Nursing Care of the

 Informal
Older Adult Wellness
ASSESSMENT
 Assessment of health and functioning of
older adults is an essential and complex
component of nursing care.
 Health assessment for older adults can
be done on several levels, ranging from
simple to complex.
 Based on immediate need recognized
by the nurse
PREPARING THE PHYSICAL SETTING
 Choose the interview environment
carefully
 Minimize distractions:
o Noise from television
o Radios
o Phones
 Lighting should be diffused
 Furniture should be comfortable
 Privacy is very important

Health Assessment of Older Adult ESTABLISHING RAPPORT

Health assessment for older adults can be done
on several levels, ranging from simple to
complex, in depth evaluation.
 Must possess necessary knowledge and
skill
 Must know how to use diagnostic tools
and equipment’s safely
 Must be knowledgeable and sensitive to
the unique needs of older adults.
 Greet the patient
 Introduce yourself
 If first contact, address the person using
their formal names (e.g. Mr. Cruz, Mrs.
Dela paz)
 Briefly explain the purpose of the
interview
 Explain how long you expect the
interview to last.
 What will happen after it is completed

STRUCTURING THE INTERVIEW

HEALTH SCREENING
 To identify older individuals who are in
 Plan sufficient time for the interview
 Try not to accomplish to much during a
need of further, more in-depth single interview
assessment  The interview should not end abruptly
 Screenings are not designed to provide
treatment NURSING HISTORY
 Intended to identify significant findings
OBTAINING HEALTH HISTORY
HEALTH ASSESSMENT
 It includes the collection of all types of
 Before starting a physical assessment,
the nurse will use interviewing techniques
important health-related data using a to obtain a health history.
variety of techniques.  History should include, but not limited to:
 The information is used to identify patient o Identifying data
problems and to plan patient care. o Past history
 Accurate and complete data should be o Present medical history/Current
collected. history
 Data can be either o Family and psychosocial history
o SUBJECTIVE DATA
o OBJECTIVE DATA Guidelines for Obtaining Health
History
1. SUBJECTIVE DATA
 Information gathered from the older General instructions:
person’s point of view.  General requests for information may
 Best described in the individual’s own prompt a discussion of health
words. information. Making some or all of the
following questions unnecessary.
 Fear  Social, cultural, developmental,
 Anxiety educational levels are assessed
 Frustration examples of throughout the interview
Subjective  During the interview note the individual’s
 pain data openness and readiness to learn

