Health Assessment



Health Assessment


Kathleen Jett




Learning Objectives


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.


image http://evolve.elsevier.com/Ebersole/TwdHlthAging


In the promotion of healthy aging, gerontological nurses conduct skilled and detailed assessments of and with the persons who entrust themselves to their care. The process of assessment of older adults is strikingly different from that of younger adults in that it is more detailed even when problem-oriented. If a complete and comprehensive assessment is needed, this is usually performed by a number of members of the health care team, led by the nurse. A comprehensive assessment requires not only physical data but also an integration of the biological, cultural, psychosocial, and functional aspects of the person. Inquiries into physiological and anatomical function, growth and development, family relationships, group involvement, and religious and occupational pursuits are included.


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 assessment provides information critical to the development of a plan of care that can enhance personal health status, decrease the potential for or the severity of chronic conditions, and encourage self-efficacy and empowerment for self-care. The nurse can consider the results of assessment as a snapshot of an individual’s health status at the time it is completed. Periodic assessment of physical, functional, social, and mental status in health and illness allows for comparison with a baseline and for that which nursing care can be planned or adjusted. Health assessment is a complex process that requires entire textbooks to address in detail. In this chapter we provide an overview of parts of the assessment and discussion of tools that are particularly unique or helpful in caring for the older adult.



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.



BOX 7-1


The Explanatory Model for Culturally Sensitive Assessment




1. How would you describe the problem that has brought you here? (What do you call your problem; does it have a name?)



2. How long have you had this problem?



3. What do you think is wrong with you?



4. Why do you think this happened to you?



5. What are the chief problems your sickness has caused you?


6. What do you think will help clear up this problem? (What treatment should you receive and what are the most important results you hope to receive?)



7. Apart from me, who else do you think can make you feel better?



Modified from Kleinman A: Patient and healers in the context of culture: an exploration of the borderland between anthropology, medicine, and psychiatry, Berkeley, CA, 1980, University of California Press; Pfeifferling JH: A cultural prescription for mediocentrism. In Eisenberg L, Kleinman A, editors: The relevance of social science for medicine, Boston, 1981, Reidel.


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).



BOX 7-2   Key Points to Consider in Observing Cultural Rules and Etiquette




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.










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:



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.


image
FIGURE 7-1 Katz Index of Independence in Activities of Daily Living. (From Katz S, Downs TD, Cash HR, et al: Progress in development of the index of ADL, Gerontologist 10:20, 1970.)


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).

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Nov 6, 2016 | Posted by in NURSING | Comments Off on Health Assessment

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