35. Assessment of Older Adults



Older people have increasingly been the focus of health and social care policy (DH, 1999, 2001, 2003; DSSSP, 2002,2004;WAG 2003 a & b; Scottish Executive, 2001 a & b,2002). Health and social care policy impacts significantly on older people, and in particular on their continuing careneeds. Changes in the boundaries of health provision and pressures for cost containment have profoundly affected older people as well as service providers.Many older people have found themselves means-tested

for services that have historically been provided free of charge. Arrangements for NHS-funded nursing care for older people (DH, 2003) limits the money available in

England by the use of a formula that interprets low,medium and high need. In Wales and Scotland a contribution to the cost of care is paid.The RCN supports the principles of a multi-agency approach to assessment, like, for example, the single assessment process (SAP) (DH, 2002b) and the national service framework (DH, 2001). However, any multiagency approach needs to reflect, in both its structure and process, good, contemporary nursing practice.The introduction of the registered nursing care contribution(RNCC) in England (DH, 2001) requires nurses to calculate registered nursing time within a prescribed framework.

This RCN assessment tool was initially developed to assist nurses in the identification and articulation of their contribution to the health and social wellbeing of older people. This new edition aims to continue with that aim, in the light of contemporary health and social care policy developments.

The tool is the first of its kind to focus on determining the level and type of registered nursing input needed by an individual older person. It has been developed by

expert gerontological nurses to identify the specific areas where nursing is needed and to provide evidence to justify the required nursing intervention.

explains why nursing assessment is important

describes the role of the expert nurse in the care of older people

outlines how the debate about continuing care affects the nursing care of older people

draws on the work of a 1997 RCN report,

What a difference a nurse makes (RCN, 2004a) on the benefits of expert nursing to the clinical outcomes in the continuing care of older people

explains each of the tool’s five stages, including the rationale that underpins them.

Primarily intended for use by registered nurses who are undertaking an assessment of an older person currently in a care home, it may also be used by nurses working in

the community and in hospitals to assess an older person’s need for nursing care. Included in this publication are some simple tables that provide you with a key to some of the questions asked. In addition, examples and case studies are provided to show how the tool might be used in your everyday work.

This RCN assessment tool enables:

comprehensive assessment of an older person’s health status

identification of the need for input by a registered nurse, through the application of a stability/predictability matrix

an estimate of the level of nursing intervention needed

an estimate of the number of registered nurse hours required, through the use of a scoring formula

identification of evidence to support decisionmaking and practice.

Designed to be used as part of the overall assessment of a resident in a care home, it can be used to contribute to the SAP process and the funded nursing determinations.

Continuing its primary intention, it can also be used to develop nursing care plans that are person-centred and that facilitate best nursing practice.The tool will assist

nurses to both articulate and quantify the nursing contributions to care,within the context of contemporary good practice. It is not meant to be used in isolation, but rather as the nursing component to the multi-disciplinary assessment of need in older people.The tool links with the framework for outcome definition developed by expert gerontological nurses and outlined in .

What a difference a nurse makes.The framework was formulated from the work of Seedhouse (1986) and Kitwood (1997), evidence of good practice and a review of the literature on the care of older people. It promotes the concept of holistic care and the aim that older people live as independent a life as possible (RCN, 1996). As a result, this assessment tool offers a nursing framework for decision-making by nurses that encompasses a comprehensive range of essential care components. For example, the tool could be used to identify a nursing intervention that could stabilise or monitor a health problem, so enabling an older person

to follow their chosen lifestyle as closely as possible. Primarily for use in care homes, this tool assumes that nursing care will be delivered within a nursing

framework.However, it seeks to make effective use of all available skills and resources. There is no intended suggestion of exclusivity in the nursing input within any

of the categories. Sometimes a nursing intervention will result in the disappearance of the need for nursing care. The ‘no nursing’ option can be selected in any category,

or the decision made that, rather than delivering the care directly, a registered nurse is needed to manage a specific aspect of care or to supervise others. Finally, while the tool aims to guide nurses to the need for specific specialist assessment, it is only part of an assessment process that must take as its starting point the biography of the older person.Within this tool, ethnicity and culture are seen as integral components of every category.

Individuals who need continuing care have inter-related health and social care needs. Nurses have long argued that distinctions between the two are unworkable

(RCN, 1993 a & b, 1995, 2004a). The SAP is intended to ensure that older people receive appropriate, effective and timely responses to their health and social care needs and that professional resources are used effectively (DH, 2002b). The challenge for nurses in articulating their distinct contribution to the overall care of older people has been that much of their work is invisible - it is not directly observed. These ‘hidden’ aspects (McKenna, 1995) can encompass highly intricate assessment, detection, monitoring and evaluation techniques, as well as subtle communication skills, which can help a patient to balance their health needs with their chosen lifestyle. Nurses use clinical judgement to enable older people to improve, maintain, or recover health, to cope with health problems, and to achieve the best possible quality of life,

whatever their disease or disability, until death (RCN, 2003). Further,nurses work in partnership with patients, their relatives and other carers,and in collaboration with others as members of a multi-disciplinary team.Where appropriate they will lead the team,prescribing,delegating and supervising the work of others.At other times they will

participate under the leadership of others,but always remaining personally and professionally accountable for their own decisions and actions (RCN,2003). In the drive for cost containment in services, it is often suggested that ‘nursing care as a product is highly simplified by non-nurse buyers not possessing a clear idea of what professional nurses can/should do and how it differs from less skilled, cheaper labour… these health care managers may accept unfounded assumptions and myths about nursing costs, care-giver mix and nursing productivity’ (Patterson, 1995). But ‘if we cannot name it,we cannot control it, finance it, research it, teach it, or put it into public policy’ (Clark Jand Lang N, 1992 in Defining nursing, RCN, 2003). As key providers of health and social care, nurses have come under increasing scrutiny from policy makers and

service providers (Bagust and Slack, 1991; Buchan and Ball, 1991; Bagust, Slack and Oakley, 1992; Carr-Hill, Dixon and Gibbs et al, 1992; Buchan, Seccombe and

Ball, 1997; Savage, 1998; Needleman et al, 2002). This extensive work demonstrates that nursing is a costeffective service, particularly when registered nurses are

present in sufficient numbers within the skill mix. The same studies also show that nursing interventions can result in significant positive patient outcomes.

