for Optimal Care
Kathleen F. Jett
7
L E A R N I N G O B J E C T I V E S
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 advantages and disadvantages of the use of standardized assessment tools in gerontological nursing.
• Begin to develop the skills needed to select an evidence-based and appropriate tool for a specific situation and use it correctly.
• 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.
• Identify ways in which errors in documentation and communication are especially dangerous when caring for older adults.
• Compare the major documentation methods used in acute, long-term, and home care.
G L O S S A R Y
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.
HIPAA Health Insurance Portability and Accountability Act of 1996, which legislated the handling of confidential patient information.
Report-by-proxy One person (the proxy) answering questions or providing information for a second person, based on the first person’s knowledge of the second person.
T H E L I V E D E X P E R I E N C E
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. Even- tually she became acutely ill, and a decision had to be made about CPR (cardiopulmonary resuscitation). When we
88
evolve.elsevier.com/Ebersole/gerontological
Assessment Tools in Gerontological Nursing
Gerontological nurses conduct skilled and detailed assess- ments 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 strik- ingly 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 inde- pendent to medically fragile and dependent. The compre- hensive 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 proba- bly 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 assess- ment 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 ge- netic 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 syn- dromes. 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, cog- nitively 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. How- ever, 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 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
unless invited to do so. The assumption of familiarity in the use of the first name in addressing an elder can easily be per- ceived as condescending especially when the nurse is younger than the patient or of a different ethnic background.
There are three approaches used for collecting assess- ment 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 abili- ties 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 measure- ment of a blood pressure, and performance-based functional assessments, such as having the person walk a certain distance, are examples of observational measures. Observa- tion 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.
• Approach questions that are more personal, such as sexual functioning, in a matter-of-fact, but nonetheless sensitive, manner.
• Record the responses accurately, using the patient’s own words where possible; do not analyze at the same time the data are being collected. For example, if the patient says “I have a runny nose,” this is not recorded as “Patient has a cold” until analysis of the data.
Ideally, the assessment should be used to gather base- line data before the older adult has a health crisis. Periodi- cally, 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 in- creasing 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 catego- rize 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 instru- ments 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 exam- ples 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 as- sessment (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 instru- ments 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 them- selves 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 prob- lem, 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 un- usual 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 for- mats 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 per- son 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 lim- ited health fluency, special attention will need to be paid to wording of questions and answers to the patient’s ques- tions. If the person is cognitively impaired he or she should be included to the extent possible with additional informa- tion 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 influ- ence 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 symp- toms 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