Interviewing older adult: Health History Data

 During admission
 May be spontaneous IDENTIFYING DATA
  Name
 Date of birth
 Residence
 Ethnicity and cultural preferences
 Language preferences
 religion
 Gender identity/preferred pronouns
 Marital/significant other status
 Previous and/or current occupation
 Educational background
 Advance directives and any other
relevant data
PAST HISTORY
 Perception of general health
 Frequency of medical and dental care,
including screenings, such as
mammography, BP
 Known or suspected allergies
(medicines, food, animals etc).
 History of serious illnesses (specify illness,
date of onset, type of treatment
received, resolved vs. ongoing problem)
 Hospitalization (reason/date)
 surgeries (type and date)
 Mental health treatment (type and
date)
 Review of personal health habits, such as
diet, fluid intake, exercise practices,
sleep patterns, bowel and bladder
routines, alcohol, caffeine and tobacco
use, sexual activity, etc.
Suggested opening statement: “It would help in
planning your care if you tell me about your
past
health.”
 Were you immunized, (given shots or
vaccinated) for any disease?
 Have you had a tetanus
vaccination?
 What childhood disease did you
have? Examples are measles and
chickenpox.
 As an adult, what illnesses have you
had that came and went, such as
pneumonia or blood clots?
 Were you ever treated for any
mental problems, such as
depression?
 What surgeries have you had?
 Did you ever injure yourself and then
receive treatment? Do you ever
fall?
 Were you ever in the hospital for any
reason?
 Have you ever had an allergic
reaction to medicine, such as
penicillin? Do you have any other
allergies?
PRESENT MEDICAL HISTORY
 Major current problems or concerns (in
person’s own words)
 Do the problems relate to an accident or
fall?
 Symptoms (location, duration, severity,
etc.)
 Date of onset (sudden or gradual onset)
 What makes problem worst or better?
 What was done an in response to
symptom(s) (home remedies, visit to
primary care provider, etc.)
 Medications currently taken (look at
bottles if possible)
 Adherence to medication regimen
 Current medical treatments or therapies
(oxygen, physical therapies, etc.)
CURRENT HEALTH
Suggested opening statement “please tell me
about your current health.”
 How would describe your general
health?
 Do you have any chronic problems,
such as diabetes, high blood
pressure, arthritis, or heart disease?
 Have you had any weight loss or
gain within last year? Within the last
several weeks? Do you have any
pain, unusual sensations, or lack of
sensation?
 Do you have any cough, shortness
of breath, other trouble breathing?
Do you cough up any sputum? If
yes, describe the sputum.
 Do you have any headaches,
dizziness, weakness, fainting spells,
or excessive sweating?
 Do you have any swelling?
 Are there any discharges or
drainage from anywhere?
 Does your heart ever race, pound,
skip a beat, or have any other
unusual sensations?
 Tell me all the medications you take,
including prescription, over-the-
counter, or home remedy
GENERAL HEALTH HABITS
 Suggested opening statement:
“Please tell me about your general
health habits.”
 Are you on a special diet? What
food do you normally eat?
 Do you have any problem eating,
such as trouble swallowing or have
nausea or vomiting after eating?
 Do you drink caffeinated beverages
such as coffee, tea, or carbonated
drinks?
 How many glasses of water do you
drink in 1 day?
 How many hours do you usually
sleep at night?
  Do you take naps? Do you have any
problems sleeping? What type of
sleeping problems?
 What are your bowel habits? Do you
use laxatives, suppositories, or
enemas? Do you ever have
diarrhea?
 Tell me about your bladder habits.
Do you urinate often during the
day? How much do you urinate?
Small amounts or fairly large
amounts? Do you have any
problems urinating? Do you get up
at night to go to the bathroom?
 What type of exercise do you
engage in? how often do you
exercise? Do you drink any
alcoholic beverages? If so, what
kind and how often?
 Do you smoke? If so, what and how
often?
 Do you wear glasses, a hearing aid,
or dentures? Describe hearing loss
and any vision loss.
 Do you use a cane, crutches or
walker?
 Tell me about your memory.
FAMILY AND PSYCHOSOCIAL HISTORY
 Living family members (spouse, children,
siblings, etc.) and nature of relationships
 Friends and social activity practices
(clubs, church activities,
community/organizations, online
interactions, etc)
 Significant deceased family members
 Hobbies and interests
 Pets
Nursing Focus
Suggested opening statement: “Please tell me
about your needs.”
 What are your strengths? Your
weaknesses?