Systematic and sensitive assessment has been a key requirement of government policy in primary health and community care. A multi-agency and multidisciplinary

partnership enhances patient care, prevents the waste of valuable resources, and could have a positive impact on the whole of the health and social care system for older people. Joint NHS and social services assessment is viewed as a necessity to enable successful hospital discharge andshould not only be offered before entering a care home.A successful multi-agency assessment will prevent delayed hospital discharge.In the face of the converging reliance on care management and the targeting of public funding, assessment has increasingly become an important policy tool (Challis et al, 1996). Much of the research and debate has focused on the role of assessment in

relation to placement (Peet, Castle, Potter et al, 1994). It is the view of the RCN that nurses in all settings will continue to work collaboratively with colleagues in the

development and delivery of integrated,‘joined up’assessments. However, it is also the view of the RCN that nurses will continue to need a nursing assessment tool to guide their day-to-day nursing practice, in keeping with their professional accountability and responsibility to older people.

In its policy development work, the RCN has focused on the need for nursing care, rather than the location of care delivery (RCN, 1993 a & c, 1995, 2004a). Evident

throughout has been absence of a tool that articulates the specific need the older person may have for an intervention from a registered nurse. Assessment strategies in nursing have been influenced by the problem-solving framework of the nursing process and nursing models. Assessment of need is integral to the care process and has received much attention in relation to the establishment of eligibility criteria for long-term care. Few people would dispute the assertion that good quality and effective care for older people is influenced by the use of comprehensive,client specific assessment (Rubenstein, Calkins and Greenfield et al,1988). The quality of assessment will be greatly enhanced by the participation of the client and carers to the assessment process ensuring that the client’s wishes are foremost and,wherever possible, the client’s own words are used to reflect their needs. Assessment is a multi-disciplinary activity, and a range of instruments has been developed. These include the index of independence in activities of daily living (Katz and Stroud, 1963), the Barthel index,(Mahoney and Barthel, 1965) the Crighton Royal behaviour rating scale (Wilkin and Jolley, 1979), the Clifton assessment procedures for the elderly (Pattie and Gilleard, 1979), the general health questionnaire (Goldberg, 1972) and the geriatric mental health state schedule (Copeland, Kelleher and Keller et al, 1976). A number of assessment tools have attempted to measure outcomes in care in terms of quality of life, but

this has remained elusive to define and difficult to measure (Bowling, 1991 and 1995; Fletcher,Dickinson and Philip, 1992).

Some tools have been developed specifically to assessneed, dependency and quality, for example:

Monitor: an index of the quality of nursing care for

acute medical and surgical wards (Goldstone, Balland Collier et al, 1984)

Senior monitor: an index of quality nursing care for

senior citizens of hospital wards (Goldstone,Maselino and Okai et al, 1986)

Nursing home monitor II: an audit of the quality of

nursing care in registered nursing homes (Morton,Goldstone and Turner et al, 1992)

Criteria of care (Ball and Goldstone, 1984)

REPDS (Fleming and Bowles, 1984)

Quality of patient care scale (QUALPACS) (Wandelt and Ager, 1974).

While such dependency tools can help to identify need for care, they do not assist in articulating the specificneed for nursing. The RCN believes this is one of the

reasons why it has been impossible to separate the social care needs of older people from their health care needs. In Selecting and applying methods for estimating

the size and mix of nursing teams,Hurst et al (2002) examine the contribution of 43 articles, books and reports that address the special issues of nursing older

people for nursing workforce planners.

Nolan and Caldock (1996) believed that any framework for assessment should be:

flexible and able to be adapted to a variety of


appropriate to the audience it is intended for

capable of balancing and incorporating the views of

a number of carers, users and agencies

able to provide a mechanism for bringing different

views together, while recognising the diversity and

variation within individual circumstances.

The role of the nurse

Older people’s continuing care needs are met in a variety of settings, including their own home, supported housing, residential care, a nursing home or hospital. At some stage many older people are likely to require registered nursing care. Older people in hospital or who live in care homes are likely to be vulnerable. Indeed the RCN would argue that if older people are vulnerable enough to require placement in a care home, then it is likely that some level of nursing intervention will be needed.The role of the nurse as an enabler of health in older people is crucial in continuing care settings (RCN, 2004a). In a care home, registered nurses have multiple roles that reflect the diverse nature of nursing. Different functions that contribute to the optimum health and overall wellbeing of older people include:

supportive - including psychosocial and emotional support, assisting with easing transition, enhancing lifestyles and relationships, enabling life review, facilitating self-expression and ensuring cultural sensitivity

restorative - aimed at maximising independence and functional ability, preventing further deterioration and/or disability, and enhancing quality of life. This is undertaken through a focus on rehabilitation that maximises the older person’s potential for independence, including assessment skills and undertaking essential care elements, for example,washing and dressing

educative - the registered nurse teaches self-care activities - for example, self-medication – health promotion, continence promotion and health screening. With other staff, the registered nurse engages in a variety of teaching activities that are aimed at maximising confidence in competence and continuously improving the quality of care andservice delivery

life-enhancing - activities that are aimed at enhancing the daily living experience of older people, including relieving pain and ensuring adequate nutrition

managerial - the registered nurse undertakes a range of administrative and supervisory responsibilities that call for the exercise of managerial skills. Such responsibilities include the supervision of care delivered by other staff and the overall management of the home environment.

Registered nurses have:

Broad empirical knowledge

This derives from the fundamental sciences from which nursing is synthesised - such as philosophy,physiology, sociology - from nursing knowledge and research, or from an allied profession, such as medicine, pharmacology or ergonomics.

Tacit knowledge

This enables nurses to act on hunches or intuition and engage in holistic problem solving. This can be particularly significant in unpacking the complexities of change in the health of older people.

Broad experience

This enables nurses to recognise similarities in patterns of events from previous encounters with older people. Registered nurses recognise the subtle changes in an older person’s health status, understand the potential consequences and then act appropriately.

