Gerontologic Assessment



Gerontologic Assessment


Sue E. Meiner, EdD, APRN, BC, GNP




The nursing process is a problem-solving process that provides the organizational framework for the provision of nursing care. Assessment, the crucial foundation on which the remaining steps of the process are built, includes the collection and analysis of data and results in a nursing diagnosis. A nursing-focused assessment is crucial in determining nursing diagnoses that are amenable to nursing intervention. Unless the approach to assessment maintains a nursing focus, the sequential steps of the nursing process—diagnosis, planning, implementation, and evaluation—cannot be carried out.


A nursing focus evolves from an awareness and understanding of the purpose of nursing. This purpose was defined in the 1980 American Nurses Association (ANA) publication, Nursing: A Social Policy Statement, as “the diagnosis and treatment of human responses to actual or potential health problems.” In 1995 the ANA developed Nursing’s Social Policy Statement, which elaborated on the above purpose of nursing based on the growth of nursing science “and its integration with the traditional knowledge base for diagnosis and treatment of human responses to health and illness.” Although providing no specific definition of nursing, this policy statement cited three “essential features of contemporary nursing practice” that are common to most definitions:



It is clear from these elements that the nurse collects subjective and objective data about the client to assist in determining the client’s response to health and illness. A comprehensive, nursing-focused assessment of these responses establishes a database about a client’s ability to meet the full range of physical and psychosocial needs. Client responses that reveal an inability to satisfactorily meet these needs indicate a need for nursing care, or the “caring relationship that facilitates health and healing” (ANA, 1995).


In 2004, Nursing: Scope and Standards of Practice entered another review process that resulted in the current ANA expectations of the professional role within which all registered nurses must practice. The ANA charged those in the nursing profession to incorporate the standards into practice settings across the country. According to the ANA (2004), “The goal is to improve the health and well-being of all individuals, communities, and populations through the significant and visible contributions of registered nurses utilizing standards-based practice.”


Nursing-focused assessment of older people occurs in the traditional settings of the hospital, home, or long-term care facility, as well as in nontraditional settings such as senior centers, congregate living units, hospice facilities, and independent or group nursing practices. The setting dictates the way data collection and analysis should be managed to serve clients best. Although the setting may vary, the purpose of nursing-focused assessment of older clients remains that of determining the older person’s ability to meet any health- and illness-related needs. Specifically, the purpose of older adult assessment is to identify client strengths and limitations so that effective and appropriate interventions can be delivered to support, promote, and/or restore optimum function and to prevent disability and dependence.


Gerontologic nurses recognize that assessing older adult clients involves the application of a broad range of skills and abilities, as well as consideration of many complex and varied issues. Nursing-focused assessment based on a sound, scientific gerontologic knowledge base, coupled with repeated practice to acquire the art of assessment, is essential for the nurse to recognize client responses that reflect unmet needs. Many frameworks and tools are available to guide the nurse in assessing older adults. Regardless of the framework or tool used, the nurse should collect the data while observing the following key principles: (1) the use of an individual, person-centered approach; (2) a view of clients as participants in health monitoring and treatment; and (3) an emphasis on clients’ functional ability.




Interrelationship Between Physical and Psychosocial Aspects of Aging


The health of people of all ages is subject to the influence of any number and kind of physical and psychosocial factors within the environment. The balance that is achieved within that environment of many factors greatly influences a person’s health status. Factors such as reduced ability to respond to stress, increased frequency and multiplicity of loss, and physical changes associated with normal aging can combine to place older adults at high risk for loss of functional ability. Consider the following case, which illustrates how the interaction of select physical and psychosocial factors can seriously compromise function.


Mrs. K, age 82, arrives in the emergency room after being found in her home by a neighbor. The neighbor had become concerned because he noticed Mrs. K had not picked up her newspapers for the past 3 days. She was found in her bed, weak and lethargic. She stated that she had the flu for the past week, so she was unable to eat or drink much because of the associated nausea and vomiting. Except for her mild hypertension, which is medically managed with an antihypertensive agent, she had enjoyed relatively good health before this acute illness. She is admitted to the hospital with pneumonia.


Because of the emergent nature of the admission, Mrs. K does not have any personal belongings with her, including her hearing aid, glasses, and dentures. She develops congestive heart failure after treatment of her dehydration with intravenous fluids. She then becomes confused and agitated and begins receiving haloperidol (Haldol). Her impaired mobility, resulting from the chemical restraint, has caused her to become incontinent of urine and stool, and she has developed a stage 2 pressure ulcer on her coccyx. She needs to be fed because of her confusion and eats very little. She sleeps at intervals throughout the day and night, and when she is awake, she is usually crying.