 What concerns do you have?
 What questions can I answer for
you?
 What kinds of help do you need?
 What could the nursing staff do to
be the most helpful to you?
FUNCTIONAL HEALTH PATTERN
 Clients’ functional health patterns
(individuals, families, or communities)
evolve from client-environment
interaction. Each pattern is an expression
of biopsychosocial integration; thus no
one pattern can be understood without
knowledge of the other patterns.
 Functional patterns are influenced by
biological, developmental, cultural,
social, and spiritual factors. A functional
pattern represents a healthy set of
behaviors. Dysfunctional health patterns
(described by nursing diagnoses) may
occur with disease; dysfunctional health
patterns may also lead to disease.
 The judgment of whether a pattern is
functional or dysfunctional is made by
comparing assessment data to one or
more of the following:
(1) INDIVIDUAL BASELINES
(2) ESTABLISHED NORMS FOR AGE GROUPS
(3) CULTURAL, SOCIAL, OR OTHER NORMS
HEALTH-PERCEPTION-HEALTH-MANAGEMENT
PATTERN
 Describes the client’s perceived pattern
of health and well-being and how health
is managed.
 Includes the individual’s perception of
health status and its relevance to current
activities and future planning.
 Includes the individual’s health-risk
management and general healthcare
behavior, such as safety practices and
adherence to mental and
physical health promotion activities,
medical or nursing prescriptions, and
follow-up care.
HEALTH-PERCEPTION-HEALTH-MANAGEMENT
PATTERN
 How has general health been?
 Any colds in the past year? If
appropriate, absences from
work/school?
 Most important things done to keep
healthy? Did these things make a
difference to health (include family folk
remedies, if appropriate)? Breast self-
examination? Use cigarettes? Drugs?
Ever had a drinking problem? When was
your last drink?
 Accidents (home, work, driving)? Falls?
 In past, easy to find ways to follow
suggestions of doctors or nurses?
 If appropriate, what do you think caused
this illness? Action taken when symptoms
perceived? Results of action?
 If appropriate, what is important to you
while you are here? How can we be most
helpful?
NUTRITIONAL-METABOLIC PATTERN
 Describes pattern of food and fluid
consumption relative to metabolic need
and pattern indicators of local nutrient
supply.
 Includes the individual’s patterns of food
and fluid consumption: daily eating
times, the types and quantity of food
and fluids consumed, particular food
preferences, and the use of nutrient or
vitamin supplements.
  Describes breastfeeding and infant  Emphasis is on the activities of high
feeding patterns. importance or significance and any
 Includes reports of any skin lesions, ability limitations.
to heal, and measures of body  Factors that interfere with desired or
temperature, height, and weight. expected activities for the individual
 General appearance of well-being and (such as neuromuscular deficits
condition of skin, hair, nails, mucous and compensations, dyspnea, angina,
membranes, and teeth are included. or muscle cramping on exertion, and
cardiac/pulmonary classification, if
NUTRITIONAL-METABOLIC PATTERN appropriate) are also included.
 Typical daily food intake? Describe.
Supplements? ACTIVITY-EXERCISE PATTERN
 Typical daily fluid intake? Describe.  Sufficient energy for desired/required
 Weight loss/gain? Amount? Height activities?
loss/gain? Amount?  Exercise pattern? Type? Regularity?
 Appetite?  Spare time (leisure) activities? Child’s
 Food or eating discomfort? Swallowing? play activities?
Diet restrictions? If appropriate,  Perceived ability for the following (code
breastfeeding? Problems with level according to Functional Levels
breastfeeding? Code below)
 Heal well or poorly?
 Skin problems, such as lesions, dryness? Feeding Grooming
 Dental problems? Bathing General Mobility
Toileting Cooking
ELIMINATION PATTERN Bed Mobility Home Maintenance
 Describes patterns of excretory function Dressing Shopping
(bowel, bladder, and skin).
 Includes the individual’s perceived Functional Levels Code
regularity of excretory function, use of  Level 0: Full self-care
routines or laxatives for bowel  Level I: Requires use of equipment or
elimination, and any changes or device
disturbances in time pattern, mode of  Level II: Requires assistance or supervision
excretion, quality, or quantity of of another person
elimination.  Level III: Requires assistance or
 Also included are any devices used to supervision of another person and
control excretion. equipment or device
 Level IV: Is dependent and does not
ELIMINATION PATTERN participate
 Bowel elimination pattern? Describe.
