXII. Nursing Standard of Assessment XXIII. Mental Status Assessment XXIV. Laboratory XXV. Key Points COMPREHENSIVE GERIATRIC ASSESSMENT An interdisciplinary process to assess the older persons using a biopsychosocial functional model to systematically collect data. An interdisciplinary and multidimensional Person-Centered CRUZ, A., CRUZ, A.Y., CRUZ, H., CRUZ J., DADIVAS, B., DECASTRO, A., DE GUZMAN, L., DE GUZMAN, S., DE JESUS, A., DE LEON, J., DELGADO, S., DELO SANTOS, E., DOCIL, P., DOLLOZA, A. | 3NU04 1  TOOLS USED IN THE FUNCTIONAL COMPREHENSIVE GERIATRIC ASSESSMENT Mobility and Balance Activities in Daily Living PHYSICAL Physical Examination BARTHEL’S INDEX OR KATZ INDEX OF Nutritional Assessment INDEPENDENCE IN ADLs BODY MASS INDEX According to WHO, an older person is someone who is 65+ years old (sometimes 60+). Based on extensive research, different BMI categories were set for older adults, where healthy weight was defined as a BMI ranging from 23 to 29.9 kg/m^2. This stems from the fact that researchers noticed that a BMI below 23 and above 33 is associated with a significantly increased risk of mortality. BMI CHART FOR ELDERLY MNA: MINI NUTRITIONAL ASSESSMENT LAWTON INSTRUMENT ADLs SCALE TIME UP AND GO (TUG) CRUZ, A., CRUZ, A., CRUZ, H., CRUZ J., DADIVAS, B., DECASTRO, A., DE GUZMAN, L., DE GUZMAN, S., DE JESUS, A., DE LEON, J., DELGADO, S., DELO SANTOS, E., DOCIL, P., DOLLOZA, A.| 3NU04 2  FULMER’S SPICES Is an efficient and effective instrument for obtaining the information necessary to prevent health alterations in the older adult patient (Fulmer, 1991, Fulmer, 2001). SPICES is an acronym for the common syndromes of the elderly requiring nursing interventions: ○ S is for Sleep Disorders ○ P is for Problems with Eating or Feeding ○ I is for Incontinence ○ C is for Confusion ○ E is for Evidence of Falls SOCIOECONOMIC ○ S is for Skin Breakdown Social Security System Re-enactment of Fulmer’s SPICES Financial Situation ○ https://www.youtube.com/watch?v=PStIKs eWa4A FAMILY APGAR (ADAPTATION, PARTNERSHIP, FANCAPES GROWTH, AFFECTION, RESOLVE) When the nurse suspects that an actual emergency A five (5) question assessment tool for rapid or serious problem is present or might be assessment of family function and dysfunction developing, in these situations, deep, focused Measures the individual’s level of satisfaction about assessments are more appropriate and necessary. family relationships. The following mnemonics can be used to organize ○ Adaptation - the ability of a family to use this assessment: and share inherent resources which can ○ F is fluid - star of hydration be either intra- or extra familial ○ A is aeration (oxygenation) - respiratory ○ Partnership - the sharing of decision function making which measures the satisfaction of ○ N is for nutrition - type and amount of solving problems through communicating food consumed ○ Growth - pertains to both physical and ○ C is for cognition, communication - emotional aspects and measures the adequate ability to communicate needs satisfaction of the freedom to change. ○ A is for activity/ability - ability to meet ○ Affection - emotions that are shared with ADLs and between family members which ○ P is for pain - physical, psychological and measures the satisfaction with the intimacy spiritual pain and emotional interaction that exist in the ○ E is for elimination - difficulty with bladder family. or bowel elimination ○ Resolve - refers to how time, money, and ○ S is for kin/socialization - ability to space are shared. This measures create meaningful relationships. satisfaction with the commitment made by the members of the family. PSYCHOLOGICAL Scoring Condition ○ 8-10 points = highly functional family Mood and Emotion ○ 4-7 points = moderately dysfunctional family MMSE: MINI MENTAL STATUS EXAM OR MINI-COG ○ 0-3 points = severely dysfunctional family OR MOCA: MONTREAL COGNITIVE ASSESSMENT The Mini-Cog - consist of three item recalls and a clock drawing test (CDT). It takes about three minutes to administer and is not affected by language, education, or culture. The tool can differentiate older persons with dementia from those without dementia. Clock Drawing Test MEDICAL Comorbidities Medication Review BEER’S CRITERIA CRUZ, A., CRUZ, A., CRUZ, H., CRUZ J., DADIVAS, B., DECASTRO, A., DE GUZMAN, L., DE GUZMAN, S., DE JESUS, A., DE LEON, J., DELGADO, S., DELO SANTOS, E., DOCIL, P., DOLLOZA, A.| 3NU04 3  incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? FEATURED 4: ALTERED LEVEL OF CONSCIOUSNESS ○ This feature is shown by any answer other than “alert” to the following questions: Overall, how would you rate this patient’s level of consciousness? (alert [normal], vigilant [hyperalert], lethargic [drowsy, easily aroused], stupor [difficult to arouse], or coma [unarousable]) The diagnosis of delirium by CAM requires the presence of features 1 and 2 and either 3 and 4. GDS: GERIATRIC DEPRESSION SCALE The short form includes 15 questions and measures depression in the older adult. The answers in bold indicate depression. Score 1 point for each bolded answer. A score of greater than 5 is suggestive of depression and indicates the need for further screening. ENVIRONMENT EVALUATION OF THE ENVIRONMENT To make the older patient and family comfortable, environmental modifications should be made, if possible. Environmental modifications may include adequate lighting, decreased background noise, comfortable seating for the older patient and family, easily accessible restrooms, examination CAM: CONFUSION ASSESSMENT METHOD tables that can be raised or lowered to assist FEATURE 1: ACUTE ONSET OR FLUCTUATION patients with disabilities, and availability of COURSE water or juice for patient use. ○ This feature is usually obtained from a Patient comfort will ease communication and family member or nurse and is shown by improve the data gathering process. positive responses to the following questions: Is there evidence of an acute HOME ENVIRONMENT change in mental status from the Some geriatric assessment teams have the time patient’s