Table 4–1 depicts the many serious consequences of the interacting physical and psychosocial factors in this case. A word of caution is warranted: Undue emphasis should not be placed on individual weaknesses. In fact, it is imperative that the gerontologic nurse search for the client’s strengths and abilities and build the plan of care on these. However, in a situation such as that of Mrs. K, the nurse should be aware of the potential for the consequences illustrated here. A single problem is not likely because multiple conditions are often superimposed. In addition, the cause of one problem is often best understood in view of the accompanying problems. Careful consideration, then, of the interrelationships between physical and psychosocial aspects in every client situation is essential.




Nature of Disease and Disability and their Effects on Functional Status


Aging does not necessarily result in disease and disability. Although the prevalence of chronic disease increases with age, older people remain functionally independent. However, what cannot be ignored is that chronic disease increases older adults’ vulnerability to functional decline. Comprehensive assessment of physical and psychosocial function is important because it can provide valuable clues to a disease’s effect on functional status. Also, self-reported vague signs and symptoms such as lethargy, incontinence, decreased appetite, and weight loss can be an indicator of functional impairment. Ignoring older adults’ vague symptomatology exposes them to an increased risk of physical frailty. Physical frailty, or impairments in the physical abilities that are needed to live independently, is a major contributor to the need for long-term care. Therefore it is essential to comprehensively investigate the report of nonspecific signs and symptoms to determine whether there are underlying conditions that may contribute to the older person’s frailty.


Declining organ and system function and diminishing physiologic reserve with advancing age are well documented in the literature. Such normal changes of aging may make the body more susceptible to disease and disability, the risk of which increases exponentially with advancing age. It can be difficult for the nurse to differentiate normal age-related findings from indicators of disease or disability. In fact, it is not uncommon for nurses and older adults alike to mistakenly attribute vague signs and symptoms to normal aging changes or just “growing old.” However, it is essential for the nurse to determine what is “normal” versus what may be an indicator of disease or disability so that treatable conditions are not disregarded.



Decreased Efficiency of Homeostatic Mechanisms


Declining physiologic function and increased prevalence of disease, particularly in the old-old (age 85 or older), are in part a result of a reduction in the body’s ability to respond to stress through all of its homeostatic mechanisms, most importantly the immune system. Older persons’ adaptive reserves are reduced and their homeostatic mechanisms weakened; these factors result in a decreased ability to respond to physical and emotional stress.


The immune system, as the body’s major defense against illness and disease, has a decreased ability to provide protection with aging (see Chapter 16). Although scientists have attempted to identify which age-related immune system changes cause the decline in immunocompetence, it has been difficult to do so because immunocompetence is affected by multiple factors.


Increasing consideration has also been given in recent years to the potential impact of psychosocial stress on the older adult immune system. This growing consideration, coupled with the knowledge about factors affecting physiologic immunocompetence, has potential clinical relevance that is a current source of controversy. The reader is referred to an immunology text for a more complete discussion of the effect of aging on the immune response.


The important point is that older adults often encounter profound and repeated losses; the time between the occurrences of these losses is often short, resulting in an inadequate period for resolution and return to a baseline state. Older adults have less ability than younger people to cope with assaults such as infection, blood loss, a high-technology environment, or loss of a significant person (see Chapter 20). The nurse should therefore assess older adults for the presence of physical and psychosocial stressors and their physical and emotional manifestations.



Lack of Standards for Health and Illness Norms


Determining older adults’ physical and psychosocial health status is not easy because norms for health and illness are always being redefined. Established standards for what is normal versus abnormal are changing as more scientific studies are conducted and the knowledge base is expanded.


One area where scientific study is changing how health care providers interpret normal versus abnormal status is that of laboratory values. Relying on established norms for laboratory values when analyzing older adults’ assessment data could lead to incorrect conclusions. Fasting blood glucose of 80 mg/100 mL may be within the normal range for a young adult, but an older person with that same level may experience symptoms of hypoglycemia. Polypharmacy and the multiplicity of illness and disease are only two variables that may affect laboratory data interpretation for older adults (see Chapters 21 and 22).