A broad range of skills

In everyday practice, registered nurses use a variety of skills including:

– Observation - for example, recognising significant changes and formulating opinions

– Psychological – for instance, interpersonal communication with residents, their families and colleagues

– Supporting, encouraging, facilitatory and counselling skills

– Reflecting, challenging and giving constructive  feeS f

Nursing and assessment

In general, outcome measurement has focused on a health gain or health maintenance score, or an overall wellbeing result (French, 1997). However, because quality of life is difficult to define and even more difficult to measure - particularly with physically and mentally vulnerable people - outcomes from nursing in continuing care are not easily articulated (RCN, 2004a). The focus of the RCN’s assessment tool is therefore on increasing quality of life, rather than perceiving health gain simply as increased longevity. Assessment is considered to be the first step in the process of individualised nursing care. It provides information that is critical to the development of a plan

of action that enhances personal health status. It also decreases the potential for, or the severity of, chronic conditions and helps the individual to gain control over

their health through self-care. Assessment of older people requires a comprehensive collection of information about the physical, biological, psychosocial, psychological and functional aspects of the older person. It will enquire into physiological functioning, growth and development, family relationships, social networks, religious and occupational pursuits. (DH, 2002b). It is vital that the health assessment includes a thorough appraisal of what are commonly referred to as ‘activities of daily living’. The RCN believes that this must be linked to the overall health assessment.Nurses should relate the person’s ability to undertake daily living activities to an assessment of health status, which is linked to medical diagnosis . The key throughout is the individual’s biography and personal circumstances more expert the nurse, the more speedy and

accurate are their judgements and predictions (Benner and Wrubel, 1989). Studies that distinguish between the ability of expert nurses and novice nurses in relation to

assessment and decision-making have helped identify the nature of expert assessment in relation to practice outcomes. (Benner, 1984; Benner, Tanner and Chesla, 1992).

For the purpose of this work, nursing is defined as ‘a service for older people who have their nursing needs identified by a nurse, receive that care either directly or

under the supervision and management of a nurse’ (RCN/ Age Concern, 1997). Nurses must be registered by the Nursing and Midwifery Council (NMC).

Both the RCN and Age Concern believe that, in the interests of equity and economy, long-term nursing should be funded for all older people who need nursing


Clearly many older people have care needs, but not all need their care to be given or supervised by a registered nurse. Care is provided by a mixed workforce. The cost

of that care can best be determined by establishing skill mix weightings.Therefore the RCN’s assessment tool provides a code to skill mix – the level of nursing

intervention required and the number of hours. It has been designed to assist both commissioners and providers in costing more accurately nursing care for older people. In order to achieve this there is a need to articulate the processes involved in ‘expert’ nursing with older people, and a need to identify the criteria for the measurement of effective practice.

The five stages of the RCN assessment mtool

The completion of all the stages of the RCN’s assessment tool ensures that the decision-making process is explicit and transparent, illustrating the contribution of expert

nurses to the care of older people.Together, the stages result in a holistic assessment of the nursing needs of an older person.

The importance of the older person’s contribution to the assessment cannot be over-emphasised. It is vital that the client and their carer are involved in its completion.

If the person being assessed is unable to contribute – for example because of lack of mental capacity - the views

and experiences of their carers should be taken into account.

The assessment tool is intended to inform everyone involved in the care of an older person – including informal carers and the client themselves - of the process leading to a care plan.To that end, it should be written in simple, easy to understand language. Wherever possible it should include the words and phrases used by the client and their carer.

Stage 1


This stage assesses the older person’s health status through essential care components and categories of ability or need. It can be used alone to formulate a care plan.

There are three essential care components:

maximising life potential

prevention and relief of distress

maintenance of health status.

These are based on Seedhouse’s (1986) concept of health as ‘potential’, and derived from the domains of the RCN framework for outcome definition in the care of older people, outlined in What a difference a nurse makes. They generate up to 25 categories of ability or need that can be used to assess an individual’s complex health status.

How it works

Within each category of need, five descriptor statements ,distinguish varying levels of an older person’s ability or disability, and their need for care.The headings are:

Essential care component 1 – maximising life potential

Categories: Personal fulfilment

Spiritual fulfilment

Social relations



Essential care component 2 – prevention and relief of stress

Categories: Communication

Pain control

The senses



Loss, change and adaptation


Relatives and carers

Essential care component 3 – promotion and maintenance of health

Categories: Personal hygiene





Elimination of urine and faeces


Eating and drinking



Within each category, the nurse should assess the older person, selecting the most appropriate descriptor, using the letters A, B, C, D or E, for the individual’s abilities or disabilities and their needs for care. This letter should be placed under the appropriate stability/predictability column – as assessed in stage 2.Not all statements within the selected descriptor may be relevant to the individual, but the nurse should select the statement that most closely represents their abilities

and needs – in other words, the best fit. At the end of the assessment form, there is space for three additional categories. These can be used for specific interventions that the assessor believes cannot be captured within other categories. For example, a resident may require frequent assessment and treatment by a registered nurse because of a wound, or may require frequent assessment and administration of medication to control pain during an acute or terminal illness.

These additional categories will also include problems not referred to in the main text of the assessment – such as falls,managing medication, or specific issues relating

to financial management. Wherever possible, needs such as wound care, self-medication or stoma care should be assessed within the 23 pre-set categories. However,where this is not possible, then the ‘extra’ blank categories should be labelled and used accordingly.

Stage 2


This stage assesses the stability and predictability of a person’s health status by applying a matrix, which acts as the trigger for potential registered nursing input. This

would be in the form of both preventive and reactive nursing interventions. This second stage is perhaps the most complex, as it analyses how an individual’s care

needs might be met – in other words, what skills, knowledge and expertise are required.

The stability and predictability matrix has been specifically devised to acknowledge and encompass the complex factors that influence health status in older age.

For example:

the physical processes of ageing can cause instability in various body systems at any one time

multiple pathologies are usually present. Older people entering the health care system commonly have upwards of four medical diagnoses

diseases present differently in older age,making recognition and diagnosis more comple to more commonly experience adverse drug reactions (ADRs) which may present differently in younger people

older people’s personal adaptation to life changes - and the changes associated with moving int communal living – create the need for management of transition

older people’s individual responses to day-to-day situations are based on their personality and life experiences.

While some factors might be stable at any one point in time, not all of them will be. The instability of various factors at different times complicates the situation.

Individuals also react psychologically and physiologically to changes in health status in ways that can be predictable or unpredictable.

Added to this, once any of these influences on an older person’s health begin to become unstable, a domino effect can be set off. This may exacerbate an already

precarious homeostasis that results in a rapid deterioration in health.