baseline? Did the (abnormal) and resources to visit the older patient’s home and behavior fluctuate during the day, that conduct an assessment of the environment. While is, tend to come and go, or increase this direct observation is the best way to gather and decrease in severity? accurate and reliable data, it is time consuming and FEATURE 2: INATTENTION can be expensive. Therefore, many geriatric ○ This feature is shown by a positive assessment teams question the older person and response to the following question: Did the the family regarding the adequacy of the home patient have difficulty focusing environment and the available resources to attention. For example, being easily maintain adequate levels of function. distractible, or having difficulty keeping track of what was being said? INTRODUCTION FEATURE 3: DISORGANIZED THINKING ○ This feature is shown by a positive NURSING PROCESS response to the following question: was the patient’s thinking disorganized or CRUZ, A., CRUZ, A., CRUZ, H., CRUZ J., DADIVAS, B., DECASTRO, A., DE GUZMAN, L., DE GUZMAN, S., DE JESUS, A., DE LEON, J., DELGADO, S., DELO SANTOS, E., DOCIL, P., DOLLOZA, A.| 3NU04 4  A problem-solving process that provides the The health of people of all ages is subject to the organizational framework for the provision of influence of multiple physical and psychosocial nursing care. factors within the environment which greatly influences a person’s health status. PURPOSE OF OLDER ADULT ASSESSMENT The following combination of factions may place To identify patient strengths and limitations so that older adults at high risk for loss of functional ability. effective and appropriate interventions can be ○ Reduced ability to respond to stress delivered to support, promote, and restore opti- mal ○ Increased frequency and multiplicity of loss function, and prevent disability and dependence. ○ Physical changes associated with normal aging NURSING FOCUS CASE: The sequential steps of the nursing process Mrs. M, age 83, arrived in the emergency room after being “ADPIE” found in her home by a neighbor. The neighbor had ○ Assessment become concerned because he noticed Mrs. M had not ○ Diagnosis picked up her newspapers for the past 3 days. She was ○ Planning found in her bed, weak and lethargic. She stated that she ○ Implementation had the flu for the past week, so she was unable to eat or ○ Evaluation drink much because of the associated nausea and Evolves from an awareness and understanding of vomiting. Except for her mild hypertension, which is the definition of nursing. medically managed with an antihypertensive agent, she had enjoyed relatively good health before this acute NURSING (ANA, 2015) illness. She was admitted to the hospital with pneumo- The protection, promotion, and optimization of nia. Because of the emergent nature of the admission, health and abilities, prevention of illness and injury, Mrs. M does not have any personal belongings with her, facilitation of healing, alleviation of suffering through including her hearing aid, glasses, and dentures. She the diagnosis and treatment of human response, develops congestive heart failure after treatment of her and advocacy in the care of individuals, families, dehydration with intravenous fluids. She becomes groups, communities, and populations. confused and agitated, and haloperidol is administered to her. Her impaired mobility, resulting from the chemical CHARACTERISTICS OF PRACTICE OF NURSING restraint, has caused urinary and fecal incontinence, and ACROSS ALL SETTINGS (ANA, 2015) she has developed a stage 2 pressure injury on her Caring and health are central to the practice of the coccyx. She needs to be fed because of confusion and registered nurse. eats very little. She sleeps at intervals throughout the day Nursing practice is individualized. and night, and when she is awake, she is usually crying. Registered nurses use the nursing process to plan and provide care tailored to the individual needs of It is key to identify the patient’s strengths and abilities to healthcare consumers. build the plan of care. Nurses coordinate care by establishing partnerships with patients and other healthcare providers. Careful considerations: A strong link exists between the professional work Interrelationships among physical, psychosocial, and environment and the registered nurse’s ability to environmental aspects of every patient situation. provide quality healthcare and achieve optimal outcomes. Settings ○ Hospitals, homes, long-term care facilities, senior centers, congregate living units, hospice facilities, and independent or group nursing practices. GERONTOLOGIC NURSING Assessing the older adult involves the application of a broad range of skills and abilities, as well as consideration of many complex and varied issues. The nurse should collect the data while observing the following key principles: ○ The use of an individual, person-centered approach ○ A view of patients as participants in health monitoring and treatment ○ An emphasis on patients’ functional ability. SPECIAL CONSIDERATIONS AFFECTING ASSESSMENT NATURE OF DISEASE AND DISABILITY AND THEIR The interrelationship between physical and EFFECTS ON FUNCTIONAL STATUS psychosocial aspects of aging. Aging does not necessarily result in disease and Assessment of the nature of disease and disability disability. and their effects on functional status. Chronic disease increases older adults’ vulnerability To tailor the nursing assessment to the individual to functional decline. older adult. Comprehensive assessment of physical and psychosocial function, as well as environmental INTERRELATIONSHIP BETWEEN PHYSICAL AND issues, is important because it can provide valuable PSYCHOSOCIAL ASPECTS OF AGING clues to a disease’s effect on functional status. CRUZ, A., CRUZ, A., CRUZ, H., CRUZ J., DADIVAS, B., DECASTRO, A., DE GUZMAN, L., DE GUZMAN, S., DE JESUS, A., DE LEON, J., DELGADO, S., DELO SANTOS, E., DOCIL, P., DOLLOZA, A.