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
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 re- sources 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 associ- ated 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 musculo skeletal 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 im- pairment. 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 ex- cellent 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.
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 assess- ment 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 priori- tized, 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 set- tings, 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 comprehen- sive 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 respira- tory 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 api- cal lung fields.
TABLE
7-1
Considerations of Common Changes in Late Life During the Physical Assessment Height and weight Monitor for changes in weightWeight 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.
N—Nutrition
What mechanical and psychological factors affect the person’s ability to obtain and benefit from adequate nutri- tion (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 per- son’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 ade- quately? 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 en- vironmental 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 find- ing meaning in life (see Chapter 11)? What are the per- son’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 spir- itual 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 facili- ties 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 de- menting 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 ge- rontological nurse must be aware of the need to conduct an assessment of mental status, especially cognitive abili- ties 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 21and 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 at- tention, 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 exten- sively 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 usu- ally 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 im- pairment and is used as a measure of severity. It requires some manual dexterity to complete. It would not be ap- propriate 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 demen- tia, 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).
The Mini-Cog. The Mini-Cog was developed as a tool that could establish cognitive status more quickly than the MMSE and without the limitations of educational adjustments. It is the evidence-based tool now recom- mended (Doerflinger & Carolan, 2007). It combines one aspect of the MMSE (short-term memory recall) with the test of executive function of the Clock Drawing Test. It has been found to be highly sensitive to diagnosing dementia (Borson et al., 2000) and as a predictor of delirium in older
BOX
7-1
Clock Drawing Test InstructionsAsk the person to do the following on a blank piece of paper:
1. Draw a circle.
2. Place the numbers 1-12 inside the circle as for a clock.
3. Place the hands at 3:45 or a similar time.
Scoring
Draws closed circle 1 point
Places numbers in correct position 1 point Includes all 12 correct numbers 1 point Places hands in correct position 1 point Interpretation
Errors such as grossly distorted contour or extraneous markings are rarely produced by cognitively intact persons. Clinical judgment must be applied, but a low score indicates the need for further evaluation.
Data from Mendez MF, Ala T, Underwood KL: Development of scoring criteria for the clock drawing task in Alzheimer’s disease, J Am Geriatr Soc 40(11):1095-1099, 1992; Tuokko H, Hadjistaropoulost T, Miller J, et al: The clock test: a sensitive measure to differentiate normal elderly from those with Alzheimer disease, J Am Geriatr Soc 40(6):
579-584, 1992.
BOX
7-2
The Mini-Cog1. Tell the person that you are going to name three objects (e.g., apple, table, coin) and ask the person to repeat the objects after you and remember them.
2. Administer the clock test (see Box 7-1).
3. Ask the person to tell you the objects.
4. Give one point for each recalled word.
SCORE: 0 recall 5 indication of dementia 1-2 recall and clock abnormal 5 indication of dementia
1-2 recall and clock normal 5 no indication of dementia
3 recall 5 no indication of dementia Borson S. The mini-cog: a cognitive “vitals signs” measure for demen- tia screening in multi-lingual elderly. Int J Geriatr Psychiatry 15(11):1021, 2000.
hospitalized persons (Brodaty et al., 2006; Alagiakrishnan et al., 2007) (Box 7-2).
The Global Deterioration Scale The Global Deteriora- tion Scale (Reisberg et al., 1982) is a classic measure of the levels of cognitive changes as one passes through the pro- cess of dementia. It is useful to both the nurse and the family to develop appropriate interventions to help the person to optimize his or her health and anticipate future needs and changes.
Mood Measures
Other tools are needed to assess mood, especially to deter- mine the presence or absence of depression, a common and too often unrecognized problem in older adults. Persons with untreated depression are more functionally impaired and will have prolonged hospitalizations and nursing home stays, lowered quality of life, and shortened length of life (see Chapter 22). Persons with depression may appear as if they have dementia, and many persons with dementia are also depressed. The interconnection between the two calls for skill and sensitivity in the nurse to ensure that elders receive the assessment and care they need. The most commonly used mood measure in both middle-aged and older adults is the Geriatric Depression Scale (GDS), devel- oped by Yesavage and colleagues (1982). The GDS has been extremely successful in determining depression be- cause it deemphasizes physical complaints, sex drive, and appetite—those things most affected by medications. It cannot be used in persons with dementia or cognitive impairment. Chapter 22 provides more detail on the assessment of mood in older adults.