ASSESSMENT OF OLDER
ADULTS
Introduction
Older people have increasingly been
the focus of health and social care policy (DH, 1999, 2001, 2003; DSSSP, 2002,2004;WAG
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,
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,
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,
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
circumstances
✦ 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
care.
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
Background
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
Sexuality
Cognition
Essential care component
2 – prevention and relief of stress
Categories: Communication
Pain control
The senses
Memory
Orientation
Loss, change and adaptation
Behaviour
Relatives and carers
Essential care component
3 – promotion and maintenance of health
Categories: Personal hygiene
Dressing
Motivation
Sleeping
Mobility
Elimination of urine and faeces
Risk
Eating and drinking
Breathing
Emotion
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
Background
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.
N U R S I N G A S S E S S M E N T A N D
O L D E R P E O P L E
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.
R O Y A L C O L L E G E O F N U R S I N
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Stage 3
Background
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.
N U R S I N G A S S E S S M E N T A N D
O L D E R P E O P L E
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
Background
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.
R O Y A L C O L L E G E O F N U R S I N
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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.
N U R S I N G A S S E S S M E N T A N D
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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:
9
x 150 = 36.5 minutes
37
✦ So in every 24 hours,
the resident needs 361/2 minutes of actual nursing care.
Stage 5
Background
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?
Conclusion
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.
History
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.
ASSESSING
FUNCTIONAL STATUS: THE “SIXTH VITAL SIGN”
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.
Skin.
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.
Scoring:
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.
·
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 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 |
|
Confusion |
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 |
||
|
Illness |
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 |
|
|
|
"Silent"
myocardial infarction |
|
|
|
Non-dyspneic
pulmonary edema |
|
|
|
Thyroid disease |
|
|
|
Depression |
|
|
|
Medical illness that
presents as depression |
|
|
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) |
|
Depression |
Factors that contribute
to the under-reporting of illnesses are:
Patient will:
Healthcare providers
will:
Institutions will:
Follow-up Monitoring
R O Y A L C O L L E G E O F N U R S I N
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N T A N D O L D E R P E O P L E
3
R O Y A L C O L L E G E O F N U R S I N
G
2N U R S I N G A S S E S S M E N T A N D
O L D E R P E O P L E
1