In addition, there are no definitive aging norms for many pathologic conditions. For example, controversy has existed over what constitutes isolated systolic hypertension in older people. Is a high systolic pressure simply a function of age, or does it require treatment? The Seventh Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII) states that cardiovascular morbidity and mortality in older people have been reduced with antihypertensive drug therapy (National High Blood Pressure Education Program, 2003). However, Moser (2007) identified that the lowering of systolic hypertension using drug therapy (diuretic or beta-blocker drugs) made more of a positive difference in the outcome than any specific antihypertensive medication(s). As more studies are conducted in this and other areas, norms for older adults will continue to be redefined.


Landmarks for human growth and development are well established for infancy through middlescence, whereas few norms are defined for older adulthood. Developmental norms that have been described for later life categorize all older people in the “older than 65” group. However, it could easily be argued from a developmental perspective that as great a difference exists among adults ages 65, 75, 85, and 95 as it does among children ages 2 through 5. In fact, given the demographic facts and predictions, there is a pressing need to know the developmental characteristics of older people for each decade of life. This is an important area for scientific inquiry.


To compensate for the lack of definitive standards, the nurse should first assume heterogeneity rather than homogeneity when caring for older people. It is crucial to respect the uniqueness of each person’s life experiences and to preserve the individuality created by those experiences. The older person’s experiences represent a rich and vast background that the nurse can use to develop an individualized plan of care. Second, the nurse can compare the older person’s own previous patterns of physical and psychosocial health and function with the current status, using the individual as the standard. Finally, the nurse must have a complete, current, scientific knowledge base and skills in gerontologic nursing to apply to each individual older adult client.



Altered Presentation of and Response to Specific Diseases


With advanced age the body does not respond as vigorously to illness or disease because of diminished physiologic reserve. The diminished reserve poses no particular problems for older people as they carry out their daily routines; however, in times of physical and emotional stress, older people will not always exhibit the expected or classic signs and symptoms. The characteristic presentation of illness in older adults is more commonly one of blunted or atypical signs and symptoms.


The atypical presentation of illness can be displayed in various ways. For example, the signs and symptoms may be modified in some way, as in the case of pneumonia, when older adults may exhibit dry coughs instead of the classic productive coughs. Also, the presenting signs and symptoms may be totally unrelated to the actual problem, such as the confusion that may accompany a urinary tract infection. Finally, the expected signs and symptoms may not be present at all, as in the case of a myocardial infarction that includes no chest pain (Table 4–2). All these atypical presentations challenge the nurse to conduct careful and thorough assessments and analyses of symptoms to ensure appropriate treatment. Again, a simple and safe strategy is to compare the presenting signs and symptoms with the older adult’s normal baselines.



TABLE 4–2


HOW ILLNESS CHANGES WITH AGE




































PROBLEM CLASSIC PRESENTATION IN YOUNG PATIENT PRESENTATION IN ELDERLY PATIENTS
Urinary tract infection Dysuria, frequency, urgency, nocturia Dysuria often absent; frequency, urgency, nocturia sometimes present. Incontinence, delirium, falls, and anorexia are other signs.
Myocardial infarction Severe substernal chest pain, diaphoresis, nausea, dyspnea Sometimes no chest pain or atypical pain location such as in jaw, neck, shoulder, epigastric area. Dyspnea may or may not be present. Other signs are tachypnea, arrhythmia, hypotension, restlessness, syncope, and fatigue/weakness. A fall may be a prodrome.
Bacterial pneumonia Cough productive of purulent sputum, chills and fever, pleuritic chest pain, elevated white blood cell (WBC) count Cough may be productive, dry, or absent; chills and fever and/or elevated WBCs also may be absent. Tachypnea, slight cyanosis, delirium, anorexia, nausea and vomiting, and tachycardia may be present.
Congestive heart failure Increased dyspnea (orthopnea, paroxysmal nocturnal dyspnea), fatigue, weight gain, pedal edema, nocturia, bibasilar crackles All the manifestations of young adult and/or anorexia, restlessness, delirium, cyanosis, and falls. Cough.
Hyperthyroidism Heat intolerance, fast pace, exophthalmos, increased pulse, hyperreflexia, tremor Slowing down (apathetic hyperthyroidism), lethargy, weakness, depression, atrial fibrillation, and congestive heart failure.
Hypothyroidism Weakness, fatigue, cold intolerance, lethargy, skin dryness and scaling, constipation Often presents without overt symptoms; majority of cases are subclinical. Delirium, dementia, depression/lethargy, constipation, weight loss, and muscle weakness/unsteady gait are common.
Depression Dysphoric mood and thoughts, withdrawal, crying, weight loss, constipation, insomnia Any of classic symptoms may or may not be present. Memory and concentration problems, cognitive and behavioral changes, increased dependency, anxiety, and increased sleep. Muscle aches, abdominal pain or tightness, flatulence, nausea and vomiting, dry mouth, and headaches. Be alert for congestive heart failure, diabetes, cancer, infectious diseases, and anemia. Cardiovascular agents, anxiolytics, amphetamines, narcotics, and hormones can also play a role.