You may find the following definitions useful:

stable – health or disease processes are in a steady state and likely to remain so, providing correct treatment and care regimes continue

unstable – a fluctuating disease process resulting in an alternating health state and requiring frequent or regular intervention or treatment

predictable – a person’s response to internal and/or external triggers can be anticipated with some certainty, through established interventions and regularly reviewed care plans

unpredictable – a person’s response to internal or external triggers cannot be anticipated with any certainty. Continuous assessment, care planning, intervention and review are required.

How it works

Place the descriptor code letter - A, B, C, D or E – that you assessed in stage 1 under the appropriate stability and predictability column.


Some examples

The following examples demonstrate how stability and predictability can be assessed within specific categories.

The examples deal with four different women in a nursing home. Each is trying to retain her independence, despite a series of strokes and multiple disabilities.

It might be assumed that each woman has the same nursing needs. However, by making decisions about the stability of each individual’s health, and the predictability of her responses, the need for nursing intervention becomes clear in each case.

Example 1 – stable and predictable

Category – social relations

This resident actively seeks and enjoys social contact. She openly acknowledges her physical difficulties and jokes with other residents about them. In this category,

she would be assessed as stable and predictable.

Category – eating and drinking

Despite some speech difficulties, this resident is able to make and express choices in food and drink. She generally enjoys food, and although she takes longer to

eat than other residents at the table, she engages their patience until she finishes her meal. In this category, she would be assessed as stable and predictable.

Example 2 – stable but unpredictable

Category – social relations

This resident actively seeks and enjoys social contact but sometimes becomes very upset by this. There is no apparent pattern to her emotional upset and so far it

has not been possible to predict when this might happen. In this category, she would be assessed as stable but unpredictable.

Category – eating and drinking

Despite speech difficulties, this resident is able to make and express choices in food and drink. She enjoys her food but will occasionally choke, usually when she

becomes embarrassed and tries to eat as quickly as other residents at her table. She then intermittently becomes distressed. In this category, she would be assessed as stable but unpredictable.

Example 3 – unstable but predictable

Category – social relations

This resident has enjoyed playing bridge for years but has recently experienced transient ischaemic attacks during which she loses touch with reality. She acknowledges her deterioration but is determined to continue playing bridge. Despite dysphasia, she jokes that there are worse places to die than at the bridge table. In this category, she would be assessed as unstable but predictable.

Category – eating and drinking

This resident is able to make and express choices, but sometimes does not have the clarity of thought to do so. Her swallowing reflex is not reliable and she often chokes. Although obviously frustrated at these changes, she usually tries to eat and sometimes glances at the feed aids as if to say,‘Oh well, this is what it’s come to’.

In this category she would be assessed as unstable but predictable.

Example 4 – unstable and unpredictable

Category – social relations

Although this resident has always enjoyed social contact, her transient mental ‘absences’ and unstable physical disabilities are making this progressively

difficult. She has begun to become frustrated and angry at these changes, and is often aggressive with other people. It can be difficult to calm her. In this category, she would be assessed as unstable and unpredictable.

Category: eating and drinking

This resident is sometimes able to make and express choices in food and drink, but often does not have the presence of mind or the interest to do so. Her

swallowing reflex causes frequent choking which frustrates her greatly. Often she refuses food and drink, despite sensitive encouragement and support. In this category, she would be assessed as unstable and unpredictable.


Stage 3


This stage assess the level and frequency of input by a registered nurse, determining what form the nursing input will take, including a ‘no nursing’ option. It defines the level of nurse intervention, differentiating between management, supervising and actual or directive care giving roles. It does this by measuring the need for four types of assistance that reflect the degree of engagement between the nurse and the older person.

These are:

actual - the registered nurse directly engages with the resident and/or significant others, undertaking clinical/technical or therapeutic activities on the resident’s behalf

directive - the registered nurse uses teaching, guiding, advisory and supportive interventions as part of the rehabilitation/maximising potential/reenablement of the resident and/or significant others

supervisory - the registered nurse monitors or guides care without frequent direct engagement with the patient and/or significant others

management - the registered nurse either manages a specific, stand alone care intervention on an intermittent basis, or the service, which delivers nursing on a continuous basis.


How it works

Each type of assistance carries a score:

0 = no nursing

1 = management

2 = supervision

3 = actual

4 = directive

Determine the level of nursing intervention needed to  meet nursing care need for each category.Once this has been identified, place the score number in the box directly beneath the appropriate heading and alongside the category.

When the level of assistance within each category has been identified the scores can be aggregated to assist in workforce planning – see the box on page 14.

Stage 4


This stage identifies the number of registered nurse hours required, through the use of the registered nursing indicator.

A review of the literature and expert opinion informed the process of developing this tool’s scoring system. Existing assessment tools were analysed in order to

establish the principles on which the level of nursing intervention was determined. The review demonstrates that Criteria of care (Ball and Goldstone, 1984) are

established on similar principles to the RCN’s assessment tool.

In the Criteria of care formula, different aspects of care are awarded different weightings – in other words, number of hours.Research concluded that the maximum contact between a patient and a registered nurse was 8.8 hours during a 24-hour period. This was calculated through continuous observation of nursing over 24 hours and through an analysis of different types of nursing activity - direct care versus indirect care. The researchers highlighted four levels of ‘patient dependency’. They also identified maximum contact between nurses and patients for each level of dependency.

Dependency level I = 1 hour

Dependency level II = 1.2 hours

Dependency level III = 2.5 hours

Dependency level IV = 4.1 hours

Using this formula, a scoring system was developed for the RCN’s assessment tool. To allow for the addition of a ‘no nursing’ score, five score ranges were developed.

Scores were calculated by dividing the total possible assessment score achievable (100) by the maximum number of hours of contact with a registered nurse (8.8

hours). For example, if in each of the 25 care components, an older person is assessed as needing the highest level of nursing care - which carries a score of 4

for each care component. Thus 25 x 4 = 100. Working with this formula the score ranges were set at intervals of 11 and calculated according to theweightings - maximum contact time in hours - from

Criteria of care.

The registered nursing indicator

Assessment score Registered nursing input

0 = 0 hour

1-11 = 1 hour

12-23 = 1.2 hours

24-48 = 2.5 hours

49-100 = 4.1 hours

As the RCN’s assessment tool focuses on ability rather than dependency, the scoring system positively rejects dependency in favour of working towards independence.To this end, it is weighted to reflect the nursing role in maximising potential. Extensive piloting demonstrates results that clearly validate the tool’s scoring system.


