LESSON 4 & 5: GERIATRIC NURSING ASSESSMENT
SYSTEMATIC GERIATRIC ASSESSMENT
 CRITICAL USE OF SENSES
- The nurses’ assessment of older adults
requires the ability to actively listen as well
as to use all other senses to gather data
 NEED EXPERIENCE AND EXPERTISE
- This often draws upon experience and
expertise gained over time in working with
the older population.
- An inexperienced nurse is often frustrated
by the length of time needed for the
geriatric assessment, and the inability of
some older adults to keep focused on
providing the necessary information.
- This assessment will probably take a long
time, and it may be necessary to
consistently encourage the client to focus
on answering the questions.
- Written forms and checklists can help the
nurse to keep the client more focused.
 PROVISION OF APPROPRIATE ENVIRONMENT
- Environmental adaptations are usually
necessary to compensate for the older
adult’s physiological and psychological
changes of aging.
- Modifications to the physical environment
start with a room that is comfortably warm
to the client and not exposing the client any
more than is necessary.
- Amella (2004) states that the “key to
providing appropriate treatment to older
adults is going beyond the usual history and
physical parameters to examine mental,
functional, nutritional and social-support
status.”
SYSTEMATIC GERIATRIC ASSESSMENT “T I P S”:
 The room should be adequately bright
but with indirect lighti ng to compensate
for diminished visual acuity.
 Fluorescent lighti ng and window glare
should be avoided.
 Straight-backed chairs with arms that are
cushioned for comfort should be uti lized,
making sure that the client’s height
allows for ease in rising from them.
 The examinati on table should be low and
well-padded to protect from discomfort.
 The head of the examinati on table should
rise up, as some older adults may have
diffi culty lying fl at for any amount of
ti me.
 There should be adequate space in the
examinati on room to accommodate
mobility aides.
 The room should be free from distracti on
and background noises.
 It is important to take into considerati on
the energy level of the older adult and
conduct the physical examinati on at the
individual’s own pace.
 Minimize skin exposure of the older adult
to prevent chilling. These factors may
indicate the need to conduct the
examinati on over more than one session.
 It is helpful to organize the examinati on
to reduce the changes in body positi ons
and conserve the client’s energy.
The following are various techniques need to be utilized
to assess each individual adequately:
 The examiner must spend some extra
ti me establishing a nonthreatening
relati onship.
 As a sign of respect, older adults should
be addressed by their last name and ti tle.
The fi rst name should be used only if
invited to do so.
 The nurse must allow the older client
enough ti me to respond to questi ons.
 The nurse should speak facing the client
and use commonly accepted wording.
 Allowing hearing-impaired clients to see
the nurse’s enti re face and body so that
LESSON 4 & 5: GERIATRIC NURSING ASSESSMENT
they may detect lip reading and body
language may be helpful.
 For clients with visual defi cits, nurses
must make sure that the clients have
their glasses on and plan to use visual
cues as needed.
 Family members can provide important
informati on, but the examiner needs to
focus on the client.
GERIATRIC INTERDISCIPLINARY TEAMS (GIT S)
 made up of physicians, nurses, physical
therapists, occupational therapists, recreational
therapists, social workers, psychologists, and
nursing assistants—make assessment more
efficient by assigning components of the
assessment to the most qualified member of
the team.
- After completing assigned components of
the assessment, GIT members gather
together to plan care for the older adult,
which is generally more comprehensive and
effective than when individual team
members work alone
 Geriatric interdisciplinary team care has been
effective in managing the complex syndromes
experienced by chronically ill and frail older
adults with multiple co-morbidities, because
such care requires skills that are not possessed
by any one professional.
 Positive outcomes of geriatric teams have been
revealed in multiple studies, including one by Li,
Porter, Lam, and Jassal (2007).
- These researchers found that a team
approach to care delivery resulted in
quicker hospital discharge and improved
functional status.
 The Institute of Medicine (IOM) of the National
Academy (2001), in attempts to reduce medical
errors and improve patient outcomes,
challenges all health care professionals to
recognize the need for effective interdisciplinary
team care for multiple patient populations.
PAY CLOSE ATTENTION TO CULTURALLY APPROPRIATE
BEHAVIORS :
 It is important to determine how the older adult
would like to be addressed and the language
that they are most comfortable speaking.
 If the older adult speaks a language foreign to
the nurse, the client should be questioned as to
whether or not an interpreter is desired or
whether a family member would like to
communicate the client’s history.
 Attention should also be paid to the older
adult’s comfort with the amount of personal
space, eye contact, and physical gestures of the
health care provider.
 The relationship of the nurse to the client
requires recognition of and sensitivity to
cultural differences, because some cultural
groups definitions of health and illness may
differ from the examiners.
 These same cultural groups may also have their
own health practices that are thought to
promote health and cure illness within the
group.
 All nurses should make efforts to modify health
care according to the client’s cultural beliefs in
order to provide culturally competent care.
REMEMBER THAT SOME OF THE STANDARDIZED ASSESSMENT
TOOLS :
 Be cautious about interpreting a tool that has
not been formally translated, as the meanings
of many words change by cultural background.
 During the assessment, it is necessary to
determine the decision maker in the family and
respect the client and families wishes in sharing
information.
 In some cultural backgrounds, older adults are
prevented from hearing about their diagnoses,
and family members are given this information.
 In addition, some diseases of older adulthood,
such as dementia and depression, are
stigmatized in many cultures.
 While some older adults will participate actively
in setting goals and objectives for care, as well
as determining acceptable interventions and
outcomes, others will be more comfortable
LESSON 4 & 5: GERIATRIC NURSING ASSESSMENT