| 3NU04 5  Self reported vague signs and symptoms such as valuable sources of data regarding the onset, lethargy, incontinence, decreased appetite, and duration, and associated symptoms. weight loss. It may be difficult for the nurse to differentiate TAILORING THE NURSING ASSESSMENT normal age-related findings from indicators of TO THE OLDER PERSON disease or disability. The health assessment may be collected in a variety of physical settings, including hospital, AGE-RELATED CHANGES home, office, day care center, and long-term care Declining physiologic function and increased facility. prevalence of disease are a result of a reduction in Environmental modifications made during the the body’s ability to respond to stress in all of its assessment should consider sensory and forms. musculoskeletal changes in the older adult. The Typical physiologic changes includes: following points should be considered in preparation ○ Decreased renal and hepatic blood flow of the environment: and mass ○ Provide adequate space, particularly if the ○ Decreased lean body mass and muscle patient uses a mobility aid. mass ○ Minimize noise and distraction such as ○ Decreased total body water and increased those generated by a television, radio, adipose tissue intercom, or other nearby activity. All leading to potential for ○ Set a comfortable, sufficiently warm pharmacokinetic and temperature and ensure no drafts are pharmacodynamic responses to present. drugs. ○ Use diffuse lighting ○ with increased illumination; avoid As individuals age, they are more susceptible to directional or localized light. cancer due to an increase in damage to cellular ○ Avoid glossy or highly polished surfaces, DNA and a reduced response to physiologic including floors, walls, ceilings, and changes increasing the risk of syncope in older furnishings. adults. ○ Place the patient in a comfortable seating The incidence of diabetes increases secondary to position that facilitates information increased insulin resistance and glucose exchange. intolerance. ○ Ensure the older adult's proximity to a It is important for the nurses to assess older adults bathroom. for the presence of physical, psychosocial, and ○ Keep water or other preferred fluids environmental stressors and their physical and available. cognitive manifestations. ○ Provide a place to hang or store garments and belongings. ATYPICAL PRESENTATION OF ILLNESS ○ Maintain absolute privacy. Determining older adults' physical and psychosocial ○ Plan the assessment, considering the health status is not easy secondary to altered older adult's energy level, pace, and presentation of illness. adaptability. More than one session may The diminished reserve poses no particular be necessary to complete the assessment. problems for older people as they carry out their ○ Be patient, relaxed, and unhurried. daily routines; in times of physical and emotional ○ Allow the patient plenty of time to respond stress, older people will not always exhibit the to questions and directions. expected signs and symptoms. ○ Maximize the use of silence to allow the Presenting signs and symptoms may be unrelated patient time to collect thoughts before to the actual problem. responding. ○ Ex: confusion accompanying a urinary ○ Be alert to signs of increasing fatigue such tract infection as sighing, gri-macing, irritability, leaning The nurse should assume heterogeneity rather against objects for support, dropping of the than homogeneity when caring for older adults. head and shoulders, and progressive slowing. COGNITIVE ASSESSMENT ○ Conduct the assessment during the Delirium is one of the most common atypical patient's peak energy time. presentations of illness in older adults, representing Failure to do so could result in inaccurate a wide variety of potential problems. conclusions about the older adults’ functional ability, Knowing older adults’ baseline mental status is which may lead to inappropriate care and treatment: essential to avoid overlooking a serious illness ○ Assess more than once and at different manifesting itself with delirium. times of the day. Other diagnostic features of dementia include ○ Measure performance under the most evidence of significant cognitive decline over time favorable of conditions. along with deficits in learning and memory, ○ Take advantage of natural opportunities language, executive function, attention, perceptual that would elicit assets and capabilities; and motor skills, and social interaction. collect data during bathing, grooming, and Delirium predominantly affects attention and is mealtime. typically reversible; dementia predominantly affects ○ Ensure that assistive sensory devices memory and irreversible. (glasses, hearing aid) and mobility devices Note: it may not be possible or desirable to (walker, cane, prosthesis) are in place and complete the total assessment during the first functioning correctly. encounter. Family and friends of the patient may be CRUZ, A., CRUZ, A., CRUZ, H., CRUZ J., DADIVAS, B., DECASTRO, A., DE GUZMAN, L., DE GUZMAN, S., DE JESUS, A., DE LEON, J., DELGADO, S., DELO SANTOS, E., DOCIL, P., DOLLOZA, A.| 3NU04 6  ○ Interview family, friends, and significant others involved in the patient's care to signs are tachypnea, validate assessment data. arrhythmia, hypotension, ○ Use body language, touch, eye contact, restlessness, syncope, and speech to promote the patient's confusion, and maximum degree of participation. fatigue/weakness ○ Be aware of the patient's emotional state and concerns; fear, anxiety, and boredom Pneumonia Cough productive Cough may be mild and may lead to inaccurate assessment of purulent nonproductive or conclusions regarding functional ability. sputum, chills absent; chills and fever and fever, and/or elevated WBC THE HEALTH HISTORY pleuritic chest also may be absent pain, elevated Tachypnea, slight The interview forms the basis of a therapeutic WBC count cyanosis, delirium, nurse-patient relationship in which the patient’s anorexia, N/V, well-being is the mutual concern. confusion, malaise and The data obtained from the health history alerts the tachycardia may be nurse to focus on key areas