How it works

After completing stages 1 to 3, you can begin to calculate the scoring by:

adding the nursing intervention score for all the descriptors in each of the three essential care components using the summary assessment sheet

adding the three sub totals to achieve one overall total

checking the total alongside the registered nursing indicators

checking that the registered nursing indicator score equates to a number of hours

inserting the number of hours of registered nurseintervention that is required each 24 hours.


Workforce planning

You can use the RCN’s assessment tool to help you with workforce planning and time management.The formula will enable you to work out the number of hours spent on management, supervision, actual and directive nursing.To calculate how the total nursing input is divided up, first convert the total registered nursing input from hours to

minutes - multiply by 60. Then add up the nursing input for each level of intervention - management,supervision, actual and directive.

To work out the number of minutes spent on management each 24 hours, divide the score for management by the total assessment score and then multiply input, in minutes.Using the same calculation – the workforce planning formula – this exercise can then be repeated for supervision, actual and directive nursing.

Workforce planning formula

total score for each nursing intervention x total registered nursing = number of minutes

total assessment score input (in minutes) spent on each nursing

intervention (per 24 hours)

The following example shows how you can calculate the number of minutes spent on ‘actual’ nursing when the scores for actual nursing add up to 9 and the total assessment score is 37. Using the registered nursing indicator, we know that the total registered nursing input is 2.5 hours.

First calculate the registered nursing input in minutes:

2.5 hours x 60 = 150 minutes

Using the actual nursing score - 9 - apply the workforce planning formula:


x 150 = 36.5 minutes


So in every 24 hours, the resident needs 361/2 minutes of actual nursing care.

Stage 5


This final stage provides the evidence for decisionmaking and practice – encouraging nurses to collect evidence to support the decisions they have made.This could include research in support of the decision, knowledge gained from working with the resident or the preferences of an individual resident.

How it works

Review your decision-making through the process of the assessment. It is important to remember that the resulting assessment may differ from your current

perception of the number of hours of nursing available. In other words the assessment may indicate that you need more or less nursing hours that are currently

available. Identify the evidence that supports your decisions and your intended practice. When identifying evidence it is useful to consider levels of ‘best evidence’. Is there robust research or knowledge gained from working with the resident? Have they expressed preferences that support your decisions?


This assessment tool can be used to:

contribute to the generation of a care plan

identify the need for registered nursing involvement

define the precise nature of that involvement

state the hours of registered nursing required for each of the residents

state the hours needed on different elements of nursing intervention for each resident

act as a trigger for further specific assessment – for example, pressure damage risk.

Additionally, each resident’s assessment can be used as a workforce-planning tool. Individual assessment scores can be aggregated to achieve organisational scores that relate both to skill mix and staffing.

The history and physical examination is the foundation of the medical treatment plan. The interplay between the physiology of aging and pathologic conditions more common in the aged complicates and delays diagnosis and appropriate intervention, often with disastrous consequences. This chapter assumes that practitioners will perform the thorough history and physical examination that is expected of an excellent general internist. It highlights the special considerations required for the older adult.


General considerations

The history may take more time because of sensory or cognitive impairment or simply because an older patient has had time to accrue numerous details. Several sessions may be required.

The patient should be recognized as the primary source of information. If doubts arise about accuracy, other sources should be contacted with due respect paid to the sensitivities and confidentiality of the patient. When interviewing the patient and caregiver together, ask questions first to the patient, then to the caregiver.

If the patient's responses to initial questions are clearly inappropriate, turn to the mental status exam immediately.

The patient should be dressed and seated. The physician should also be seated and facing the patient at eye level, speaking clearly with good lip movement. If the patient is severely hearing impaired and an amplifier is not available, write questions in large print.

Use honorifics (i.e., Mr., Mrs., Miss, or Ms.) unless the patient specifically requests you to do otherwise.

Areas requiring special emphasis

Physical Examination

General considerations

Limit the time the patient is in the supine position as this may cause back pain for persons with osteoarthritis or kyphoscoliosis and shortness of breath for those with cardiopulmonary disease--having several pillows on hand for these patients will be greatly appreciated.

Multiple sessions may be required for a complete physical exam due to patient fatigue. While they are important, the rectal and pelvic exams may be deferred to a later session, if not urgently required.

Areas requiring special emphasis

When physicians have a high index of suspicion with knowledge of the subleties of physical assessment in the older adult, an adequate information base can guide timely intervention.

Techniques of Examination

As you have seen, assessment of the older adult does not follow the traditional format of the history and physical examination. It calls for enhanced interviewing techniques, special emphasis on daily function and key topics related to older adult health, and a focus on functional assessment during the physical examination. Because of its importance to the health of older adults and the order of your assessment, this section begins with Assessing Functional Status: the “Sixth Vital Sign.” This segment includes how to evaluate risk for falls, one of the greatest threats to health and well-being in older adults. Next, are elements of the traditional “head-to-toe” examination tailored to the older adult.


During assessment of older adults, place a special premium on maintaining the patient’s health and well-being. In a sense, all visits are opportunities to promote the patient’s independence and optimal level of function. Although the specific goals of care may vary, preserving the patient’s functional status, the “sixth vital sign,” is of primary importance. Functional status specifically means the ability to perform tasks and fulfill social roles associated with daily living across a wide range of complexity.99 Your assessment of functional status begins as the patient enters the room. Several validated and time-efficient assessment tools can facilitate this approach.

Assessing functional status provides a baseline for establishing interventions to optimize the health of your older patients and for identifying geriatrics conditions and syndromes that can be modified or prevented, such as cognitive impairment, falls, incontinence, low body mass index, dizziness, impaired vision and hearing. Deficits in function are now recognized as better predictors of patient outcome and mortality after hospitalization than the admitting diagnoses. The USPSTF in 2010 outlined new prevention recommendations for older adults that better recognize the multifactorial nature of geriatric syndromes and bundles recommendations on related topics, such as osteoporosis, vitamin D supplementation, and prevention of falls, so that they are “more consistent, interlinked, and comprehensive” and directed at interventions that are effective.

