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Ebersole: Chapter 13

Assessment Tools in Gerontological


Nursing

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Health History
• Patient profile
• Past medical history
• Review of symptoms and systems
• Medication history
• Family history
• Social history
• Functional status

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Physical Assessment
• Vital signs
• Laboratory results
• Physical examination

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Comprehensive Assessment for the
Frail and Medically Complex Elder
• FANCAPES (p.207)
• Fluids (hydration)
• Aeration (oxygen)
• Nutrition
• Communication
• Activity
• Pain
• Elimination
• Socialization and social skills

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Functional Assessment (p.208)
• Identifying the specific areas in which help is
needed or not needed
• Identifying changes in abilities from one period
of time to another
• Assisting in the determination of the need for
specific service(s)
• Providing information that may be useful in
determining the safety of a particular living
situation

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Functional Assessment (cont’d)
• Tools that describe, screen, assess, monitor,
and predict functional ability
• Functional Independence Measure

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Mental Status Assessment (p.210)
• Older adults are at great risk for impaired
mental capacity
• Cognitive ability is also easily threatened by
any disturbance in health
• Altered or impaired mental status may be the
first sign of anything from a heart attack to a
urinary tract infection

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Cognitive Measures

• Mini-Mental State Examination


• Clock Drawing Test

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Mood Measures (p.211)
• Assess the presence or absence of depression
• Untreated depression
• More functionally impaired
• Prolonged hospitalizations and nursing home stays
• Lowered quality of life
• Shortened length of life

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Geriatric Depression Scale
• A 30-item tool designed for gerontological
patients and based almost entirely on
psychological discriminators
• Cannot be used in persons with dementia or
cognitive impairment

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Assessment of Social Support
• Family APGAR (p.213)
• Explores five specific family functions
• Adaptation
• Partnership
• Growth
• Affection
• Resolution

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Environmental and Safety
Assessment
• Persons with limitations in cognition, mobility,
vision, or hearing are at risk for fall-related
injury
• Fire hazards, poisoning, and problems with
temperature (hypothermia or hyperthermia)

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Integrated Assessment (p. 215)

• Older American’s Resources and Service


• Social resources
• Economic resources
• Mental health
• Physical health
• Activities of daily living

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Integrated Assessment
• Fulmer SPICES
• Sleep disorders
• Problems with eating or feeding
• Incontinence
• Confusion
• Evidence of falls
• Skin breakdown

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Implications for Gerontological
Nursing
• Goal of assessment is always to collect data
that are the most accurate and to do so in the
most efficient, yet caring manner possible
• Gerontological nurse challenged to provide
highest level of excellence in assessment of
elderly without burdening person

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