of the physical present. examination that require further investigation. The process of recounting a patient’s history in a purposeful, systematic way may have the Heart Failure Increased Anorexia, confusion, therapeutic effect of serving as a life review. dyspnea agitation, weakness, The nursing health history for the older adult should (orthopnea, restlessness, delirium, include assessment of functional, cognitive, paroxysmal cyanosis, affective, and social well-being. nocturnal and falls may be dyspnea), fatigue, present. INDICATORS OF FUNCTIONAL IMPAIRMENT weight gain, Cough, may not report pedal edema, dyspnea nocturia, bibasilar “WILD” – Vague S/Sx that could increase risk of physical crackles frailty. Weight Loss Hyperthyroidism Heat intolerance, Subtle symptoms, Incontinence fast pace, lethargy, weakness, Lethargy exophthalmos, depression, atrial Decreased appetite increased pulse, fibrillation, tachycardia, hyperreflexia, weight loss, fatigue, ATYPICAL PRESENTATION OF ILLNESS IN OLDER tremor palpitations, tremor, and ADULTS HF Hypothyroidism Weakness, Often presents without fatigue, cold overt symptoms; intolerance, cognitive dysfunction, lethargy, skin fatigue, anorexia, and dryness and arthralgias may be scaling, present. constipation Delirium, dementia, depression/lethargy, constipation, weight loss, and muscle weakness/unsteady gait are common. Depression Dysphoric mood Any of the classic and thoughts, symptoms may or may withdrawal, not be present. crying, weight Memory and loss, constipation, concentration problems, PROBLEM CLASSIC PRESENTATION IN insomnia cognitive and behavioral PRESENTATION OLDER ADULT changes, increased IN YOUNG PATIENTS dependency, anxiety PATIENTS and increased sleep. Muscle aches, Urinary Tract Dysuria, Dysuria, frequency, and abdominal pain or Infection frequency, urgency often absent tightness, flatulence, urgency, nocturia nausea and vomiting, dry mouth, and Myocardial Severe Sometimes no chest headaches. Infarction substernal chest pain; or atypical pain Be alert for CHF, pain, diaphoresis, location such as in jaw, diabetes, cancer, nausea, dyspnea neck, shoulder, infectious diseases, and epigastric area. anemia. Dyspnea may or may Cardiovascular agents, not be present. Other anxiolytics, CRUZ, A., CRUZ, A., CRUZ, H., CRUZ J., DADIVAS, B., DECASTRO, A., DE GUZMAN, L., DE GUZMAN, S., DE JESUS, A., DE LEON, J., DELGADO, S., DELO SANTOS, E., DOCIL, P., DOLLOZA, A.| 3NU04 7  Believing that older adults do not participate in amphetamines, sexual relationships may result in the nurse's failure narcotics, and hormones to interview the patient about sexual health matters. may also play a role. To ensure a successful interview, the nurse should explain the reason for the interview to the patient THE INTERVIEWER and give a brief overview of the format to be The interviewer's ability to elicit meaningful data from the followed. This alleviates anxiety and uncertainty, patient depends on the interviewer's attitudes and and the patient can then focus on telling the stereotypes about aging and older people. story. Older people have lengthy and often complicated histories. A goal-directed interviewing process helps Cultural Considerations and the Interviewer the patient share the pertinent information, but the Health care personnel must be mindful of the tendency to reminisce may make it difficult for the different approaches to health care each culture patient to stay focused on the topic. Guided prefers. Research indicates that persons who reminiscence, however, can elicit valuable data and consider themselves without prejudice tend to can promote a supportive therapeutic relationship. express overt prejudice. Self-awareness can Using such a technique helps the nurse balance help overcome this issue and facilitate the need to collect the required information with compassionate, culturally appropriate care the patient's need to relate what is personally Be respectful of, interested in, and understanding important. of other cultures without being judgmental. Setting a time limit in advance helps the patient Avoid stereotyping by race, gender, age, focus on the interview and aids with the problem of ethnicity, religion, sexual orienta-tion, diminished time perception. Keeping an socioeconomic status, and other social easy-to-read clock within view of the patient categories. may be helpful. Know the traditional health-related beliefs and The patient should feel that the nurse is a caring practices prevalent among members of a person who treats others with respect. Self-esteem patient's cultural group and encourage patients is enhanced if the patient feels included in the to discuss their cultural beliefs and practices. decision-making process. Learn about the traditional or folk illnesses and At the beginning of the interview, the nurse and folk remedies common to patients' cultural patient need to determine the most effective and groups. comfortable distance and position for the session. Try to understand patient perceptions of The ability to see and hear is critical to the appropriate wellness and illness behaviors and communication process with an older adult, and expectations of health care providers in times of adaptations to account for any disability must health and illness. include consideration of personal space Study the cultural expressions and requirements. manifestations of caring and noncang behaviors The importance and comfort of touch is highly expected by patients. individual, but older persons need and appreciate it. Avoid stereotypical associations with violence, Touch should always convey respect, caring, and poverty, crime, low level of education, sensitivity. Nurses should not be surprised if an nonadherent behaviors, and nonadherence to older person reciprocates because of an unmet time-regimented schedules, and avoid any other need for intimacy. stereotypes that may adversely affect nurse The nurse does not have to obtain the entire patient relationships. history in the traditional manner of a seated, Be aware that patients