Kathleen F. Jett
Assessment and documentation for optimal care
THE LIVED EXPERIENCE
I was so happy to be able to make a big difference in Mrs. Jones’s life. She was 97 and had grown slowly confused over the years. She was also profoundly hard of hearing. She spent the majority of time calling for “Mary,” her deceased sister. We really could not communicate effectively with her; we could only show her we cared and keep her safe. Eventually she became acutely ill, and a decision had to be made about CPR (cardiopulmonary resuscitation). When we tried to find out what her wishes were, we could not immediately find any record of them, and she had no living relatives or friends, just an attorney. I searched and searched and finally found documentation about her wishes. We were able to provide her the comfort she wanted because of a nurse’s careful documentation years before.
Kathleen, GNP, age 45
Learning objectives
Upon completion of this chapter, the reader will be able to:
• Identify key differences in assessing older adults and younger adults.
• Describe the range of tools that may be used in the comprehensive gerontological assessment.
• Discuss the impact of common normal changes with aging on the assessment.
• Describe the reasons for accurate and thorough documentation in gerontological nursing.
• Identify potential problems in documentation.
• Compare the major documentation methods used in acute, long-term, and home care.
Glossary
ADLs, Activities of daily living Those tasks necessary to maintain one’s health and basic personal needs.
IADLs, Instrumental activities of daily living Those tasks necessary to maintain one’s home and independent living.
Health fluency The ability to understand and interpret language and wording used in the health care setting. Health Insurance Portability and Accountability Act of 1996, which legislated the handling of confidential patient information.
HIPAA Health Insurance Portability and Accountability Act of 1996, which legislated the handling of confidential patient information.
evolve.elsevier.com/Ebersole/gerontological
Assessment tools in gerontological nursing
Gerontological nurses conduct skilled and detailed assessments of and with the persons who entrust themselves to their care. While many of the skills used in the physical assessment of younger and older adults are the same, the overall process of working with persons later in life is strikingly different if for no reason other than their medical, psychological, and social complexity. Older adults vary greatly in their health and function, from active and independent to medically fragile and dependent. The comprehensive assessment is more complex, more detailed, and takes much longer to complete. More often, partial or problem-oriented assessments are done. If a more thorough assessment is needed, this is usually performed by a nurse-led interdisciplinary health care team. The assessment is not complete until it is documented. Nursing documentation is an age-old practice of making a permanent record of the conditions of our patients, our actions, and the patients’ responses to our actions or those of others. There is probably not a nurse alive who does not know the mantra, “If you didn’t document it—you didn’t do it!”
In this chapter the basic concepts of the general assessment process as it applies to working with elders are reviewed as well as discussions of commonly used instruments that are available for the collection of assessment data. The chapter further provides the reader with basic information about documenting the assessment and other pertinent data in the health record in the various settings in which older adults are cared for by nurses. References are provided throughout for more information about specialized assessments and documents both in other parts of this text and in other sources. (See Appendix 7-1 at the end of this chapter for a list of chapters in which assessment topics are addressed.)
The health assessment is composed of a number of parts; the collection of physical data as well as integration of biological, psychosocial, and functional information. It also may include cultural and spiritual assessments and occurs at all levels of Maslow’s Hierarchy. Additional assessment areas include cognitive abilities, psychological well-being; caregiver stress or burden; and patterns of health and health care. Areas or problems frequently not addressed by the care provider or mentioned by the elder but that should be addressed are sexual function, depression, alcoholism, hearing loss, oral health, and environmental safety. Part of a safety assessment usually includes consideration of gait and balance (see Chapter 13). Although not usually conducted by a nurse, a driving assessment may be recommended any time there is a question of ability. Questions regarding genetic background in this age group, especially for those in the younger range, have most relevance as they relate to Alzheimer’s disease, stroke, diabetes, and several types of cancer. The assessment is also an opportunity to review the elder’s preferences for advanced care planning. Finally a comprehensive assessment includes consideration of the somewhat vague conditions referred to as geriatric syndromes. These most often include delirium, falls, dizziness, syncope, and urinary incontinence (see Fulmer’s SPICE tool later in this chapter).