Frequency? Character? Discomfort? SLEEP-REST PATTERN
Problem in control? Laxatives?  Describes patterns of sleep, rest, and
 Urinary elimination pattern? Describe. relaxation.
Frequency? Discomfort? Problem in  Includes patterns of sleep and
control? rest/relaxation periods during the 24-hour
 Excess perspiration? Odor problems? day.
 This pattern includes perception of the
ACTIVITY-EXERCISE PATTERN quality and quantity of sleep and rest,
 Describes pattern of exercise, activity, perception of energy level after sleep,
leisure, and recreation. and any sleep disturbances, as well as
 Includes activities of daily living requiring aids to sleep such as medications or
energy expenditure, such as hygiene, nighttime routines that the individual
cooking, shopping, eating, working, and uses.
home maintenance.
 Also included are the type, quantity, and SLEEP-REST PATTERN
quality of exercise, including sports, that  Generally rested and ready for daily
describe the typical pattern for the activities after sleep?
individual  Sleep-onset problems? Aids? Dreams
 Leisure patterns are also included and (nightmares)? Early awakening?
describe the activities the client  Rest/relaxation periods?
undertakes as recreation either with a
group or as an individual. COGNITIVE-PERCEPTUAL PATTERN
  Describes sensory-perceptual and
cognitive pattern.
 It includes the adequacy of sensory
modes, such as vision, hearing, taste,
touch, and smell, and the compensation
or prostheses currently used.
 Reports of pain perception and how
pain is managed are included when
appropriate.
 Also included are cognitive functional
abilities such as language, memory,
judgment, and decision making.
COGNITIVE-PERCEPTUAL PATTERN
 Hearing difficulty? Aid?
 Vision? Wear glasses? Last checked?
 Any change in memory lately?
 Easy/difficult to make decisions?
 Easiest way for you to learn things? Any
difficulty learning?
 Any discomfort? Pain? How do you
manage it?
SELF-PERCEPTION-SELF-CONCEPT PATTERN
 Describes self-concept pattern and
perceptions of mood state.
 Includes the individual’s attitudes about
self, perception of abilities (cognitive,
affective, or physical), body image,
identity, general sense of worth, and
general emotional pattern.
 Body posture and movement, eye
contact, voice, and speech pattern are
included.
SELF-PERCEPTION-SELF-CONCEPT PATTERN
 How would you describe yourself? Most
of the time, do you feel good (not so
good) about yourself?
 Changes in your body or the things you
can do? Are these problematic for you?
 Changes in way you feel about yourself
or your body (since illness started)?
 Find things frequently make you angry?
Annoyed? Fearful? Anxious? Depressed?
What helps?
 Ever feel you lose hope? Not able to
control things in life? What helps?
ROLE-RELATIONSHIP PATTERN
 Describes pattern of role engagements
and relationships.
 Includes the individual’s perception of
the major roles and responsibilities in his
or her current life situation.
 Satisfaction or disturbances in family,
work, or social relationships and
responsibilities related to these roles are
included.
ROLE-RELATIONSHIP PATTERN
 Live alone? Family? Family structure?
Draw diagram.
 Any family problems you have difficulty
handling (nuclear/extended)?
 How does the family usually handle
problems?
 Family depend on you for things? How
are you managing?
 If appropriate, how do family/others feel
about your illness/hospitalization?
 If appropriate, problems with children?
Difficulty handling?
 Belong to social groups? Close friends?
Feel lonely (frequency)?
 Things generally go well for you at work?
School? If appropriate, income sufficient
for needs?
 Feel part of (or isolated in) neighborhood
where living?
SEXUALITY-REPRODUCTIVE PATTERN
 Describes patterns of satisfaction or
dissatisfaction with sexuality; describes
reproductive pattern.
 Includes the individual’s perceived
satisfaction or reports of disturbances in
his or her sexuality.
 Included also is the female’s
reproductive stage (premenopause or
postmenopause) and any perceived
problems.
SEXUALITY-REPRODUCTIVE PATTERN
 If appropriate to age/situation, sexual
relationships satisfying? Changes?
Problems?
 If appropriate, use of contraceptives?
Problems?
 For females, when menstruation started?
Last menstrual period? Menstrual
problems? Para? Gravida?
COPING-STRESS-TOLERANCE PATTERN
 Describes general coping pattern and
effectiveness of the pattern in terms of
stress tolerance.
 Includes the individual’s reserve or
capacity to resist challenge to self-
integrity, modes of handling stress, family
or other support systems, and perceived
ability to manage stressful situations.
COPING-STRESS-TOLERANCE PATTERN