who have lived in the face-to-face interview. United States for many years may have become This technique may be inappropriate with the older increasingly westernized and have fewer adult, depending on the situation. The nurse remaining practices of their birth culture. should not overlook the natural opportunities Learn to value the richness of cultural diversity available in the setting for gathering as an asset rather than a hindrance to information. Interviewing the patient at mealtime, communication and effective intervention. or even while participating in a game, hobby, or other social activity, often provides more meaningful Attitude - a feeling, value, or belief about data about a variety of areas. something that determines behavior. If the nurse has an attitude that characterizes ELECTRONIC HEALTH RECORDS older adults as less healthy and alert, and more Patients and providers feel the connection has dependent, then the interview structure will become impersonal. The lack of eye contact and reflect this attitude. Myths and stereotypes about personal interaction affects communication. older adults also may affect the nurse's questioning. STRATEGIES TO MITIGATE ISSUES Gerontologic nurses have a responsibility to Position the keyboard/monitor to allow face-to-face themselves and to their older adult patients to interaction with the older adult. improve their understanding of the aging process Prioritize eye contact during communication. and aging people. Input as much data as possible into the EHR before engaging with the patient. Examples: Alternate between talking and entering data to If the nurse believes that dependence in self-care maintain a personal connection. normally accompanies advanced age, the patient will not be questioned about strengths and abilities. POSITIVE ASPECTS OF EHR USE: The resulting inaccurate functional assessment Reduces the need for patients to repeat information. will do little to promote patient independence. CRUZ, A., CRUZ, A., CRUZ, H., CRUZ J., DADIVAS, B., DECASTRO, A., DE GUZMAN, L., DE GUZMAN, S., DE JESUS, A., DE LEON, J., DELGADO, S., DELO SANTOS, E., DOCIL, P., DOLLOZA, A.| 3NU04 8  Sharing EHR information with patients facilitates communication. Patients feel included in health care planning when providers involve them in reviewing EHR data. HEALTH HISTORY FORMAT When the patient does NOT display specific symptomatology but instead has broader health concerns, the nurse should identify those concerns to begin establishing potential nursing interventions. Information about the patient’s knowledge and understanding of his or her current health state, including treatments and management strategies, helps the nurse focus on possible areas of health teaching and reinforcement, identify a patient’s DESCRIPTION OF A TYPICAL DAY access to and use of resources, discover coping Identifying the activities of a patient during a full styles and strategies,and determine health behavior 24-hour period provides data about practices that patterns. either support or hinder healthy living. Data about the patient’s perception of functional ability regarding perceived health problems and PRESENT HEALTH STATUS medical diagnoses provide valuable insight into the The patient’s perception of health in both the past individual’s overall sense of physical, social, year and the past 5 years, coupled with emotional, and cognitive well-being. information about health habits, reveals much about his or her physical integrity. DRUGS Based on how the patient responds, the nurse may Assessment of the older adult’s current drugs is be able to ascertain whether the patient needs usually accomplished by having the patient bring in health maintenance, promotion, or restoration. all prescription and over-the-counter drugs, as The chief complaint, stated in the patient’s own well as regularly and occasionally used home words, enables the nurse to specifically identify why remedies. the patient is seeking health care. It is best to ask The nurse should also inquire about the patient’s about this using a term other than chief use of herbal and other related products and ask complaint, because patients may take offense at how each drug is taken—by the oral, topical, that choice of words. inhaled, or other route. If a symptom is the reason, usually its duration is Obtaining the drugs in this manner allows the also included. A complete and careful symptom nurse to examine drug labels, which may show analysis may be carried out for the chief complaint the use of multiple physicians and pharmacies. by collecting information on the factors identified Also, this helps the nurse determine the patient’s pattern of drug taking (including adherence), his or her knowledge of drugs, the expiration dates of drugs, and the potential risk for drug interactions. IMMUNIZATION AND HEALTH SCREENING STATUS The older adult’s immunization status for specific diseases and illnesses is particularly important because of the degree of risk for this age group. More attention is increasingly paid to the immunization status of the older adult population, CRUZ, A., CRUZ, A., CRUZ, H., CRUZ J., DADIVAS, B., DECASTRO, A., DE GUZMAN, L., DE GUZMAN, S., DE JESUS, A., DE LEON, J., DELGADO, S., DELO SANTOS, E., DOCIL, P., DOLLOZA, A.