relinquishing this task to family members and

health care providers.
 it is essential for nurses to assess clients’
understanding of their role in the plan of care
and whether or not the plan is consistent with
cultural beliefs.

 HEALTH HISTORY
 REVIEW OF SYSTEM
WHO
 PHYSICAL ASSESSMENT
SHOULD
BE

EVALUATED ?

INTERDISCIPLINARY TEAM

❑ Family ❑ Caregiver

GOALS

SIGNIFICANCE
LESSON 4 & 5: GERIATRIC NURSING ASSESSMENT

GERIATRIC GIANTS  The sources of information and tools used as

well as the nurse’s skill level have consequences
for the older adult’s individualized plan of care.
 The physical and social environment can
support or suppress an older adult’s abilities.
 Comprehensive assessment consists of
objective and subjective elements, and how the
assessment data are interpreted is of major
importance.
 As Kane (1993) has suggested, “interpretation is
an art, and it is an art that nurses must aspire to
master both as students and as practitioners.”

FUNCTIONAL ASSESSMENT

 PURPOSE:
COMPREHENSIVE GERIATRIC ASSESSMENT IS COMPOSED OF
- to identify an older adult’s ability to
THE FOLLOWING COMPONENTS :
perform selfcare, self-maintenance, and
1. Functional Assessment physical activities, and plan appropriate
a. Activities Daily Living (ADLs) nursing interventions.
b. Instrumental Activities of Daily Living  APPROACHES:
(IADLs) 1. to ask questions about ability
c. Advanced Activities of Daily Living (AADLs) 2. to observe ability through evaluating task
2. Physical Assessment completion.
a. Circulatory Function
ACTIVITIES OF DAILY LIVING (ADLS)
b. Respiratory Function
c. Gastrointestinal Function
d. Genitourinary Function
e. Sexual Function
f. Neurological Function
g. Musculoskeletal Function
h. Sensory Function
i. Integumentary Function
j. Endocrine and Metabolic Function  Katz Activities of Daily Living (ADL)
k. Hematologic and Immune Function  Older American Resources and Services
3. Cognitive Assessment Assessment (OARS)
4. Psychological Assessment  Bathing
a. Quality of Life  Dressing
b. Depression  Toileting
5. Social Assessment  Transferring
6. Spiritual Assessment  Continence
7. Other Assessment: Obesity  Feeding

CAUTIONARY NOTE

 Comprehensive assessment is not a neutral

process;
LESSON 4 & 5: GERIATRIC NURSING ASSESSMENT

At 3yrs, IADL impairment is a predictor of incident

dementia

 1 impairment, OR=1
 2 impairments, OR=2.34
 3 impairments, OR=4.54
 4 impairments, lacked statistical power

ADVANCED ACTIVITIES OF DAILY LIVING (AADLS)

 Advanced activities of daily living include

societal, family, and community roles, as well as
participation in occupational and recreational
activities.
 AADL assessment tools tend to be used less
often by nurses and more often by occupational
INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADLS)
therapists and recreation workers to address
 Lawton Instrumental Activities of Daily Living specific areas of social tasks.
(IADL)  TOOL: Canadian Occupational Performance
 Ability to Telephone Measure (COPM)
 Shopping  The COPM asks older adults to identify daily
 Food Preparation activities that are difficult for them to do but, at
 Housekeeping the same time, are self-perceived as being
 Laundry Lawton Instrumental Activities of Daily important to do.
Living (IADL)  The tool asks about self-care activities (personal
 Mode of Transportation care, functional mobility, and community
 Responsibility for Own Medication management), productivity (paid/ unpaid work,
 Ability to Handle Finances household management, and play/ school), and
leisure (quiet recreation, active recreation, and
socialization).
 Consequently, interventions to enhance and
support ability are planned to address those
activities of importance to the older adult.