 Any big changes in your life in the last
year or two? Crisis?
 Who’s most helpful in talking things over?
Available to you now?
 Tense a lot of the time? What helps? Use
any medicines, drugs, alcohol?
 When (if) problems occur in your life, how
do you handle them?
  Most of the time, is this way(s) successful?
VALUE-BELIEF PATTERN
 Describes patterns of values, goals, or
beliefs (including spiritual) that guide
choices or decisions.
 Includes what is perceived as important
in life, quality of life, and any perceived
conflicts in values, beliefs, or
expectations that are health related.
VALUE-BELIEF PATTERN
 Generally, get things you want out of
life? Important plans for the future?
 Religion important in your life? If
appropriate, does this help when
difficulties arise?
 If appropriate, will being here interfere
with any religious practices?
2. OBJECTIVE DATA
 is part of the health assessment that
involves the collection of information
through observations.
 In the health care environment, the
senses of seeing, hearing, smelling and
touching are used to gather information
about the patient.
 The patient's behaviors, actions, test
results, measurements and the physical
examination are also included.
 Objective information is collected by
means of direct observation, physical
examination, and laboratory or
diagnostic tests.
 Can be made more precise and specific
by using meters, monitors and other
measuring device.
PSYCHOLOGICAL ASSESSMENT
 Psychological assessment is performed
to determine whether the older is alert
and aware of the surroundings or suffers
from some level of confusion, delirium, or
dementia.
 Psychological status is best assessed by
direct observation and by means of
standardized assessment tools. •  Scores:
Performing this assessment can identify
cognitive impairments that can be
tracked over time. • The test can be
administered in 3 to 4 minutes, making it
ideal for both hospital and routine visits
 Assessment of social function is
determined by observing the amount,
frequency, and type of social interaction
in which the older person participates. •
A variety of levels and degrees of social
interaction can be classified as normal
as long as the individual is happy or
content with that level
 Instructions for the Mini-Cog Test
Administration:
 the Mini-Cog test is a 3-minute
instrument to screen for cognitive
impairment in older adults in the
primary care setting.
 The Mini-Cog uses a three-item
recall test for memory and a
simply scored clock-drawing test
(CDT).
 The latter serves as an
“informative distractor,” helping
to clarify scores when the memory
recall score is intermediate
 The Mini-Cog was as effective as
or better than established
screening tests in both an
epidemiologic survey in a
mainstream sample and a multi-
ethnic, multilingual population
comprising many individuals of
low socioeconomic status and
education level.
 In comparative tests, the Mini-
Cog was at least twice as fast as
the Mini-Mental State
Examination.
 The Mini-Cog is less affected by
subject ethnicity, language, and
education, and can detect a
variety of different dementias.
Moreover, the Mini-Cog detects
many people with mild cognitive
impairment (cognitive
impairment too mild to meet
diagnostic criteria for dementia).
Scoring (see figure 1)
 1 point for each recalled word
 Score clock drawing as Normal (the
patient places the correct time and the
clock appears grossly normal) or
Abnormal Score 0 Positive for cognitive
impairment 1-2 Abnormal CDT then
positive for cognitive impairment 1-2
Normal CDT then negative for cognitive
impairment 3 Negative screen for
dementia (no need to score CDT)
 0 Positive for cognitive impairment
 1-2 Abnormal CDT then positive
for cognitive impairment
 1-2 Normal CDT then negative for
cognitive impairment
 3 Negative screen for dementia
(no need to score CDT)
Pt. Name:______________________
DOB:_______________________
Date:__________________________
Instructions:
Inside the circle draw the hours of a clock Type
equation here.
as if a child would draw them Place the hands  A score below 20 usually indicates
of the clock to represent the time “forty five cognitive impairment.
minutes past ten o’clock”
• DRAW CIRCLE HERE The Mini-Mental Status Examination
• Name: _______________DOB:_______________
1. Instruct the patient to listen carefully Years of School:________Date of Exam:_______
and repeat the following
Orientation to Time Correct Incorrect
APPLE WATCH PENNY MANZANA RELOJ
What is today's date?
PESETA
What is the month?
2. Administer the Clock Drawing Test
What is the year?
3. Ask the patient to repeat the three
words given previously What is the day of the week today?