| 3NU04 9  primarily because of inappropriate use and underuse of vaccines in the past, especially the influenza and pneumococcal vaccines. Tetanus and diphtheria toxoids (Td) boosters are recommended at 10-year intervals for those who have been previously immunized as adults or children. Adults over the age of 60 should receive the herpes zoster immunization whether they remember having had chickenpox or not. Older adults should still participate in health screenings for the most recent recommendations. Tuberculosis, a disease that was once well controlled, is now resurfacing in this country. Older adults who may have had a tubercular lesion at a young age may experience a reactivation because PREVIOUS HEALTH STATUS of age-related immune system changes, chronic Childhood illness history: Include illnesses such illness, and poor nutrition. as measles, mumps, rubella, chickenpox, Frail and institutionalized older adults are diphtheria, tetanus, rheumatic fever, and polio to particularly vulnerable and should be screened for identify risk factors for future health concerns. exposure or active disease through an annual Chronic illnesses: Assess for conditions like purified protein derivative (PPD) test. hypertension, diabetes, respiratory or cardiac diseases, and others affecting current health. ALLERGIES Injuries and trauma history: Document dates, Determining the older adult’s drug, food, and other types, circumstances, and their impact on health. contact and environmental allergies is essential for Surgical history: Record past hospitalizations, planning nursing interventions. It is particularly operations, and treatments. important to note the patient’s reaction to the Reproductive health: Include obstetric or allergen and the usual treatment. gynecologic history if applicable. Medication history: List past and current NUTRITION medications, including prescribed and A 24-hour diet recall is a useful screening tool that over-the-counter drugs. provides information about the intake of daily Significant health events: Focus on issues that requirements, including the intake of “empty” have a direct effect on the patient’s current health. calories, the adherence to prescribed dietary therapies, and the practice of unusual or “fad” diets. FAMILY HISTORY The nurse should also assess the time meals and Inherited diseases: Identify risks related to genetic snacks are eaten. conditions like diabetes, cardiovascular diseases, or If a 24-hour recall CANNOT be obtained or the information gleaned raises more questions, having cancer. the patient keep a food diary for a select period Familial tendencies: Assess patterns like obesity, may be indicated. mental health issues, or autoimmune disorders. The diets of older Chronic illnesses in family members: Determine Adults may be nutritionally inadequate because possible risk factors related to shared environments of advanced age, multiple chronic illnesses, or lifestyles. lack of financial resources, mobility Longevity and cause of death: Record impairments, dental health problems, and information on deceased relatives, focusing on loneliness. The diet recall and diary provide chronic conditions leading to death. nutritional assessment data that reflect the patient’s overall health and well-being. REVIEW OF SYSTEMS Systematic assessment: Conduct a head-to-toe review to identify symptoms within major systems (e.g., cardiovascular, respiratory, gastrointestinal, musculoskeletal). Identify abnormalities: Look for changes in vision, hearing, swallowing, bowel or bladder function, mobility, or mental clarity. Assess symptom severity and duration: Understand the extent and progression of symptoms affecting quality of life. Secondary sources: Collaborate with caregivers or review medical records to ensure accuracy in reporting. APPROACH TO PHYSICAL ASSESSMENT Respect privacy and dignity: Ensure the patient is comfortable, especially during gown changes and exams. Adjust for limitations: Modify the approach based on physical or cognitive impairments. CRUZ, A., CRUZ, A., CRUZ, H., CRUZ J., DADIVAS, B., DECASTRO, A., DE GUZMAN, L., DE GUZMAN, S., DE JESUS, A., DE LEON, J., DELGADO, S., DELO SANTOS, E., DOCIL, P., DOLLOZA, A.| 3NU04 10  Systematic examination: Use techniques such as Ensure proper function and readiness of all inspection, palpation, percussion, and auscultation equipment within reach and the order in which it will in an organized manner. be used. Minimize fatigue: Schedule assessments at times The traditional techniques: inspection, palpation, when the patient is most alert and rested. percussion, and auscultation Use SPICES framework: Screen for Sleep disorders, Problems with eating, Incontinence, ADDITIONAL ASSESSMENT MEASURES Confusion, Evidence of falls, and Skin breakdown. The use of standardized tools and measures of Promote collaboration: Involve caregivers or functional status are important adjuncts to family members for additional insights when traditional assessment, as they enable health care needed. providers to objectively determine the older Prioritize urgent issues: Address critical concerns person’s ability to function independently in spite of first, followed by a comprehensive assessment. disease, altered cognition, and other disabilities. Document findings accurately: Focus on These assessments include the determination of objective data while considering patient-reported the patient’s ability to perform activities of daily information. living and instrumental ADLs, as well as the patient’s cognitive, affective, and social levels of GENERAL GUIDELINES function. Obtaining these additional data provides a regardless of the approach and sequence used, the more comprehensive view. following principles should be considered during physical assessment. FUNCTIONAL STATUS ASSESSMENT Recognize that the older adult may have no Considered as a significant component of older previous experience with a nurse conducting a adult’s quality of life physical assessment; each step should be Measurement of the older adult’s ability to perform explained, and the patient reassured. The examiner basic self-care tasks, or ADLs, and tasks that needs to project warmth sincerity, and interest to require complex activities for independent living allay any anxiety or fear Determination of the degree of functional Be alert to the older patient’s energy level. If the independence helps identify a patient’s abilities and situation warrants it, complete the most important limitations, leading to appropriate intervention parts of the assessment first, and complete the The patient’s situation determines the location and other parts of the assessment at another time. time when any of the scales or tools should be Generally, it should take approximately 30-45 mins administered, as well as the number of times the to