Mobility

 The Get Up and Go Test is a practical balance

and gait assessment test for an office
assessment. The Timed Up and Go Test is
another test of basic functional mobility for frail
elderly persons.
 Balance can also be evaluated using the
Functional Reach Test. In this test the patient
stands next to a wall with feet stationary and
one arm outstretched. They then lean forward
as far as they can without stepping. The reach
distance of less than six inches is considered
LESSON 4 & 5: GERIATRIC NURSING ASSESSMENT
abnormal. If further testing is advisable, the
Tinetti Balance and Gait Evaluation is the
standard.
Get up and Go test
Staff should be trained to perform the “Get Up and Go
Test” at check-in and query those with gait or balance
problems for falls.
 Rise from an armless chair without using hands.
 Stand still momentarily.
 Walk to a wall 10 feet away.
 Turnaround without touching the wall.
 Walk back to the chair.
 Turn around.
 Sit down. Individuals with difficulty or
demonstrate unsteadiness performing this test
require further assessment.
 ONLY VALID FOR PATIENTS NOT USING AN
ASSISTIVE DEVICE
 Get up and walk 10ft, and return to chair
 Sensitivity 88%
 Specificity 94%
 Time to complete
 Requires no special equipment
Shoulder Function
 A simple test is to inquire about pain and
observe range of motion. Ask the patient to put
their hands behind their head and then in back
of their waist. If any pain or limitation is
present, a more complete examination and
potentially referral are recommended.
Hand Function
 The ability grasp and pinch are needed for
dressing, grooming, toileting and feeding.
 to pick up small objects (coins, eating utensils,
cup) from a flat surface.
 Another measure is of grasp strength.
 The patient is asked to squeeze two of the
physician or examiner’s fingers with each hand.
 Pinch strength can be assessed by having the
patient firmly hold a paper between the thumb
and index finger
PHYSICAL ASSESSMENT
 Conducting a physical assessment of an older
adult is based on: 1. Technical competence in
physical assessment 2. Knowledge of the
normal changes and diseases associated with
aging 3. Good communication skills
 Physical assessment with a “systems” approach
reviews each body system by first taking a
history and then conducting a physical
examination.
 It is important to ask questions that produce an
accurate description of the older adult’s
physical status and furthermore explore the
meaning and implications of physical status on
an individual basis. *
CARDIO VASCULAR SYSTEM
Characteristics:
 Valves of the heart become thick and rigid as a
result of sclerosis and fibrosis.
 Blood vessels become thick and rigid, resulting
in elevated blood pressure.
 Maximum heart rate and aerobic capacity
decreases with age.
 Decline in maximum oxygen consumption.
 Decreased baroreceptor sensitivity.
Physical Assessement:
Cardiac
 History
- Shortness of breath, chest pain
- History of smoking, exercise
Inspection
- Visual pulsations, lifts, heaves
- Cough, shortness of breath
- Cyanosis of mucous or nail beds
LESSON 4 & 5: GERIATRIC NURSING ASSESSMENT

Palpation

- Thrills, heaves, lifts Auscultation

- Capillary refill
 Abnormal sounds on inspiration and expiration
- Skin temperature
à Crackles, wheezing, whistling, pleural
- Blood pressure
friction rub
- Auscultation
- Irregular heartbeat Assessment Findings
- Murmurs
• Prolonged cough, inability to raise secretions.
Assessment findings • Increased frequency of respiratory infections.
• Normal blood pressure or below
• Pre hypertension
• Stage I hypertension
• Stage II hypertension GENITO URINARY SYSTEM
• Prolonged tachycardia may occur following the Female
stress
• Thinning of the vaginal wall,
• Narrowing of vagina in size and loss of elasticity
• Decreased vaginal secretions resulting in vaginal
dryness, itching and decreased acidity
RESPIRATORY SYSTEM • Involution of the uterus and ovaries
Characteristics • Decreased pubococcygeal muscle tone resulting
• Weakening of intercostal respiratory muscles in relaxed vagina and perineum,
and the elastic recoil of the chest wall Males
diminishes.
• Residual volume and functional residual • Penis and testes decrease in size, and levels of
capacity increase. androgens diminishes
• Partial pressure of oxygen decreases • Erectile dysfunction
• Decrease in mucus transport or ciliary system, Physical Assessment
therefore reduced clearance of mucus and
foreign bodies. History