Assessment of the older adult requires special abilities: to listen patiently, to allow for pauses, to ask questions that are not often asked and to obtain data from all available sources, and to understand that not all positive findings will require interventions. The nurse must be able to recognize normal changes of aging (see Chapter 5) and atypical presentations (see Section 3) in order to appropriately and effectively conduct the assessment and interpret the findings. The assessment must be paced according to the stamina of both the person and the nurse. If the elder is physically frail, cognitively impaired, is unable to speak or does not speak the same language as the nurse, the health assessment becomes particularly difficult but even more important. The quality and speed of the assessment are a reflection of experience. Novice nurses should neither be expected to nor expect themselves to do this proficiently but should expect to see their skills, the amount of information obtained, and the speed at which it is obtained, increase over time. According to Benner (1984), assessment is a task for the expert. However, an expert is not always available. By following some basic guidelines and learning how to use the wide range of assessment tools and resources now available, the quality of data collected by all nurses can be improved.
Collecting assessment data
Conducting assessment data begins with establishing rapport. It is never appropriate to address the patient by the first name unless invited to do so. The assumption of familiarity in the use of the first name in addressing an elder can easily be perceived as condescending especially when the nurse is younger than the patient or of a different ethnic background.
There are three approaches used for collecting assessment data: self-report, report-by-proxy, and observation. In the self-report format, questions are either asked directly or the person is expected to respond to written questions about his or her health status. Patients tend to overestimate their own abilities and older adults in particular have been found to under-report symptoms, often due to the erroneous belief that what they are experiencing are normal parts of aging. When assessment information is obtained indirectly (report-by-proxy) the nurse asks another person, such as a staff nurse, aide, spouse, or friend, relative or caretaker to report their observations. This approach is used extensively with persons who are cognitively impaired; the elder’s abilities and health are often underestimated. In the observational approach the nurse collects and records the data as she or he has measured and observed using what are believed to be objective parameters.
The usual physical examination, such as the measurement of a blood pressure, and performance-based functional assessments, such as having the person walk a certain distance, are examples of observational measures. Observation and the use of previously developed tools are probably the most accurate but are limited in that they only represent a snapshot in time.
Certain guidelines should be followed regardless of the approach used in the data collection:
• Whenever possible, conduct the assessment at a time when the patient is at his or her best.
• If a standard tool is being used, be sure it is used correctly; training may be required.
• To avoid biasing the response, do not direct the way the question is answered.
• Explore for more information only if it is needed to complete the assessment.
Ideally, the assessment should be used to gather baseline data before the older adult has a health crisis. Periodically, the person can be reassessed to monitor health status. For example, a person who has an altered mental status as a result of an illness or medication (delirium) should be reassessed later when the underlying problem has been resolved.
The appropriate and accurate use of assessment and documentation instruments will increase the likelihood of obtaining reliable, useful data; especially that which can be compared over time to monitor changes in health status and therefore health needs. This of course implies that data collection is followed by the analysis and determination of the person’s needs followed by the development of nursing interventions. By accomplishing both, the nurse contributes to the nation’s goal of increasing the quality of life for all Americans and the health of older adults (see Chapter 1 and http://www.healthypeople.gov/2020).
Assessment instruments exist that can broadly categorize physical health, mood, motor capacity, manual ability, self-care ability, more complex instrumental abilities, and cognitive and social function. Assessments are completed in every setting. In most settings, standardized formats of some kind are used. Which assessments are done depends both on the setting and the purpose. Sometimes these tools come directly from the gerontological literature or payer sources like Medicare, and other times they are modified to meet the particular needs of the setting.
Fortunately we have a number of excellent instruments at our disposal to help us do this. Several tools are discussed or referred to in this chapter. We ask the reader to note that those described herein serve only as examples of what is available. The Try This:® series available from the Hartford Institute for Geriatric Nursing is one of the sources for ever-evolving information, tools, and evidence-based protocols (http://www.hartfordign.org/practice/try_this). The Try This: series includes copies of commonly used and tested instruments for general assessment (e.g., the Geriatric Depression Scale [GDS]) (see the Evidence-Based Practice box) as well as those needed in specialized circumstances (e.g., measurement of the Ankle-Brachial Index [ABI]) and other instruments specific to working with the person with dementia. Although several of the tools are discussed in this chapter and elsewhere throughout the book (see Appendix 7-1), complete descriptions of the tools, how they are best used in the older population, and the instruments themselves are provided for educational, non-profit use online. Information about use is provided at the ConsultGeriRN website (http://consultgerirn.org/resources). Finally, with the current volume of materials available on the Internet, additional information about the use of and research related to any of the tools discussed throughout this text can be found easily.