conduct the head-to-toe assessment. patient may need to be tested to ensure accurate Respect the patient's modesty. Allow privacy for results changing into a gown; if assistance is needed, Many tools are available but should only use assist in such a way as not to expose the patient’s those that are valid, reliable, and relevant to the body or cause embarrassment. practice setting Keep the patient comfortably draped. Do not Katz Index of ADLs - a tool widely used to unnecessarily expose a body part; expose only the determine the results of treatment and the part to be examined. prognosis in older adult and chronically ill patients Sequence the assessment to keep position ○ The index ranks adequacy of performance changes to a minimum. Patients with limited range in six functions: bathing, dressing, toileting, of motion and strength may require assistance. Be transferring, continence, and feeding. prepared to use alternative positions if the patient is ○ A dichotomous rating of independence or unable to assume the usual position for assessment dependence is made for each of the of a body part. ○ Functions. Develop an efficient sequence for assessment that ○ One point is given for each dependent item minimizes both nurse and patient movement. ○ Only people who can perform the function Variations that may be necessary will not be without any help at all are rated as disruptive if the sequence is consistently followed. independent; the actual evaluation form Working from one side of the patient, generally the merely shows the rater how a dependent right side, promotes efficiency. item is determined. The order of items Make sure the patient is comfortable. Offer a reflects the natural progression in loss and blanket for added warmth or a pillow or alternative restoration of function, position for comfort ○ The Katz Index is a useful tool for the Explain each step in simple terms. Give clear, nurse because it describes the patient’s concise directions and instructions for performing functional level at a specific point in time required movements. and objectively measures the effects of the Warn any discomfort that might occur. Be gentle treatment intended to restore function. The Probe painful areas last tool takes only about 5 minutes to For reassurance, share findings with the patient administer and may be used in most when possible. Encourage the patient to ask settings. questions Older adults in most health care settings benefit Take advantage of “teachable moments” that may from functional status assessment, but those in occur while conducting the assessment acute care settings are particularly in need of such Develop a standard format on which to note an assessment because of their advanced age, selected findings. Not all data need to be recorded, level of acuity, comorbidity, and risk for iatrogenic but the goal is to reduce the potential for forgetting conditions such as urinary incontinence, falls, certain data, particularly measurements. delirium, and polypharmacy. The hospitalization experience for older adults may EQUIPMENT AND SKILL cause loss of function and self-care ability because of the many extrinsic risk factors associated with CRUZ, A., CRUZ, A., CRUZ, H., CRUZ J., DADIVAS, B., DECASTRO, A., DE GUZMAN, L., DE GUZMAN, S., DE JESUS, A., DE LEON, J., DELGADO, S., DELO SANTOS, E., DOCIL, P., DOLLOZA, A.| 3NU04 11  this setting, including aggressive treatment time-consuming instruments in accurately interventions, bed rest, lack of exercise, insufficient identifying cognitive impairment nutritional intake, and iatrogenic infection. ○ Uninfluenced by education level or Nurses in this setting are in a key position to assess language. the older adult’s function and implement ○ Affective status measurement tools are interventions aimed at preventing decline. used to differentiate serious depression Specialized care units known as acute care for that affects many domains of function from elders (ACE) units have been developed in the low mood common to many people. hospitals around the country to better address these ○ Depression is common in older adults and issues. is often associated with confusion and Research has demonstrated this age-specific, disorientation, so older people with comprehensive approach reduces morbidity and depression are often mistakenly labeled as mortality associated with hospitalizing older adults having dementia. It is important to note Nurses practicing in all settings should begin here that depressed people usually incorporating valid and reliable tools into routine respond to items on mental status assessments to determine a patient’s baseline examinations by saying, “I don’t know,” functional ability. However, the nurse should which leads to poor performance. remember the following points: ○ Because mental status examinations are ○ The environment in which the tool is not able to distinguish between dementia administered will affect scores. and depression, a response of “I don’t ○ The patient’s affective and cognitive state know” should be interpreted as a sign will affect performance. that further affective assessment is ○ The result represents but one piece of the warranted. total assessment. The Geriatric Depression Scale - valid and reliable tool, is derived from the original COGNITIVE & AFFECTIVE ASSESSMENT 30-question scale. The purpose is to determine the patient’s level of ○ It is a convenient instrument designed cognitive function (which implies all those specifically for use with older people to processes associated with mentation or intellectual screen for depression. function). ○ Of the 15 items on the short form GDS, This assessment is usually integrated into the 10 indicate depression when answered interview and physical examination, and testing is positively; the remaining 5 (questions 1, conducted in a natural, non-threatening manner 5, 7, 11, and 13) indicate depression with consideration of ethnicity. when answered negatively. A score of 0 The multiple physiologic, psychological, and to 4 is considered normal; a score