One useful performance-based assessment tool is the 10-Minute Geriatric Screener, which is brief, has high interrater agreement, and can be easily used by office staff. It covers three important areas of geriatric assessment: cognitive, psychosocial, and physical function. It includes vision, hearing, and questions about urinary incontinence, an often hidden source of social isolation and distress in up to 30% of older women and 15% to 28% of men. For elucidating causes of incontinence, two mnemonics may be helpful: DIAPERS, (Delirium, Infection, Atrophic urethritis/vaginitis, Pharmaceuticals, Excess urine output from conditions like hyperglycemia or heart failure, Restricted mobility, and Stool impaction) and DDRRIIPP (Delirium, Drug side effects, Retention of feces, Restricted mobility, Infection of urine, Inflammation, Polyuria, and Psychogenic).

Further Assessment for Preventing Falls.

A preponderance of evidence links falls, a multifactorial geriatric syndrome, to fatal and nonfatal injuries, mortality, and burgeoning medical costs that exceed $20 billion annually.Falls are also linked to declines in function and early admission to long-term care facilities. At least one-third of adults aged 65 years or older fall at least once a year, and falls are the leading cause of fatal and nonfatal injuries in this age group. Investigators point out that falls “are not purely random events but can be predicted by assessing a number of risk factors.” Several recent reviews and meta-analyses have identified risk factors and effective interventions more precisely. In 2010, the American Geriatrics Society and British Geriatrics Society updated their algorithm for preventing falls in older adults (see p. 944). Study the algorithm and note the key features you should incorporate into your practice:

·         Screen fall risk for all community-dwelling older adults

·         Identify high-risk older adults, namely those with a single fall in the past 12 months with abnormal gait and balance and those with two or more falls in the prior 12 months, an acute fall, and/or difficulties with gait and balance

·         Assess older adults at high risk by conducting:

·         A detailed fall history, medication review, and history of relevant risk factors such as acute and chronic medical problems

·         A detailed assessment of gait, balance, mobility, and lower extremity joint function; neurologic function, lower extremity muscle strength; cardiovascular status; visual acuity, and examination of the feet and footwear

·         Functional assessment

·         Environmental assessment

·         Implement multifactorial/multicomponent interventions to address identified risks and prevent falls

Although study methodologies for fall interventions vary greatly, evidence is strongest for the following: gait, balance, and strength training, particularly over an extended period, reported to reduce falls by about 13%; vitamin D supplementation of 700 IU to 1,000 IU daily, which reduces falls by 17%; and minimization or withdrawal of psychoactive and other medications. Multifactorial interventions appear to be more effective than interventions targeted to specific risk factors, reducing falls by 6%, increasing to 11% when there is fall risk management. Additional prevention strategies that have been evaluated include reducing home hazards, vision correction, and improved management of chronic conditions such as change in postural blood pressure, and numerous types and combinations of exercise. Gait velocity and hand grip are also emerging as possible predictors of falls.

Deepen the observations about the patient that you have been compiling since the visit began. What is the patient’s apparent state of health and degree of vitality? What about mood and affect? Is screening for cognitive changes needed? Note the patient’s hygiene and how the patient is dressed. How does the patient walk into the room? Move onto the examining table? Are there changes in posture or involuntary movements?

Vital Signs.

Measure blood pressure using recommended techniques, checking for increased systolic blood pressure (SBP) and widened pulse pressure (PP), defined as SBP minus diastolic blood pressure (DBP). With aging, SBP and peripheral vascular resistance increase, whereas DBP decreases. In the “oldest old,” those 80 years of age and older, blood pressure targets of 140 to 150/70 to 80 appear optimal.

Assess the patient for orthostatic hypotension, defined as a drop in SBP of ≥20 mm Hg or DBP of ≥10 mm Hg within 3 minutes of standing. Measure blood pressure and heart rate in two positions: supine after the patient rests for up to 10 minutes; then within 3 minutes.

Review the JNC 7 categories of prehypertension to help you with early detection and treatment of hypertension

Measure heart rate, respiratory rate, and temperature. The apical heart rate may yield more information about arrhythmias in older patients. Use thermometers accurate for lower temperatures. Obtain oxygen saturation using a pulse oximeter.

Weight and height are especially important in the elderly and are needed for calculation of the body mass index. Weight should be measured at every visit.


Note physiologic changes of aging, such as thinning, loss of elastic tissue and turgor, and wrinkling. Skin may be dry, flaky, rough, and often itchy (asteatosis), with a latticework of shallow fissures that creates a mosaic of small polygons, especially on the legs.

Observe any patchy changes in color. Check the extensor surface of the hands and forearms for white depigmented patches, or pseudoscars, and for well-demarcated vividly purple macules or patches, actinic purpura, that may fade after several weeks.


Look for changes from sun exposure. Areas of skin may appear weather beaten, thickened, yellowed, and deeply furrowed; there may be actinic lentigines, or “liver spots,” and actinic keratoses, superficial flattened papules covered by a dry scale.

Inspect for the benign lesions of aging, namely comedones, or blackheads, on the cheeks or around the eyes; cherry angiomas, which often appear early in adulthood; and seborrheic keratoses, raised yellowish lesions that feel greasy and velvety or warty.

Watch for any painful vesicular lesions in a dermatomal distribution.

In older bed-bound patients, especially those emaciated or neurologically impaired, inspect the skin thoroughly for damage or ulceration.

Head and Neck.

Conduct a careful and thorough evaluation of the head and neck.

Inspect the eyelids, the bony orbit, and the eye. The eye may appear recessed from atrophy of fat in the surrounding tissues. Observe any senile ptosis arising from weakening of the levator palpebrae, relaxation of the skin, and increased weight of the upper eyelid. Check the lower lids for ectropion or entropion. Note yellowing of the sclera, and arcus senilis, a benign whitish ring around the limbus.

Test visual acuity, using a pocket Snellen chart or wall-mounted chart. Note any presbyopia, the loss of near vision arising from decreased elasticity of the lens related to aging.

The pupils should respond to light and near effort. Except for possible impairment in upward gaze, extraocular movements should remain intact.

Using your ophthalmoscope, carefully examine the lenses and fundi.

Inspect each lens carefully for any opacities. Do not depend on the flashlight alone because the lens may look clear superficially.

In older adults, the fundi lose their youthful shine and light reflections, and the arteries look narrowed, paler, straighter, and less brilliant. Assess the cup-to-disc ratio, usually 1:2 or less.

Inspect the fundi for colloid bodies causing alterations in pigmentation, called drusen.

Test hearing by occluding one ear and using the techniques for whispered voice or an audioscope. Be sure to inspect the ear canals for cerumen, because removal can quickly improve hearing.