Physical Assessment • Prior problems with urinary tract

• Medications affecting urination
History • Surgeries
 Difficulty breathing, cough, pneumonia, lung • Renal disease
disease Inspection
 Oxygen use
 Vaccinations • Amount and color of urine

Inspection Palpation

 Use of accessory muscles, nasal flaring, cyanosis • Bladder distention, masses

 Posture Functional assessment
Palpation • Important as physical assessment
 Masses and tenderness of ribs • Evaluate physical, cognitive, and social function
• Evaluate strengths and deficit
LESSON 4 & 5: GERIATRIC NURSING ASSESSMENT

Assessment Findings • Thinning of three layers of skin and decreased

ability to function as a barrier.
• Vaginal dryness, painful intercourse.
• Fewer melanocyte and decrease tanning.
• Atrophic vaginitis
• Less efficient thermoregulation because fewer
• Urinary incontinence, BPH and prostatic cancer
sweat glands.
• Drier skin because of decreased number of
sebaceous glands

MUSCULOSKELETAL SYSTEM Physical Assessment

Characteristics History
• Declining muscle mass • Skin problems, allergies, skin regimen
• Decreased bone density, more in women.
• Decreased thickness and resiliency of cartilage Inspection
• Bone resorption exceeds bone formation, • Observe entire body, including fingernails and
resulting in decline of bone density. toenails
• Injuries to the cartilage • Check for pallor, jaundice, petechiae, cyanosis,
• With age, the receptors in the joints and erythema
muscles loss their ability to function, so there is • Pressure ulcers and other lesions
a change in balance.
• Walking with shorter step length, less leg lift, a Palpation
wider base, and tendency to lean forward • Turgor, texture, and temperature
• With age less ability to stop a fall from occurring
Assessment Findings:
Physical Assessment
• Reduced sensory output and decreased
History elasticity.
• Pain in joints and back • More prone to heat stress
• Hypothermia
Inspection

• Observe gait, range of motion

Assessment Findings SENSORY SYSTEM

VISION
• Muscle atrophy
• Increased incidence of fractures. • Decreased visual acuity
• Joint stiffness. • Decreased peripheral vision
• Decreased bone density • Decreased dark adaptation
• Alteration in posture, ability to transfer, and • Elevated minimal threshold of light perception
gait • Presbyopia
• Complaint of dizziness • Decreased colour discrimination
• Increased sensitivity to glare
• Decreased depth sensation
• Decreased tears

Physical Assessment
INTEGUMENTARY SYSTEM
Characteristics History
LESSON 4 & 5: GERIATRIC NURSING ASSESSMENT

• Changes in vision, excessive tearing, discharge • Turning of head toward speaker.

Inspection
• Symmetry of eyebrows, pupils
• Redness, swelling, discharge
• Perform eye exam using Snellen’s eye chart
• Check glasses
• Request of a speaker to repeat.
• Inappropriate answers
• The person may withdraw, demonstrate short
attention span and become frustrated, angry
and depressed.
• Lack of response to a loud noise.

Assessment Findings SMELL

• Arcus senilis Characteristics

• Cataracts
• Changes in smell due to nasal sinus disease
• Macular degeneration Glaucoma
preventing odours from reaching smell
• Smaller pupil size
receptors
• Dry, red eyes
• Decreased discrimination of odours.
• Vitreous floaters
• Decreased more in men than women
HEARING
Physical Assessment
• Hearing loss-
Nose and sinuses
- Usual progression from high tone or high
frequency loss to a general loss of both high and History
low tones.
• Problems with nose or sinuses
• Consonants are not heard well.
• Hearing loss increases with age and greater in Inspection
men.
• Increase in the sound threshold. • Size, shape, color of nose, swelling, drainage,
• Decreased speech discrimination. difficulty moving air through nostrils, ability to
• Cerumen impaction smell

Physical Assessment Palpation

History • Tenderness, masses

• Hearing loss, corrective devices, pain in ears, Assessment Findings

dizziness, drainage • Inability to notice unpleasant odors
Inspection • Decreased appetite.