Modified from Henderson ML: Altered presentations. Am J Nurs 15:1104, 1986.



Cognitive Impairment


As can be seen in Table 4–2, delirium is one of the most common, atypical presentations of illness in older adults, representing a wide variety of potential problems.


Confusion, mental status changes, cognitive changes, and delirium are some of the terms used to describe one of the most common manifestations of illness in old age. Foreman (1986) advocates use of the term acute confusional state (ACS) to describe “an organic brain syndrome characterized by transient, global cognitive impairment of abrupt onset and relatively brief duration, accompanied by diurnal fluctuation of simultaneous disturbances of the sleep–wake cycle, psychomotor behavior, attention, and affect.” Unfortunately, the ageist views of many health care providers cause them to believe that an ACS is a normal, expected outcome of aging, thus robbing older adults of complete and thorough workups of this syndrome. The nurse as an advocate for older persons may need to remind other team members that a sudden change in cognitive function is often the result of illness, not aging. Knowing older adults’ baseline mental status is essential to avoid overlooking a serious illness manifesting itself as an ACS. Box 4–1 outlines the multivariate causes of an ACS that the nurse must consider during assessment.



BOX 4–1   PHYSIOLOGIC, PSYCHOLOGIC, AND ENVIRONMENTAL CAUSES OF ACUTE CONFUSIONAL STATES IN HOSPITALIZED OLDER ADULTS


Physiologic




Primary Cerebral Disease



Extracranial Disease



1. Cardiovascular abnormalities



2. Pulmonary abnormalities



3. Systemic infective processes—acute and chronic



4. Metabolic disturbances



5. Drug intoxications—therapeutic and substance abuse



6. Endocrine disturbance



7. Nutritional deficiencies



8. Physiologic stress—pain, surgery


9. Alterations in temperature regulation—hypothermia and hyperthermia


10. Unknown physiologic abnormality—sometimes defined as pseudodelirium




Modified from Foreman MD: Acute confusional states in hospitalized elderly: a research dilemma, Nurs Res 35(1):34, 1986.


One of the more challenging aspects of older adult assessment is distinguishing a reversible ACS from irreversible cognitive changes such as those seen in dementia and related disorders. In contrast to the characteristics of an ACS noted previously, dementia is a global, sustained deterioration of cognitive function in an alert client. Other diagnostic features of dementia include memory impairment and one or more of the following cognitive disturbances: aphasia, apraxia, agnosia, or disturbance in executive functioning (e.g., planning, organizing, sequencing, abstracting) (American Psychiatric Association, 1994). Primary dementias include senile dementia of the Alzheimer’s type, Lewy body disease, Pick’s disease, Creutzfeldt-Jakob disease, and multiinfarct dementia. Secondary dementias that have the same presenting symptoms but that are often reversible with early diagnosis include normal pressure hydrocephalus, intracranial masses or lesions, pseudodementia, and Parkinson’s dementia. Table 4–3 depicts the distinguishing features of an ACS and dementia. See Chapter 29 for a complete description of these primary and secondary dementing diseases.



Assessment can be complex because of the multiple associated characteristics of an ACS and dementia. In fact, it is not uncommon for an ACS to be superimposed on dementia. In this case the symptoms of a new illness may be accentuated or may be masked, thus confounding assessment. Therefore the nurse must have a clear understanding of the differences between an ACS and dementia and must recognize that only subtle evidence may be present to indicate the existence of a problem. Also, it may not be possible or desirable to complete the total assessment during the first encounter with the client. In conducting the initial assessment of the course of the presenting symptoms, the nurse should remember that families and friends of the client can be valuable sources of data regarding the onset, duration, and associated symptoms.



Tailoring the Nursing Assessment to the Older Person


The health assessment may be collected in a variety of physical settings, including the hospital, home, office, day care center, and long-term care facility. Any of these settings can be adapted to be conducive to the free exchange of information between the nurse and an older adult. The overall atmosphere established by the nurse should be one that conveys trust, caring, and confidentiality. The following general suggestions related to preparation of the environment and consideration of individual client needs foster the collection of meaningful data (see the Cultural Awareness Box).