environmental causes of cognitive impairment in greater than or equal to 5 indicates older adults, coupled with the view that mental depression impairment is a normal, age-related process, often ○ The instruments described here for lead to incomplete assessment of this problem. assessing cognitive and affective status Standardized examinations test a variety of are valuable screening tools that the nurse cognitive functions, aiding the identification of may use to supplement other deficits that affect overall functional ability. assessments. Formal, systematic testing of mental status helps to ○ They may also be used to monitor a determine which behaviors are impaired and patient’s condition over time. The results of warrant intervention. any mental or affective status examination The Montreal Cognitive Assessment (MoCA) - should never be accepted as conclusive; was developed as a quick screening tool for mild they are subject to change based on cognitive impairment and Alzheimer’s dementia. further workup or after treatment ○ It assesses attention, concentration, interventions have been implemented. executive functions, memory, language, visuoconstructional skills, conceptual SOCIAL ASSESSMENT thinking, calculations, and orientation. Several legitimate reasons exist for the need for ○ The tool has extensive testing in multiple healthcare providers to screen for social function for languages in older adults over 85 years of older people, despite the diverse concepts of what age covering a wide range of disorders constitutes social function (Kane & Kane, 1981) affecting cognition. 1. Social Function is correlated with ○ The total possible score is 30 points, physical and mental function. Alterations with a score of 26 or more considered in activity patterns may negatively affect normal. To compensate for a limited physical and mental health and vice versa. educational background, older adults with 2. An individual's social well-being may only 4 to 9 years of education should positively affect his or her ability to have 2 points added to the total score; cope with physical impairments and the for those with only 10 to 12 years of ability to remain independent education, 1 point should be added to 3. A satisfactory level of social function is the total score. A modified version of the a significant outcome in and of itself. tool is available for use in older adults with The quality of life an older person visual impairment experiences is closely linked to social The Mini-Cog - instrument that combines a simple function dimensions such as self-esteem, test of memory with a clock drawing test. life satisfaction, socioeconomic status, ○ Mini-Cog is both quick and easy to use, physical health, and functional status. and is as effective as longer, more CRUZ, A., CRUZ, A., CRUZ, H., CRUZ J., DADIVAS, B., DECASTRO, A., DE GUZMAN, L., DE GUZMAN, S., DE JESUS, A., DE LEON, J., DELGADO, S., DELO SANTOS, E., DOCIL, P., DOLLOZA, A.| 3NU04 12  Assessment, 1978). It has been used for the clinical assessment, population surveys, program evaluation, personnel training, and service planning. NURSING STANDARD OF PRACTICE PROTOCOL : ASSESSMENT OF FUNCTION IN ACUTE CARE The following nursing care protocol has been designed to assist bedside nurses in monitoring function in older patients, preventing decline and maintaining the function of older adults during acute hospitalization The objective or the goal of nursing care is to maximize the physical function and prevent or minimize declines in ADL (Activities of Daily Living) function. I. BACKGROUND A. The functional status of individuals describes the capacity to safely perform ADLs. Functional status is a sensitive indicator of health or illness in older adults and therefore a critical nursing assessment. B. Some functional decline may be prevented or ameliorated with prompt and aggressive nursing intervention (e.g., ambulation, enhanced communication, adaptive equipment). OARS MULTIDIMENSIONAL FUNCTIONAL C. Some functional decline may occur ASSESSMENT QUESTIONNAIRE progressively and is not reversible. This decline often accompanies chronic and terminal disease It was developed in 1978 at Duke University to states such as Parkinson disease and dementia. provide an assessment of individual functioning in elderly individuals (Multidimensional Functional CRUZ, A., CRUZ, A., CRUZ, H., CRUZ J., DADIVAS, B., DECASTRO, A., DE GUZMAN, L., DE GUZMAN, S., DE JESUS, A., DE LEON, J., DELGADO, S., DELO SANTOS, E., DOCIL, P., DOLLOZA, A.| 3NU04 13  a. Physiologic and psychological D. Functional status is influenced by physiologic value of independent functioning aging changes, acute and chronic illness, and b. Reversible functional decline adaptation. Functional decline is often the initial associated with acute illness symptom of acute illness such as infections c. Strategies to prevent functional (pneumonia, urinary tract infection). These declines decline—exercise, nutrition, and are usually reversible. socialization E. Functional status is contingent on cognition d. Sources of assistance to and sensory capacity, including vision and manage decline hearing. 3. Encourage activity, including routine F. Risk factors for functional decline include exercise, range of motion exercises, and injuries, acute illness, drug side effects, depression, ambulation to maintain activity, flexibility, malnutrition and decreased mobility (including the and function. use of physical restraints). 4. Minimize bed rest. G. Additional complications of functional decline 5. Explore alternatives to physical restraint include loss of independence, loss of socialization, use. and increased risk for long-term institutionalization 6. Judiciously use psychoactive drugs in and depression. geriatric dosages. H. Recovery of function can also be a measure of 7. Design environments with handrails, return to health such as in those individuals wide doorways, raised toilet seats, shower recovering from exacerbations of cardiovascular seats, enhanced lighting, low beds, and disease. chairs.