week 4 Nursing aging

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Chapter 8

Assessment and Documentation for Optimal Care

Is more complex
Is more detailed
Takes longer to perform
Requires special abilities
Done in every setting

Assessment of Older Adults

Collection of data
Biological, psychosocial, and functional information
Cultural and spiritual assessments
Cognitive abilities
Psychological well-being
Caregiver stress or burden
Patterns of health and health care
Review of preferences for advanced care
Presence of any geriatric syndromes

Assessment Components

Sexual function
Depression
Alcoholism
Hearing loss
Oral health
Environmental safety

Problems to Address in an Assessment

Listen patiently
Allow for pauses
Ask questions that are not often asked
Obtain data from all available sources
Know that not all positive findings need interventions
Know normal changes
Pace the assessment according to the patient’s stamina

Special Assessment Abilities

Establish rapport
Data collection approaches include
Self-report
Report by proxy
Observation
Ideally should be done to gather baseline data before the older adult has a health crisis

Collecting Assessment Data

Conduct the assessment at a time when the patient is at his or her best
Avoid biasing the response
Explore for more information only if needed
Approach sensitive information in a matter-of-fact manner
Record the patient’s words for accuracy

Guidelines for an Assessment of the Older Adult

What is the best approach to take when obtaining a health history from an older adult?

Choose a private, quiet area in a comfortable room

Ask a family member to respond to some of the questions

Raise your voice if the patient does not appear to hear you

Take thorough notes during the interview, asking detailed questions as needed

Question

A—When collecting a verbal health history, the nurse should use techniques that optimize communication. This includes choosing a private, quiet area in a comfortable room.

Answer

Increase the likelihood of obtaining reliable, useful data
Can be used to monitor changes over time
Existing instruments can categorize physical health, mood, motor capacity, manual ability, self-care ability, instrumental abilities, and cognitive and social function

Assessment Instruments

Is collected in a face-to-face approach with the patient or a review of the patient’s written history
Includes medical history, review of systems, medication history, nutritional history, and factors that influence the person’s quality of life, including
Living arrangements
Financial resources
Support

Health History

Begins the moment the nurse sees the person
Perform a problem assessment first because of the length of time it takes to conduct an assessment
When the focus is a well-check assessment, the emphasis is placed on health problems in later life

Physical Assessment

FANCAPES
Fluids: State of hydration
Aeration: Respiratory function
Nutrition: Type and amount of food consumed
Communication: Adequate ability to communicate his or her needs
Activity: Ability to meet basic needs of toileting, grooming, and meal preparation
Pain: Physical, psychological, or spiritual pain
Elimination: Difficulty with bladder or bowel elimination
Socialization: Ability to give and receive love and friendship

Assessing Frail and Medically Complex Patients

Need to conduct an assessment of mental status, especially cognitive abilities and mood whenever there is a change in an elder’s condition or safety
Assess whether an increase in chronological age has resulted in an increased rate of dementing illness
Assess cognition and mood

Mental Status Assessment

Tools for cognition assessment
Mini-Mental State Examination
Clock Drawing Test
The Mini-Cog
Global Deterioration Scale
Tools for mood assessment
Geriatric Depression Scale

Cognition and Mood Assessment

Thorough functional status of the patient includes
Identifying areas where help is needed
Determining whether a change in abilities from one period to another has occurred
Assisting in the determination of a need
Determining the safety of the patient’s living situation
If the patient is healthy and active, record a simple statement such as, “The patient is active and independent and denies functional difficulties.”

Functional Assessment

Include
Eating
Toileting
Ambulation
Bathing
Dressing
Grooming
Tools to assess ADLs
Katz Index
Barthel Index
Functional Index Measure

Activities of Daily Living (ADLs)

Considered to be more complex activities necessitating higher physical and cognitive functioning than ADLs
Include
House cleaning
Shopping
Managing money
Tools to assess IADLs

Instrumental Activities of Daily Living (IADLs)

OARS Multidimensional Functional Assessment Questionnaire (OMFAQ)
Fulmer SPICES (sleep disturbance, problems with eating and feeding, incontinence, confusion, evidence of falls, and skin breakdown)
Minimum Data Set used in skilled nursing facilities
OASIS used in certified home care agencies

Comprehensive Assessments

A nurse who needs to assess a patient’s ability to perform ADLs will choose which tool for this assessment?

OASIS

Katz Index

Fulmer SPICES

Global Deterioration Scale

Question

B—The Katz Index measures the ability to perform ADLs and has served as a basic framework for most of the subsequent measures.

Answer

Chronicles, supports, and communicates the patient’s condition
Provides the data needed for the development of the individualized plan of care
Helps the nurse identify, monitor, and evaluate treatment or interventions
Provides the communication needed to ensure continuity of care
Determines reimbursement
Demonstrates the quality of care provided

Documentation

Level of documentation required varies by setting and determined by state and local laws
Documents and communicates day to day care
When care is not considered “skilled” and covered by Medicare, narrative notes are reduced to “problem-oriented only” or “as needed” depending on the facility and licensing body

Skilled Nursing Facility Documentation

When care is covered by Medicare, Medicaid, or another insurer, reimbursement in all settings is based on the assessment and the documentation
Documentation used varies by setting
Skilled nursing facilities—MDS and RUG
Skilled home care—OASIS
Initial reimbursement in acute care settings—DRGs

Documentation and Reimbursement

Nursing responsibilities
Make sure that communication and documentation are of the highest quality
Communicate important information regarding safe patient care
Collect accurate data in the most efficient yet caring manner possible
Use tools as a way to organize assessment data and compare the data from time to time

Implications for Gerontological Nursing and Healthy Aging