• Do you have to repeat, size, shape, symmetry,

lesions

Palpation

• Pain or tenderness

Assessment Findings

• Increased volume of patients own voice. TASTE

LESSON 4 & 5: GERIATRIC NURSING ASSESSMENT

Characteristics

• Taste buds decreases with age especially in

men.
• Taste buds lost from the front to the back.

Physical Assessment

Mouth and throat

Scoring:
History
• 0-2= You have good nutrition.
• Pain, swelling, difficulty swallowing, sensitive
• 3 to 5= You are at moderate nutritional risk,
teeth, fit of dentures, last dental exam
• 6 or more= You are at high nutritional risk.
Inspection and palpation

• Gums pink, moist, smooth

• Teeth in good repair
• Dentures fit well
• Gag reflex and uvula
TASTE
Assessment Findings
• Complaints of food has no taste.
• Excessive use of sugar and salt.
• Inability to identify the foods.
• Decrease in appetite and weight loss.
• Decrease pleasure from food
VISION
• The U.S. Preventive Services Task Force
(USPSTF): found insufficient evidence to
recommend for or against screening with
ophthalmoscope in asymptomatic older
patients.
• Common causes of vision impairment :
presbyopia, glaucoma, diabetic retinopathy,
cataracts, and ARMD
HEARING
Updated USPSTF recommendations since 1996:

• Recommends screening older patients for

hearing impairment by periodically questioning
MORE TOOLS them about their hearing.
NUTRITION :FOUR COMPONENTS SPECIFIC TO THE • (Hearing Handicap Inventory for the Elderly)
GERIATRIC ASSESSMENT • Audioscope examination, otoscopic
• Nutritional history performed with a nutritional examination, and the whispered voice test are
health checklist also recommended.
• Record of a patient's usual food intake based on
24-hour dietary recall
• Physical examination with particular attention
to signs associated with inadequate nutrition or
overconsumption and
• Select laboratory tests, if applicable

VISUAL IMPAIRMENT
LESSON 4 & 5: GERIATRIC NURSING ASSESSMENT

• Older persons with visual impairment are twice

as likely to have difficulties performing ADLs and
HEARING HANDICAP INVENTORY FOR THE ELDERLY
IADLs, quality of life, mental health, life
satisfaction, and involvement in home and
community activities.

HEARING IMPAIRMENT

INTERPRETATION

• A raw score of 0 to 8 = 13 percent probability of

• Audioscope hearing impairment (no handicap/no referral)
à A handheld otoscope with a built-in • 10 to 24 = 50 percent probability of hearing
audiometer impairment (mild to moderate
• Whisper Test handicap/referral)
• 26 to 40 = 84 percent probability of hearing
impairment (severe handicap/referral).
• Potentially ototoxic drugs.
• Failure of screening tests should be referred to
an otolaryngologist.
• Treatment of choice - Hearing aids
• To minimize hearing loss and improve daily
functioning.

SCREENING VERSION OF THE HEARING HANDICAP

INVENTORY FOR THE ELDERLY
LESSON 4 & 5: GERIATRIC NURSING ASSESSMENT

URINARY CONTINENCE
• Complications: decubitus ulcers, sepsis, renal
failure, urinary tract infections, and increased
mortality.
• Psychosocial implications : loss of self-esteem,
restriction of social and sexual activities, and
depression.
• Key deciding factor: Nursing home placement.

QUESTIONS TO ASK

Urge incontinence:

• “Do you have a strong and sudden urge to void

that makes you leak before reaching the toilet?”

Stress incontinence:

• “Is your incontinence caused by coughing,

sneezing, lifting, walking, or running?”

BALANCE AND FALL PREVENTION

• Leading cause of hospitalization and injury-

related death in persons 75 years and older.
• Tool to assess a patient's fall risk- 16 seconds

The Tinetti Balance and Gait Evaluation:

• This test involves observing as a patient gets up

from a chair without using his or her arms,
walks 10 ft, turns around, walks back, and
returns to a seated position.
• Failure or difficulty to perform the test:
increased risk of falling and need further
evaluation.
• INTERPRETATION OF TEST
à 7 -10 sec: Normal time
à 10-19 sec: Fairly mobile
à 20-29 sec: Variable mobility
à 30 sec or more: Functionally dependent
in balance and mobility