The health history
The initiation of the health history marks the beginning of the nurse-client relationship and the assessment process. It begins with a review of what the person reports as a problem, known as the “chief complaint.” This is considered subjective data that is documented in the patient’s own words. In an older adult this is much more likely to be vague and less straightforward. For example, it is not unusual for the person to say “I just don’t feel well.”
The health history is best collected either verbally in a face-to-face interview or using the interview to review a written history completed by the patient or patient’s proxy beforehand. Although longer for the patient, written formats are usually much faster than the verbal for the nurse. The written format should never be used if the person has limited vision, questionable reading level, the person has limited health fluency or written in a language or at a level in which the patient does not have reading ability. Written histories provide reliable information only when the person is able to adequately complete the documents alone or with some assistance. If collecting the history verbally or when reviewing a previously written document, the nurse uses techniques which optimize communication. If the elder has limited language proficiency, a trained medical interpreter is needed and the interview will generally take about twice as long (see Chapter 4). If the person has limited health fluency, special attention will need to be paid to wording of questions and answers to the patient’s questions. If the person is cognitively impaired he or she should be included to the extent possible with additional information obtained from the proxy.
Any health history form or interview should include a patient profile, a past medical history, a review of systems, a medication history (see Chapter 8), nutritional history (see Chapter 9) and include any other factors which influence the person’s quality of life. The nurse should be aware that in an older adult the traditional review of systems may be quite lengthy due to the number of years the person has had the opportunity to have had problems. It may be easier and more appropriate to begin with reviewing the symptoms the person is currently having and gear the system review accordingly. In the oldest older adult, family history in and of itself becomes less important as the person ages, and it is replaced with the increasing importance of the social history. The social history, an essential part of the history, includes current living arrangements, economic resources to meet current health-related or food expenses, amount of family and friend support, and community resources available if needed. Tools to adequately measure social networks have been in development for a number of years. However, the many nuances and configurations of social support networks make standardized measurements difficult.
Finally, to meet the needs of our increasingly diverse population of elders, the use of questions related to the explanatory model (Kleinman, 1980) is recommended to complement the health history (see Chapter 4 and Box 4-5). The responses will better enable the nurse to understand the elder and to plan culturally and individually appropriate and effective interventions.
Physical assessment
Nurses learn to conduct a complete “head-to-toe” when conducting a physical assessment. While this is usually done when assessing younger persons it is rarely possible when working with an older adult, especially one who is medically complex or fragile. To do so would be excessively time-consuming and burdensome to all involved. Instead the assessment is first directed to that which is most likely associated with the presenting problem or major diagnoses and progresses from there. When performing a physical assessment the gerontological nurse must be able to quickly prioritize what is the most necessary to know (based on the chief complaint) and proceed to what would be nice to know. When the chief complaint is not known, such as in persons with moderate to advanced dementia, persons who are unable to express themselves (such as those with expressive aphasia), or in the presence of any other type of language barrier, a more thorough assessment is always necessary. When the focus is on a well check or a health care contact related to health promotion and disease prevention, the emphasis is on the major preventable health problems in later life, especially those of cardiovascular and musculoskeletal origins.
The collection of data for the physical assessment begins the moment the nurse sees the person, noting skin color and texture, presence or absence of lesions. If the person “looks ill,” this should be noted in the medical record. Is the person able to ambulate alone or does he or she hold on to the walls along the way to the exam room, dining room, or bathroom? Are assistive devices used? Is the person able to follow directions when the nurse uses a normal voice volume or is an elevated one needed? If unable to follow directions at all or only with difficulty, it will be necessary to determine first whether this is related to sensory losses or indicates cognitive impairment. It may even be from something as simple as a cerumen (ear wax) impaction (see Chapter 5).
While considering the expected findings related to normal age changes discussed in Chapter 5, the manual techniques used in the physical exam are applicable to any age group and the reader is referred to any number of excellent textbooks solely dedicated to this. However, extra time is usually needed for dressing and undressing and some positions (e.g., lying flat for an abdominal exam) may not be possible. Several modifications may be necessary due to common changes see in later life (Table 7-1). For additional information, see http://www2.kumc.edu/coa/education/AMED900/PhysiologicAging/Physical DiagnosisinOlderAdults.htm.
