Health Assessment
It takes so long to get a health history from an older person, they have so many stories. I now know to listen carefully and I will find out what I need to know. After all, most of them have had their health problem longer than I have been alive!
Whenever I go to one of my doctors I feel like they are rushing through and never really give me a good examination. Then I had an appointment with a nurse practitioner who specialized in us older folks. I couldn’t believe the difference. I not only felt listened to but I also felt like I got the best exam I have had in a long time. I am sure it will help me get better!
On completion of this chapter, the reader will be able to:
1. List the essential components of the comprehensive health assessment of an older adult.
2. Discuss the advantages and disadvantages of the use of standardized tools in the gerontological assessment.
3. Describe the purpose of the inclusion of functional assessment when caring for an older adult.
http://evolve.elsevier.com/Ebersole/TwdHlthAging
Assessment of the older adult requires special abilities of the nurse: to listen patiently, to allow for pauses, to ask questions that are not often asked, to observe minute details, to obtain data from all available sources, and to recognize normal changes associated with late life that might be considered abnormal in one who is younger (see Chapter 4). In gerontological nursing, assessment takes more time than it does with younger adults because of the increased medical and social complexities of living longer. The quality and speed of the assessment are an art born of experience. Novice nurses should neither be expected nor expect themselves to do this proficiently but should expect to see both their skills and the amount of information obtained increase over time. According to Benner (1984), assessment is a task for the expert. However, an expert is not always available. By using both a high degree of sensitivity, knowledge of normal changes with aging, and appropriate assessment tools, reasonably reliable data may be obtained by nurses at all skill levels.
The Health History
The initiation of the health history marks the beginning of the nurse–client relationship and the assessment process. The health history is collected either in written format or verbally in a face-to-face interview or in combination. The history may be given by the person or through a proxy, with the person’s consent. If the elder has limited English proficiency, a knowledgeable interpreter is needed and the interview will generally take approximately double the amount of time.
Any health history form or interview should include a patient profile, a past medical history, a review of symptoms and systems, a medication history (prescribed, over-the-counter, “home remedies,” and herbals and dietary supplements), and a social history. The health history also includes the self- or proxy-report of functional status. The social history of the older adult should include the current living arrangements, economic resources to deal with current health issues, amount of family and friend support if needed, and the types of community resources available if needed or used. It should also include the identification of those who are involved in health care decision-making and state of advanced care planning. For those who are very old, a family history is only relevant secondary to the social history.
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 standard health history, making it applicable to everyone (Box 7-1). The responses will better enable the nurse to understand the elder and plan culturally appropriate and effective interventions.
A comprehensive assessment includes psychological parameters such as cognitive and emotional well-being; caregiver stress or burden; the individual’s self-perception of health; and patterns of health and health care, education, family structure, plans for retirement, and living environment. For those living at home, a home safety assessment is important. Areas or problems not frequently addressed by the care provider or mentioned by the elder but that should be addressed are sexual dysfunction, depression, incontinence, alcoholism, hearing loss, and memory loss or confusion (Ham, 2002).
Physical Assessment
The health history is followed by the physical assessment or examination at that time or at a time in the near future. Although the manual techniques of the examination do not differ significantly from those used with younger persons, knowledge of the normal changes with aging is essential for the appropriate analysis of the data obtained. When assessing persons from ethnically distinct groups, is it also necessary to be aware of cultural rules of etiquette and taboos that influence the examination (Box 7-2) (see also Chapter 5).
Because of the complex interrelationship among the parts of the complete assessment process, the use of a model or tools may be helpful. The website of the Hartford Institute for Geriatric Nursing (New York, NY; http://hartfordign.org) provides a compilation of key tools used in assessment in their Try This series. New evidence-based protocols are regularly added. The tools and directions for their use can be viewed at http://hartfordign.org. This site is a portal to a wealth of information, especially for assessing a number of specific conditions or situations, such as fall risk or restraint use.