Examine the oral cavity for odor, appearance of the gingival mucosa, any caries, mobility of the teeth, and quantity of saliva. Inspect closely for lesions on any of the mucosal surfaces. Ask the patient to remove dentures so you can check the gums for denture sores.

Continue with your usual examination of the thyroid gland and lymph nodes.

Thorax and Lungs.

Complete the usual examination, making note of subtle signs of changes in pulmonary function.

Cardiovascular System.

Review your findings from measurement of the blood pressure and heart rate.

As with younger adults, begin by inspecting the jugular venous pressure, palpating the carotid upstrokes, and listening for any overlying carotid bruits.

Assess the point of maximal impulse (PMI), then auscultate S1 and S2. Listen also for the extra sounds of S3 and S4.

Beginning in the second right interspace, listen for cardiac murmurs in all areas of auscultation. Describe the timing, shape, location of maximal intensity, radiation, intensity, pitch, and quality of each murmur you detect.

For systolic murmurs over the clavicle, check for delay between the brachial and radial pulses.

Breasts and Axillae.

Palpate the breasts carefully for lumps or masses. Include palpation of the tail of Spence that extends into the axilla. Examine the axillae for lymphadenopathy. Note any scaly, vesicular ulcerated lesions on or near the nipple.

Peripheral Vascular System.

Auscultate the abdomen for bruits, as above, and assess the width of the abdominal aorta in the epigastric area; examine for a pulsatic mass.

Palpate pulses carefully.

Female Genitalia and Pelvic Examination.

Take special care to explain the steps of the examination and allow time for careful positioning. Ask an assistant to help the older woman move onto the examining table, then into the lithotomy position. Raising the head of the table may make her more comfortable. For the woman with arthritis or spinal deformities who cannot flex her hips or knees, an assistant can gently raise and support the legs, or help the woman into the left lateral position.

Inspect the vulva for changes related to menopause such as thinning of the skin, loss of pubic hair, and decreased distensibility of the introitus. Identify any labial masses. Note that bluish swellings may be varicosities. Bulging of the anterior vaginal wall below the urethra may indicate a urethrocele or urethral diverticulum.

Look for any vulvar erythema.

Inspect the urethra for caruncles, or prolapse of fleshy erythematous mucosal tissue at the urethral meatus. Note any enlargement of the clitoris.

Spread the labia, press downward on the introitus to relax the levator muscles, and gently insert the speculum after moistening it with warm water or a water-soluble lubricant. If you find severe vaginal atrophy, a gaping introitus, or an introital stricture from estrogen loss, you will need to vary the size of the speculum.

Inspect the vaginal walls, which may be atrophic, and the cervix. Note any thin cervical mucus or vaginal or cervical discharge.

Use an endocervical brush (or less commonly, a wooden spatula) to obtain endocervical cells for the Pap smear. Consider using a blind swab if the atrophic vagina is too small.

After removing the speculum, ask the patient to bear down to detect uterine prolapse, cystocele, urethrocele, or rectocele.

Perform the bimanual examination. Check for motion of the cervix and for any uterine or adnexal masses.

Perform the rectovaginal examination if indicated. Assess for uterine and adnexal irregularities through the anterior rectal wall, and check for rectal masses. Change gloves if blood from the bimanual examination is on the vaginal examining glove to obtain an accurate stool sample.

Male Genitalia and Prostate.

Examine the penis, retracting the foreskin if present. Examine the scrotum, testes, and epididymis.

Proceed with the rectal examination, paying special attention to any rectal masses and any nodularity or masses of the prostate. Note that the anterior and median lobes of the prostate are inaccessible to rectal palpation, limiting the utility of the digital rectal examination for detecting prostate enlargement or possible malignancy.

Musculoskeletal System.

Begin your evaluation with the 10-Minute Geriatric Screener on p. 942. Be sure to include the test for leg mobility, also known as the timed “get up and go” test for gait and balance, an excellent screen for risk of falling. Ask the patient to get up from a chair, walk 10 feet, turn, and return to the chair. Most older adults can complete this test in 10 seconds.

If the patient has joint deformities, deficits in mobility, pain with movement, or a delayed “get up and go.” conduct a more thorough examination. Apply the techniques for examining individual joints and pursue a more comprehensive neurological examination.

Timed Get Up and Go Test

Performed with patient wearing regular footwear, using usual walking aid if needed, and sitting back in a chair with armrest.

On the word, “Go,” the patient is asked to do the following:

1.     Stand up from the arm chair

2.     Walk 3 m (in a line)

3.     Turn

4.     Walk back to chair

5.     Sit down

Time the second effort.

Observe patient for postural stability, steppage, stride length, and sway.


Low scores correlate with good functional independence; high scores correlate with poor functional independence and higher risk of falls.

As with the musculoskeletal examination, begin your evaluation with the 10-Minute Geriatric Screener .

Pursue further examination if you note any deficits. Focus especially on memory and affect.

Pay close attention to gait and balance, particularly standing balance; timed 8-foot walk; stride characteristics like width, pace, and length of stride; and careful turning.

Note that standard neuromuscular tests have not been shown to predict impairments in mobility. Although neurologic abnormalities are common in the older population, their prevalence without identifiable disease increases with age, ranging from 30% to 50%.Examples of age-related abnormalities include unequal pupil size, decreased arm swing and spontaneous movements, increased leg rigidity and abnormal gait, presence of the snout and grasp reflexes, and decreased toe vibratory sense.

Search for evidence of flexed posture, tremor, rigidity, bradykinesia, micrographia, shuffling gait, and difficulty rising from a chair.

Because illness in older adults is complicated by physical changes of aging and by multiple medical problems, it is essential for nurses to recognize more commonly seen atypical presentations of illness in older adults. For example, subtle changes like a decrease in function or a diminished appetite very often are the first signs of illness in an older adult. This section provides specific information on the atypical presentation of illness in older adults.


Risk Factors


·         Over age 85 in particular

·         Multiple co-morbidities

·         Multiple medications

·         Cognitive or functional impairment




Consequences (of not identifying)


·         Increased morbidity and mortality

·         Missed diagnosis

·         Unnecessary use of Emergency Rooms



Assessment/Screening Tools

Assessment and Care Strategies Three strategies to assess for atypical presentation of illness include: (1) Vague Presentation of Illness; (2) Altered Presentation of Illness; and (3) Non-presentation (under-reporting) of Illness.