TABLE 7-1
Considerations of Common Changes in Late Life During the Physical Assessment
| Height and weight | Monitor for changes in weight Weight gain: especially important if the persons has any heart disease, being alert for early signs of heart failure Weight loss: be alert for indications of malnutrition from dental problems, depression, or cancer. Check for mouth lesions from ill-fitting dentures. |
| Temperature | Even a low-grade fever could be an indication of a serious illness. Temperatures of as low as 100° F may indicate pending sepsis. |
| Blood pressure | Positional blood pressure readings should be obtained due to high occurrence of orthostatic hypotension. Both arms should be checked (at heart level) and recording of the highest one used. Isolated systolic hypertension is common. |
| Skin | Check for indications of solar damage, especially among persons who worked outdoors or live in sunny climates. Due to thinning, “tenting” cannot be used as a measure of hydration status. |
| Ears | Cerumen impactions are common. These must be removed before hearing can be adequately assessed. High-frequency hearing loss (presbycusis) is common. The person often complains that he or she can hear but not understand as some, but not all sounds are lost. The person with severe but unrecognized hearing loss may be incorrectly thought to have dementia. |
| Eyes | Increased glare sensitivity, decreased contrast sensitivity and need for more light to see and read. Ensure that waiting rooms, hallways, and exam rooms are adequately lit. Decreased color discrimination may affect ability to self-administer medications safely. |
| Mouth | Excessive dryness common and exacerbated by many medications. Cannot use mouth moisture to estimate hydration status. |
| Neck | Due to loss of subcutaneous fat it may appear that carotid arteries are enlarged when they are not. |
| Chest | Any kyphosis will alter the location of the lobes, making careful assessment more important. Risk for aspiration pneumonia increased and therefore the importance of the lateral exam. |
| Heart | Listen carefully for third and fourth heart sounds. Fourth heart sounds common. Determine if this has been found to be present in the past or is new. |
| Extremities | Dorsalis pedis and posterior tibial pulses very difficult or impossible to palpate. Must look for other indications of vascular integrity. |
| Abdomen | Due to deposition of fat in the abdomen, auscultation of bowel tones may be difficult. |
| Musculoskeletal | Osteoarthritis very common and pain often undertreated. Ask about pain and function in joints. Conduct very gentle passive range of motion if active range of motion not possible. Do not push past comfort level. |
| Neurological | Although there is a gradual decrease in muscle strength, it still should remain equal bilaterally. Greatly diminished or absent ankle jerk (Achilles) tendon reflex is common and normal. Decreased or absent vibratory sense of the lower extremities, testing unnecessary. |
Most often the physical exam is only one part of the evaluation of one or more other aspects of the person and his or her life. Due to the complexity of life and health in later life, this elevates the responsibility of the nurse. The nurse working in the geriatric setting must have a considerable repertoire of physical assessment skills and be able to draw upon these as the circumstance arises; in some cases this may need to be done quickly. In most circumstances the quality of care the elder receives is dependent on the quality of the assessment conducted.
Comprehensive physical assessment of the frail and medically complex elder
FANCAPES is a model for a comprehensive yet prioritized, primarily physical assessment that is especially useful for the frail elder (Resnick & Mitty, 2009). It emphasizes the determination of very basic needs and the individual’s functional ability to meet these needs independently; these are the needs that form even the most basic levels of Maslow’s Hierarchy. The acronym FANCAPES represents Fluids, Aeration, Nutrition, Communication, Activity, Pain, Elimination, and Socialization. It can be used in all settings, may be used in part or whole depending on the need, and is easily adaptable to functional pattern grouping if nursing diagnoses are used. The nurse obtains comprehensive information in each section, guided by the questions provided in the following text.
F—fluids
What is the current state of hydration (see Chapter 9)? Does the person have the functional capacity to consume adequate fluids to maintain optimal health? This includes the abilities to sense thirst, mechanically obtain the needed fluids, swallow them, and excrete them.
A—aeration
Is the person’s oxygen exchange adequate for full respiratory functioning (see Chapter 19)? This means the ability to maintain an oxygen saturation of at least 96% in most situations. Is supplemental oxygen required, and if so, is the person able to obtain it? What is the respiratory rate and depth at rest and during activity, talking, walking, exercising, and while performing activities of daily living? What sounds are auscultated, palpated, and percussed, and what do they suggest? For the older person, it is particularly important to carefully assess lateral and apical lung fields.
N—nutrition
What mechanical and psychological factors affect the person’s ability to obtain and benefit from adequate nutrition (see Chapter 9)? What is the type and amount of food consumed? Does the person have the abilities to bite, chew, and swallow? What is the oral health status and what is the impact of periodontal disease if present? For edentulous persons, do their dentures fit properly and are they worn? Does the person understand the need for special diets? Has this diet been designed so that it is consistent with the person’s eating and cultural patterns? Can the person afford the special foods needed? If the person is at risk for aspiration, including those who are tube fed, have preventive strategies been taught, including the need for meticulous oral hygiene?