Two tools for a basic overall assessment of older adults and those who are medically vulnerable are SPICES and FANCAPES. They use a framework with an emphasis on function at the most basic level and the extent to which assistance is necessary. When alterations are found then further assessment in that particular area is indicated (Montgomery et al., 2008). The acronym FANCAPES stands for Fluids, Aeration, Nutrition, Communication, Activity, Pain, Elimination, and Socialization and social skills. SPICES is the mnemonic for Sleep disorders, Problems with eating or feeding, Incontinence, Confusion, Evidence of falls, and Skin breakdown. Both can be used in all settings, may be used in part or total (depending on the need), and are easily adaptable to the functional pattern grouping if nursing diagnoses are used.
Fancapes
Fluids
Evaluation of fluids requires an assessment of the client’s state of hydration and those physiological, situational, and mental factors that contribute to the maintenance of adequate hydration. Attention is directed to the ability of the person to obtain adequate fluids independently, to express thirst, to swallow effectively, and to evaluate medications that affect intake and output.
Aeration
Aeration refers to the adequacy of oxygen exchange. Observations include respiratory rate and depth at rest and during activity; talking, walking, and situations requiring added exertion; and the presence or absence of edema in the extremities or abdomen. At a minimum, breath sounds should be evaluated and medications reviewed to evaluate their effects on aeration. A determination of oxygen saturation level is essential any time that respiratory compromise is suspected, such as the potential of pneumonia.
Nutrition
Nutrition assessment includes mechanical and psychological factors in addition to the type and amount of food consumed; ability to bite, chew, and swallow; fit of dentures and condition of the gums and teeth. Alterations in diet related to culture, medical restrictions, available economic resources, and living conditions should be included. If a special diet is needed, it is necessary to know and work with the person who prepares meals if other than the elder. Visual and neurological impairment, which might interfere with the person’s ability to prepare a meal or feed him- or herself, should be noted. Functional or economic status may interfere with obtaining groceries or foods for special diets.
Communication
Communication includes sending and receiving verbal and nonverbal information. Assessment of communicative ability includes the determination of sight and sound acuity; voice quality; and adequate function of the tongue, teeth, pharynx, and larynx. Appraisals of the person’s ability to read, write, and understand the spoken language of the nurse should be ascertained. This is an important issue, since an undetected limitation of these skills can lead to erroneous conclusions or to the patient’s inability to follow directions. Determination of both literacy and health literacy is necessary.
Activity
Although the ability to ambulate is a major component in activity assessment, activity includes more than movement or exercise. The nurse assesses the person’s ability to eat, toilet, dress, and groom; to prepare meals; to use the telephone; and to move about with or without assistive devices. Coordination and balance, finger dexterity, grip strength, and other abilities necessary in daily life should also be assessed.
Pain
Physical, mental, and spiritual pain is considered. The presence and absence of pressure and discomfort are key aspects of pain assessment. Information about recent losses or visible symptoms of anxiety may help identify persons in pain. The manner by which a client customarily attains relief from pain or discomfort will provide further information.
Elimination
Bladder and bowel elimination are assessed and include evidence of urinary dribbling or incontinence, use of protective garments or devices. and medications that affect voiding and intestinal peristalsis. The nurse and patient will need to find words that they both understand when talking about bowel and bladder functioning. The words used in health care, such as “stooling” or “voiding,” should be avoided unless it is known that they are understood.
Social Skills
Assessment of socialization and social skills includes the individual’s ability to negotiate in society, to give and receive love and friendship, and to feel self-worth. Assessment focuses on the individual’s ability to deal with loss and to interact with other people in give-and-take situations.
Spices
The Fulmer SPICES has been used widely with older adults as an overall assessment tool regardless of health status or setting (Wallace and Fulmer, 2007). The acronym SPICES refers to six common geriatric syndromes of the elderly that require nursing interventions: Sleep disorders, Problems with eating or feeding, Incontinence, Confusion, Evidence of falls, and Skin breakdown. Like with FANCAPES, anything that indicates a problem in one of the categories warns the nurse that more in-depth assessment is needed. It is a system for alerting the nurse to the most common problems that interfere with the health and well-being of older adults, particularly those who have one or more medical conditions.