Vague Presentation of Illness Table 1 lists some non-specific symptoms, such as falls, confusion or other symptoms that may signify an impending acute illness in an older adult. Changes in behavior or function in an older adult are often a prodrome (symptoms(s) indicative of an approaching disease) of an acute illness, especially for frail older adults. It is essential to take reports seriously from patients, family and non-professional care providers as to subtle symptoms such as mild confusion, changes in ability to perform activities of daily living (ADL), and decreased appetite. Timely identification of acute illnesses with vague presentation enables early treatment of illness resulting in reduced morbidity and mortality and an enhanced quality of life in older adults.

Table 1 Non-specific Symptoms
that may Represent Specific Illness (Ham, 2002)


Instrument: Standardized mechanisms for nurse's aides to communicate changes in patient's behavior or ability to perform ADL have been developed to ensure the communication between the nurse's aides and the nurses.

Altered Presentation of Illness Some of the more common altered presentations in older adults are listed in Table 2 below. The presentation of a symptom or a group of symptoms in older adults may present a confusing picture to health care provides. The classic presentation of common illnesses in a general adult population such as chest pain during a myocardial infarction, burning with a urinary tract infection or sadness with depression does not hold true with older adults. For example, a change in mental status is one of the most frequently presenting symptoms at the onset of acute illness in older adults.

Altered Presentation of Illness in Elderly Persons


Atypical Presentation

Infectious diseases

·         Absence of fever

·         Sepsis without usual leukocytosis and fever

·         Falls, decreased appetite or fluid intake, confusion, change in functional status

"Silent" acute abdomen

·         Absence of symptoms (silent presentation)

·         Mild discomfort and constipation

·         Some tachypnea and possibly vague respiratory symptoms

"Silent" malignancy

  • Back pain secondary to metastases from slow growing breast masses
  • Silent masses of the bowel

"Silent" myocardial infarction

  • Absence of chest pain
  • Vague symptoms of fatigue, nausea and a decrease in functional status.
  • Classic presentation: shortness of breath more common complaint than chest pain

Non-dyspneic pulmonary edema

  • May not subjectively experience the classic symptoms such as paroxysmal nocturnal dyspnea or coughing
  • Typical onset is insidious with change in function, food or fluid intake, or confusion

Thyroid disease

  • Hyperthyroidism presenting as "apathetic thyrotoxicosis," i.e. fatigue and a slowing down
  • Hypothyroidism, presenting with confusion and agitation


  • Lack of sadness
  • Somatic complaints, such as appetite changes, vague GI symptoms, constipation, and sleep disturbances
  • Hyper activity
  • Sadness misinterpreted by provider as normal consequence of aging
  • Medical problems that mask depression

Medical illness that presents as depression

  • Hypo- and hyper- thyroid disease that presents as diminished energy and apathy

Source: Ham, R. (2002). Reprinted with permission of Elsevier publishers.

Depression: Although most depression in older adults is associated with a sad mood, it often presents as a preoccupation with somatic symptoms related to appetite changes, vague GI symptoms, constipation, and sleep disturbances. Also problematic is that clinicians may interpret patient's sad affect as an appropriate reaction to multiple medical problems and thus miss the primary pathology of depression. Older adults are more likely than their younger counterparts to present with an agitated depression. In addition, the diagnosis of depression is complicated by the overlay of multiple medical problems and their corresponding symptoms that mask the depression.
Paradoxically, it is equally important to recognize medical illnesses that may present as depression. For example, both hypo and hyper thyroid disease may present as diminished energy and apathy and be miss-diagnosed as depression in older adults. 

Infectious Diseases: The lack of typical signs of infection in older adults is common. Older adults with sepsis may not present with the usual leukocytosis and fever but rather with a decreased appetite and or functional status. Considering the frequency of infections in older adults, more often affecting the urinary tract, the respiratory tract, the skin or the GI tract, an infection should be suspected with any change in condition, including falls, a decrease in food or fluid intake, confusion, and/or a change in functional status 

Acute Abdomen: Most patients suspected of having an "acute abdomen" present with a series of complaints and or signs such as pain, diminished or absent bowel sounds, and fever. Atypical nursing assessment would also include vital signs, recording a patient's intake and output and possibly their abdominal girth. However, in older adults an acute abdomen may present silently with mild discomfort and constipation with some tachypnea, and possibly some vague respiratory symptoms. Therefore, it is extremely important for nurses to recognize those patients with significant bowel disturbances and a change in food or fluid intake.

Malignancy: A comprehensive physical exam is vitally important in older adults who may not be aware of hidden masses. For example, breast masses in older women may be very slow growing and exist for some time before they are discovered during a work up for back pain secondary to bone metastases. Silent masses of the bowel especially those from the ascending colon, may exist without major symptoms due to reduced neuronal sensitivity in the GI tract.Myocardial Infarction: Most myocardial infarctions in older adults do NOT present with clinical symptoms such as chest pain. Clinicians need to be astute to patients at risk who present with vague symptoms of fatigue, nausea, and a decline in functional status. When patients do present with a more classic picture of an acute event, a more common complaint than chest pain is shortness of breath. Pulmonary Edema: Older adults experiencing pulmonary edema will often exhibit specific clinical signs associated with CHF such as increased fluid retention, fatigue, and possibly dyspnea. However, the patient may not subjectively experience or recognize the classic symptoms such as paroxsymal nocturnal dyspnea, or coughing. More typically the onset is insidious and presents as a change in function, decreased food or fluid intake, or confusion.

Thyroid Disease: Although patients will often present with the classis signs and symptoms of both hypothyroidism and hyperthyroidism, it is not uncommon to see altered presentation of both. For example, hyperthyroidism may present as "apathetic thyrotoxicosis" whereby a patient presents with fatigue and a slowing down as opposed to the classic thin, hyperactive hyperthyroid patient. Also, hypothyroidism, classically seen presents as fatigue and weight gain and instead may present with confusion and agitation.

Non-presentation of Illness
A host of illnesses in older adults may go unrecognized for many years and significantly impact quality of life and are summarized in Table 3.

Table 3 "Hidden" Illness in Older Adults (Ham, 2002)

Musculoskeletal stiffness
Hearing loss
Dental Problems
Poor nutrition
Sexual dysfunction

Factors that contribute to the under-reporting of illnesses are:


Expected Outcomes

Patient will:


Healthcare providers will:


Institutions will:


Follow-up Monitoring








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