C—communication
Is the person able to communicate his or her needs adequately? Do the persons who provide care understand the patient’s form of communication? What is the person’s ability to hear in various environments? Are there any environmental situations in which understanding of the spoken word is inadequate? If the person depends on lip-reading, is his or her vision adequate? Is the person able to clearly articulate words that are understandable to others? Does the person have either expressive or receptive aphasia (see Chapter 20), and if so has a speech therapist been made available to the person and significant others? What is the person’s reading and comprehension levels? (Assume it is no greater than fifth grade if unknown.)
A—activity
Is the person able to participate in the activities necessary to meet basic needs such as toileting, grooming, and meal preparation? How much assistance is needed, if any, and is someone available to provide this if needed? Is the person able to participate in activities that meet higher levels of needs such as belonging (e.g., church attendance) or finding meaning in life (see Chapter 11)? What are the person’s abilities to feed, toilet, dress, and groom; to prepare meals; to dial the telephone; and to voluntarily move about with or without assistive devices? Does the person have coordination, balance, ambulatory skills, finger dexterity, grip strength, and other capacities that are necessary to participate fully in day-to-day life?
P—pain
Is the person experiencing physical, psychological, or spiritual pain? Is the person able to express pain and the desire for relief? Are there cultural barriers between the nurse and the patient that make the assessment of or expression of pain difficult? How does the person customarily attain pain relief (see Chapter 15)?
E—elimination
Is the person having difficulty with bladder or bowel elimination (see Chapter 10)? Is there a lack of control? Does the environment interfere with elimination and related personal hygiene; for example, are toileting facilities adequate and accessible? Are any assistive devices used, such as a high rise toilet seat or bedside commode, and if so, are they available and functioning? If there are problems, how are they affecting the person’s social functioning?
S—socialization and social skills
Is the person able to negotiate relationships in society, to give and receive love and friendship, and to feel self-worth (see Chapter 24)?
Mental status assessment
As persons enter their eighties and nineties their risk for impaired cognitive abilities increases (Snowdon, 2002). With increases in age there is an increased rate of dementing illnesses, such as Alzheimer’s and Lewy body dementia. Cognitive ability is also easily threatened by any disturbance in physical health. Indeed, altered or impaired mental status may be the first sign of anything from a heart attack to a urinary tract infection. The gerontological nurse must be aware of the need to conduct an assessment of mental status, especially cognitive abilities and mood whenever there is a change in an elder’s condition or safety. Several of the most commonly seen instruments are described here, with more details in Chapters 21 and 22. The nurse working in the geriatric setting is often expected to be proficient in their use. To ensure that the results are valid and reliable, they must be administered exactly as they have been created and tested.
Cognitive measures
Mini-mental state examination.
The Mini-Mental State Examination (MMSE) by Folstein and colleagues (1975) is a 30-item instrument that has been used to screen for cognitive difficulties and is one of the tools often used in the determination of a diagnosis of dementia or delirium. It tests orientation, short-term memory and attention, calculation ability, language, and construction. It cannot be given to persons who cannot see or write or who are not proficient in English. It has not been tested extensively in cultures other than those of northern European descent and so culture bias must always be considered. A score of 30 suggests no impairment, and a score below 24 suggests potential dementia; however, adjustments are needed for educational level (Osterweil et al., 2000). In the long-term care setting, the MMSE is administered by either the nurse or the social worker as part of a required periodic assessment. It is used in primary care but not usually in the acute care setting.
Clock drawing test.
The Clock Drawing Test has been used since 1992 (Mendez et al., 1992; Tuokko et al., 1992) as a tool to help identify those with cognitive impairment and is used as a measure of severity. It requires some manual dexterity to complete. It would not be appropriate to use with individuals with any limitations in the use of their dominant hand. A person is presented with a blank piece of paper. He or she is asked to draw a circle and the face of a clock so that it says 2:40 or some other time. Scoring is based on both the position of the numbers and the position of the hands on the clock (Box 7-1). This tool does not establish criteria for dementia, but if performance on the clock drawing is impaired, it suggests the need for further investigation and analysis. It has also been found very useful for assessing delirium in the hospitalized patient (Moylan & Lin, 2004). Another evidence-based version of this measure is Royall’s CLOX (Kennedy, 2007).