Functional Assessment
Whereas the emphasis of FANCAPES and SPICES is on physical parameters and those associated with geriatric syndromes, a full functional assessment is broader. It encompasses the evaluation of a person’s ability to carry out basic tasks for self-care and tasks needed to support independent living. A thorough functional assessment will help the gerontological nurse work toward healthy aging by accomplishing the following:
• Identifying the specific areas in which help is needed or not needed
• Identifying changes in abilities from one period of time to another
• Determining the need for specific service(s)
• Providing information that may be useful in assessing the safety of a particular living situation
Numerous tools are available that describe, screen, assess, monitor, and predict functional ability. The major tools used in functional assessment determine the individual’s ability to perform the tasks needed for self-care (i.e., those needed to maintain one’s health), referred to as activities of daily living (ADLs), and, separately, those tasks needed for independent living (i.e., those needed to maintain one’s home), referred to as instrumental activities of daily living (IADLs). ADLs and IADLs are universal needs; how these needs are met is socially and culturally constructed.
The majority of tools do not break down a task (e.g., eating) into its component parts, such as picking up a spoon or cup or swallowing water; eating is seen as a total task when a person may be able to perform one part and not the other. Most of the tools result in a score of some kind—a rating of the person’s ability to do the task alone, to need assistance, or to not be able to perform the task at all. These categories are intended to be mutually exclusive. The ratings are done by self-report, proxy, or observer. It should be noted that research has found that self-reports usually overestimate, and proxies underestimate, abilities to perform activities of daily living. The tools are beneficial in their ability to serve the purposes just noted. However, most are not sensitive to small changes and can be used only as part of a holistic assessment.
The FAST (Functional Assessment Staging) tool for Alzheimer’s disease was designed by Barry Reisberg in 1988. It has been found to be a reliable and valid measurement for the evaluation and staging of functional decline in persons with Alzheimer’s disease (Sclan and Reisberg, 1992). The tool uses ordinal ranking of seven stages beginning with what is referred to as a “normal adult” to one with “severe dementia.” This can be used to plan care and work with the individual and family to prepare for future needs. Varitions of this tool can be easily found on the internet.
Activities of Daily Living
What have become know as activities of daily living (ADLs) were first classified as such in 1963 by Sidney Katz and colleagues. These include bathing, dressing, toileting, continence, transferring (refers to ambulation as well), and feeding. Two of these tasks (dressing [including grooming], and bathing) require higher cognitive function than the others.
Katz Index
The Katz Index (Katz et al., 1963) has served as a basic framework for most of the measures of ADLs since that time (Figure 7-1). There are several versions of the Katz Index. One is based on a three-point scale and allows one to score client performance abilities as independent, assistive, dependent, or unable to perform. Another version of the tool assigns 1 point to each ADL that can be completed independently and a zero (0) if it cannot. Scores will range from a maximum of 6 (totally independent) to 0 (totally dependent). A score of 4 indicates moderate impairment, whereas 2 or less indicates severe impairment (see Figure 7-1). This scoring puts equal weight on all activities, and the determination of a cutoff score is completely arbitrary. Despite these limitations, the tool is useful because it creates a common language about functioning for all caregivers involved in planning overall care and discharge.
Barthel Index and Functional Independence Measure
The Barthel Index (BI; Mahoney and Barthel, 1965) and the Functional Independence Measure (FIM) are the two tools most commonly used in the rehabilitation setting to assess a person’s need for assistance with ADLs. The data are used for both inpatient and postdischarge planning relative to the amount of physical assistance required. In some studies the BI and FIM were found to be comparable (Sangha et al., 2005). In others the FIM was deemed preferable (Kidd et al., 1995). The BI has proved easy to use and especially useful as a method of documenting improvement of a patient’s ability. The BI ranks functional status as either independent or dependent and then allows for further classification of “independent” as intact or limited, and of “dependent” as needing a helper or unable to do the activity at all. Instruction is needed in the use and scoring of this tool before using it. The FIM is widely used and the most comprehensive functional assessment tool for rehabilitation settings. It includes measures of ADL, mobility, cognition, and social functioning. It has been widely tested and rates 18 ADLs on a seven-point scale from independent to dependent. The items are sorted into 13 motor items and 5 cognitive items. The tool is highly sensitive but complex and requires training to use accurately and to obtain interrater reliability. Ordinarily the tool is completed by the joint efforts of the multi-disciplinary team and used for both planning and evaluation of progress. Use of this instrument can be requested from the Uniform Data System for Medical Rehabilitation (www.udsmr.org).
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