_________ _________ __________ What season is it?

Scoring Number of correct items recalled Total:_________

_______ [if 3 then negative screen. STOP] If
Orientation to Place Correct Incorrect
answer is 1-2 Is CDT Abnormal? No Yes If No,
Whose home is this?
then negative screen If Yes, then screen
positive for cognitive impairment What room is this?
THE MINI-COG Scoring What city are we in?

Number of correct items recalled _______ [if 3 What county are we in? What state are we in?
then negative screen. STOP]
IMMEDIATE RECALL
If answer is 1-2
Ask if you may test his/her memory. Then say
Is CDT Abnormal? No Yes "ball", "flag", "tree" clearly and slowly, about 1
second for each. After you have said all 3
If No, then negative screen If Yes, then screen
words, ask him/her to repeat them - the first
positive for cognitive impairment
repetition determines the score (0-3):
Mini-Mental Status Examination Correct Incorrect
 The Mini-Mental Status Examination offers
Ball
a quick and simple way to quantify
cognitive function and screen for Flag
cognitive loss. It tests the individual's
Tree
orientation, attention, calculation, recall,
language and motor skills. Total:____
 Each section of the test involves a
related series of questions or commands. ATTENTION
 The individual receives one point for A) Ask the individual to begin with 100 and
each correct answer. count backwards by 7. Stop after 5 subtractions.
 To give the examination, seat the
individual in a quiet, well-lit room. Ask Score the correct subtractions.
him/her to listen carefully and to answer
Correct Incorrect
each question as accurately as he/she
can. 93
 Don't time the test but score it right away.
86
To score, add the number of correct
responses. The individual can receive a 79
maximum score of 30 points. A score
72
below 20 usually indicates cognitive
impairment. 65 Total____
 Don't time the test but score it right away.
To score, add the number of correct B) Ask the individual to spell the word "WORLD"
responses. The individual can receive a backwards. The score is the number of letters in
maximum score of 30 points. correct position.
 Correct Incorrect Correct Incorrect

D WRITING
L Give the individual a piece of paper and ask
him/her to write a sentence. It is to be written
R
spontaneously. It must contain a subject and
0 verb and be sensible.

w Correct Incorrect

Total: ___ COPYING

Give the individual a piece of paper and ask
him/her to copy a design of two intersecting
DELAYED VERBAL RECALL
shapes.
Ask the individual to recall the 3 words you
One point is awarded for correctly copying the
previously asked him/her to remember.
shapes.
Correct Incorrect
All angles on both figures must be present, and
Ball the figures must have one overlapping angle.