Environmental modifications made during the assessment should take into account sensory and musculoskeletal changes. The following points should be considered in preparation of the environment:



• Provide adequate space, particularly if the client uses a mobility aid.


• Minimize noise and distraction such as those generated by a television, radio, intercom, or other nearby activity.


• Set a comfortable, sufficiently warm temperature and ensure there are no drafts.


• Use diffuse lighting with increased illumination; avoid directional or localized light.


• Avoid glossy or highly polished surfaces, including floors, walls, ceilings, and furnishings.


• Place the client in a comfortable seating position that facilitates information exchange.


• Maintain proximity to a bathroom.


• Keep water or other preferred fluids available.


• Provide a place to hang or store garments and belongings.


• Maintain absolute privacy.


• Plan the assessment, taking into account the older adult’s energy level, pace, and adaptability. More than one session may be necessary to complete the assessment.


• Be patient, relaxed, and unhurried.


• Allow the client plenty of time to respond to questions and directions.


• Maximize the use of silence to allow the client time to collect thoughts before responding.


• Be alert to signs of increasing fatigue such as sighing, grimacing, irritability, leaning against objects for support, dropping of the head and shoulders, and progressive slowing.


• Conduct the assessment during the client’s peak energy time.



Regardless of the degree of decrement and decline an older adult client may exhibit, there are assets and capabilities that allow the client to function within the limitations imposed by that decline. During the assessment the nurse must provide an environment that gives the older adult the opportunity to demonstrate those abilities. Failure to do so could result in inaccurate conclusions about the client’s functional ability, which may lead to inappropriate care and treatment:



• Assess more than once and at different times of the day.


• Measure performance under the most favorable of conditions.


• Take advantage of natural opportunities that would elicit assets and capabilities; collect data during bathing, grooming, and mealtime.


• Ensure that assistive sensory devices (glasses, hearing aid) and mobility devices (walker, cane, prosthesis) are in place and functioning correctly.


• Interview family, friends, and significant others who are involved in the client’s care to validate assessment data.


• Use body language, touch, eye contact, and speech to promote the client’s maximum degree of participation.


• Be aware of the client’s emotional state and concerns; fear, anxiety, and boredom can lead to inaccurate assessment conclusions regarding functional ability.



The Health History


The nursing health history and interview, as the first phase of a comprehensive, nursing-focused health assessment, provide a subjective account of the older adult’s current and past health status. The interview forms the basis of a therapeutic nurse–client relationship, in which the client’s well-being is the mutual concern. Establishing this relationship with the older adult is essential for gathering useful, significant data. The data obtained from the health history alert the nurse to focus on key areas of the physical examination that require further investigation. By talking with the nurse about health concerns, the older adult increases his or her awareness of health, and topics for health teaching can be identified. Finally, the process of recounting a client’s history in a purposeful, systematic way can have the therapeutic effect of serving as a life review.


Although a number of formats exist for the nursing health history, all have similar basic components (Fig. 4–1). In addition, the nursing health history for the older adult should include assessment of functional, cognitive, affective, and social well-being. Specific tools for the collection of these data are addressed later in this chapter.



The physical, psychosocial, cultural, and functional aspects of the older adult client, coupled with a life history filled with people, places, and events, demand adaptations in interviewing styles and techniques. Making adaptations that reflect a genuine sensitivity toward the older adult and a sound, theoretic knowledge base of aging enhances the interview process.



The Interviewer


The interviewer’s ability to elicit meaningful data from the client depends on the interviewer’s attitudes and stereotypes about aging and older people. The nurse must be aware of these factors because they affect nurse–client communication during the assessment (see Cultural Awareness Boxes).


Attitude is a feeling, value, or belief about something that determines behavior. If the nurse has an attitude that characterizes older people as less healthy and alert and more dependent, then the interview structure will reflect this attitude. For example, if the nurse believes that dependence in self-care normally accompanies advanced age, the client will not be questioned about strengths and abilities. The resulting inaccurate functional assessment will do little to promote client independence. Myths and stereotypes about older adults also can affect the nurse’s questioning. For example, believing that older people do not participate in sexual relationships can result in the nurse’s failure to interview the client about sexual health matters (see Chapter 13). The nurse’s own anxiety and fear of personal aging, as well as a lack of knowledge regarding older people, contribute to commonly held negative attitudes, myths, and stereotypes about older people. Gerontologic nurses have a responsibility to themselves and to their older adult clients to improve their understanding of the aging process and aging people.


Nov 26, 2016 | Posted by in NURSING | Comments Off on Gerontologic Assessment
Premium Wordpress Themes by UFO Themes