Week 2 Flashcards
(27 cards)
What is important to know about assessments of older patients compared to younger patients?
Assessment of the older person differs from a younger person as it is more complex, more detailed and will likely take longer to complete.
Why are assessments different for older adults?
-Symptoms are different in older adults then in younger patients
-Holistic assessments are needed to know the whole picture for the patient
-Older people need to focus on social complexity
-Comprehensive assessments should be interprofessional
Why do we as nurses assess people?
Help nurses and other health care professionals to objectively and subjectively identify the needs and concerns of people and their families.
What kind of data do we collect with assessments?
- Health history
- Observation
- Standardised measures/ scores
- Functional assessment
- Mental status assessment
- Assessment of social support
- Comprehensive holistic assessment includes cultural, psychological, psychosocial, physical, environmental and safety considerations
When is the preferred time to collect data?
when the older person is at their best
How do we collect data in an assessment?
- Observation
- Physical assessment
- Conversation
What is important to remember while collecting data?
not to interpret data when you are collecting data
What is the difference between a screening tool and an assessment?
-Screening is a process for evaluating the possible presence (ie risk) of a particular problem. The outcome is normally a simple yes or no to identify those in need of further evaluation. Generally brief and narrow in scope.
-Assessment is a more comprehensive process for defining the nature of that problem, determining a diagnosis, and developing specific treatment recommendations/ care plan for addressing the problem or diagnosis
What are examples of screening tools?
PHQ-9
Fall risk assessment tool
COVID-19 assessment tool
What is involved in a health history assessment?
- Profile
- Past medical history
- Review of systems and symptoms
- Medication history
- Family history
- Social history
What is involved in a physical assessment?
Vital signs
Mobility
Lab Results
What is involved in a comprhensive assessment? (Remember FANCAPES)
F- Fluids
A- Aeration
N-Nutrition
C- Communication
A- Activity
E- Elimination
S- Socialization
What are standradised assessments you’d complete on an older adults?
-Functional Assessment
-Performance Assessment
-Mental Status Assessment
-Social Support Assessment
-Inappropriate Medication in Older Adults (BEERS assessment)
What is involved in a functional assessment?
Activities of Daily Living (Katz index)
* toileting, eating, ambulation, bathing, dressing, and grooming Instrumental Activities of Daily Living (IADLs)
* cleaning, yard work, shopping, and money management
what are the aspects of a performance assessment?
- Objective measurement of performance
- Grip strength, Shuttle test, timed walk, balance test
What are some mental status assessments?
-Cognition: MMSE, Clock drawing test, Mini-Cog Delirium Index
-Mood: geriatric depression scale
What does the older Americans resources and services evaluate?
Evaluates the (dis)ability and capacity level at which the person is able to function. Includes five sub-scales: Social & economic resources; physical and mental health and ability to perform ADLs
What is the Fulmer SPICES for and what does it stand for?
SPICES stands for six common syndromes of the older person that require nursing interventions:
Sleep disorders
Problems with eating or feeding Incontinence
Confusion
Evidence of falls
Skin breakdown
What is involved in an environmental and safety assessment?
-Intrinsic safety factors
-Extrinsic safety assessment
What are intrinsic safety issues?
Mobility concerns
Vision and hearing impairment Cognition
What are extrinsic safety assessments?
Fire hazards
Poisoning
Medication (Beers)
Fall hazards
Temperature regulation
Crime and abuse
what is the golden standard in best practice for managin fraility?
the Comprehensice geriatric assessment
What is the goal of a comprehensice geriatric assessment?
to optimize health and well-being in older adults – a holistic approach
What are the 4 steps to a comprehensive geriatric assessment?
- Screening
- Assessment
- Creation of a Problem List
- Planning Goal-Directed Interventions