Flag Correct Incorrect

Tree

Total:___ Total Score:____________

NAMING GERIATRIC DEPRESSION SCALE

Show the individual a wristwatch and ask  The Geriatric Depression Scale (GDS) is a
him/her what it is. Repeat for pencil. self-report measure of depression in older
adults.
Correct Incorrect
 Users respond in a “Yes/No” format.
Watch  The GDS was originally developed as a
30item instrument.
Pencil  Since this version proved both time-
Repetition consuming and difficult for some
patients to complete, a 15-item version
Ask the individual to repeat the following: was developed
Correct Incorrect Geriatric Depression Scale (short form)
"No if, ands, or buts“ Instructions: Circle the answer that best
describes how you felt over the past week.
3-STAGE COMMAND
1. Are you basically satisfied with your life?
Give the individual a plain piece of paper and Yes no
say, "Take the paper in your hand, fold it in half, 2. Have you dropped many of your
and put it on the floor.“ activities and interests?
Yes no
Correct Incorrect
3. 3. Do you feel that your life is empty?
Takes Yes no
4. Do you often get bored?
Folds Yes no
Puts 5. Are you in good spirits most of the time?
Yes no
READING 6. Do you feel happy most of the time?
Yes no
Hold up the card reading: "Close your eyes" so
7. Do you often feel helpless?
the individual can see it clearly.
Yes no
Ask him/her to read it and do what it says. Score 8. Do you prefer to stay at home, rather
correctly only if the individual actually closes than going out and doing things?
his/her eyes Yes no
 9. Do you feel that you have more
problems with memory than most?
Yes no
10. Do you think it is wonderful to be alive
now?
yes no
11. Do you feel worthless the way you are
now?
yes, no
12. Do you feel full of energy?
Yes no
13. Do you feel that your situation is
hopeless?
Yes no
14. Do you think that most people are better
off than you are?
Yes no
 Answer in bold indicate depression. Score
1 point for each bold letter answer
 A score > 5 points is suggestive of
depression
 A score > 10 points is almost always
indicate of depression
 A score > 5 points should warrant a follow
up comprehensive assessment
Sources:
http://www.stanford.edu/yesavage/GDShtml
 Of the 15 items, 10 indicate the presence
of depression when answered positively
while the other 5 are indicative of
depression when answered negatively.
 This form can be completed in
approximately 5 to 7 minutes, making it
ideal for people who are easily fatigued or
are limited in their ability to concentrate for
longer periods of time.
PHYSICAL ASSESSMENT
Nurses use physical assessment skills to:
 Develop (obtain baseline data) and
expand the data base from which
subsequent phases of the nursing
process can evolve
 To identify and manage a variety of
patient problems (actual and potential)
 Evaluate the effectiveness of nursing
care
 Except for those occasions when you see
a patient specifically to conduct a
nursing assessment, the assessment must
be integrated into routine nursing care
 Example: the bath is a perfect time to
incorporate assessment
When performing physical assessment, nurse
use a variety of techniques, including:
 Inspection
 Palpation
 Auscultation
 Percussion
INSPECTION
 Is the most commonly used method of
physical assessment in which the senses
of
o Vision
o Smell
o Hearing
 Are used to collect data
 Can be both general and specific.
General Inspection is used to detect the
need for more specific inspection.
 Is used when assessing the overall level of
function, as well as when looking for
specific areas of need with in any
particular area of function
PALPATION
 Uses the sense of touch in the fingers and
hands to obtain data.
 Use for evaluation in many parts of
physical assessment including:
o Pulses
o temperature, and texture of the
skin texture and condition of the
hair Presence and consistency of
tumors or masses under the skin
o Distention of urinary bladder and
presence of pain or tenderness 48
When palpating:
 Use the finger tips, wand reduce which
are most sensitive part of the finger tips
 Warm hands and short fingernails
promote comfort and reduce the risk for
trauma to fragile older skin.
 Light touch should be used before
deeper touch is attempted
 Painful areas should be palpated last
AUSCULTATION
 Uses the sense of hearing to detect
sounds produced with in the body.
 Involves the use of a stethoscope or
other sound or other sound amplifier
(such as Doppler) to make the sounds
louder and more easily heard.
FUNCTIONAL ASSESSMENT
 Is a systematic method of evaluating the
older adult’s ability to function within the
environment • identifies the self-care
abilities and deficits of the older adult in
 order for needs to be matched with
services.
 It is a multidimensional and often
interdisciplinary diagnostic process,
which assesses and quantifies an older
adult’s medical, psychosocial and
functional status.
 Information gathered in this process is
used by practitioners, the patient, and
family to develop a comprehensive plan
of therapy and future care decisions and
can also help in the process of long-term
care decisions-making.
Assessing Patients’ Functional Status
Lawton Scale -instrumental ADL (IADL)
 Definition: Functional impairment is
defined as difficulty performing, or
requiring the assistance of another
person to perform, one or more of the
following Activities of Daily
 Functional impairments and cognitive
and affective problems are particularly
prevalent among older patients, and
can be improved with early recognition
and treatment
FANSCAPES
 evaluates the ability to perform more
complex personal care activity -it
addresses the activities needed to
support independent living such as:
a. Use of telephone
b. Cook
c. Shop
d. Do laundry
e. Manage finances
f. Take medications
g. Prepare meals
-the activities are rated on a 3-point
scale ranging from independence, to
needing some help, to complete
disability -when using IADL, be sure to
evaluate patient's safety
 When the nurse suspects that an actual
emergency or serious problems is present
or might be developing in these
situations, deep, focused assessments
are more appropriate and necessary.
 The following mnemonic can be used to
organized this assessment.
 focuses on assessing physiologic function
F-fluids (state of hydration and factor
contributing to maintenance of adequate
hydration)
A-aeration (adequacy of oxygen
exchange)
N-nutrition (mechanical, psychological
factors, amount of food consumed)
C-communication (sight and sound, voice
quality, adequate functioning of the teeth,
pharynx, ability to reads words and
understand spoken language)
A -activity (ADL, coordination, balance and
strength)
 P -pain (pressure, discomfort, looses) E-
elimination (bladder and bowel, assistive
devices)

S- socialization (giving and receiving love,

function in society, feeling of self-worth)

 it provides helpful information about a

person’s ability to meet his own needs
and the amount of assistance he may
need.

FULMER SPICES
 SPICES is an acronym for six common
“marker conditions” in older adults that
can identify potential health related
problems • This screening too can be
used routinely during assessment to
identify and/or prevent potential
problems and monitor health status
overtime.

S – sleep disorders

P – problem with eating or feeding

I – incontinence

C – confusion

E – evidence of falls

S – skin breakdown