NURSING PROCESS

and the OLDER

ADULT
A. Special Assessment
Guidelines for Elderly
of Older Adults
 Health Assessments
• Used to formulate nursing diagnoses and to plan patient care
• Therefore, it is essential that accurate and complete data be
collected

Purpose of nursing-focused assessment of older clients:

- Determine the older persons ability to meet any health-and-
illness related needs.
- Identify client strengths and limitations so that effective and
appropriate interventions can be delivered to support, promote,
and/or restore optimum function and to prevent disability and
dependence.
The nurse should collect data based on the following key
principles:
1. Use of an individual, person-centered approach
2. A view of clients as participants in health monitoring and
treatment
3. An emphasis on clients’ functional ability
 Health Assessments

• Objective data
– Information that can be gathered using the
senses of vision, hearing, touch, and smell
– Collected by means of direct observation,
physical examination, and laboratory or
diagnostic tests
 Health Assessments

• Subjective data
– Information gathered from the older
person’s point of view
– Best described in the individual’s own
words
INTERVIEWING
OLDER ADULTS
Preparing the Physical Setting
• Minimize noise and distraction
• Lighting should be diffuse
• Furniture should be comfortable
• Privacy is very important
• Provide adequate space, particularly if the client uses a mobility aid.
• Avoid glossy or highly polished surfaces, including floors, walls,
ceilings, and furnishings.
• The room should be comfortably warm and should be free from drafts
• Place the client in a comfortable seating position that facilitates
information exchange
• Maintain proximity to a bathroom
• Keep water or other preferred fluids available
• Plan the assessment, taking into account the older adults energy level,
pace, and adaptability
• Be patient, relaxed and unhurried.
• Allow the client plenty of time to respond to questins and directions
• Maximize the use of silence to allow the client time to collect thoughts
before responding
• Be alert to signs of increasing fatigue such as sighing, grimacing,
irritability, leaning against objects for support, dropping of head and
shoulders, and progressive slowing
• Conduct asessment during client’s peak energy time

During the assessment the nurse must provide an environment that gives
the older adult the opportunity to demonstrate those abilites. Failure to
do so could result in inaccurate conclusions about the client’s funcional
ability, which may lead to inappropriate care and treatment:
• Assess more than once and at different times of day
• Measure performance under the most favorable of condiitons
• Take advantage of natural opportunities that would elicit assets and
capabilities; collect data during bathing, grooming, and mealtime
• Ensure that assistive sensory devices (glasses, hearing aid) and mobility
devices (walker, cane, prosthesis) are in place and functioning correctly
• Interview family, friends, and significant others who are involved in the
client’s care to validate assessment data
• Use body language, touch, eye contact, and speech to promote the
client’s maximum degree of participation
• Be aware of the client’s emotional state and concerns; fear, anxiety,
and boredom can lead to inaccurate assessment conclusions regarding
funcional ability
 Establishing Rapport
• It is most appropriate to begin the
interview by greeting the older person
and introducing yourself
• Appropriate use of names indicates
respect and helps build rapport
• Use of the individual’s first name only
without the person’s consent is
presumptuous and overly familiar
 Establishing Rapport

• The nurse should briefly explain the

purpose of the interview so that the
individual will know what to expect
• Nurses should focus on and speak
directly to the older person being
interviewed
 Structuring the Interview

• It is important to plan sufficient time for

the interview
• The nurse should try not to accomplish
too much during a single interview
 Structuring the Interview

• A variety of communication techniques should

be used to ensure that the patient accurately
understands the information
• The nurse should remain attentive and calm
and allow patients to complete their own
sentences
• The nurse should try not to end an interview
too abruptly
To ensure a successful interview, the nurse should:
• Explain the reason for the interview to the client and should give
a brief overview of the format to be followed.
- this alleviates anxiety and uncertainty, and the client can then
focus on telling the story.
• Give the client selected portions of the interview form to
complete before meeting with the nurse.
- this allows clients sufficient time to recall their long life
histories, thus facilitating the collection of important health-
related data
• Guided reminiscence- can elicit valuable data and can promote
a supportive therapeutic relationship. Using such a technique
helps the nurse balance the need to collect the required
information with the client’s need to relate what is personally
important
• The nurse does not have to obtain the entire history in the traditional
manner of a seated, fcae-to-face inteview. In fcat, this technique may
be inappropriate with the older adult, depending on the situation. The
nurse should not overlook the natural opportunities available in the
setting for gathering information. Interviewing the client at mealtime, or
even while participating in a game, hobby, or other social activity, often
provides more meaningful data about a variety of areas.
 Obtaining the History
• Starts with basic identifying data,
followed by a history of past health
concerns, and then a review of current
health issues
• Much will depend on the cognitive level
of the individual and the complexity of
his or her particular medical history
 Obtaining the History

• Information gathered from the history

will help the nurse form an overall
impression of the older person
• Can help the nurse focus on those
areas most in need of further
exploration and assessment
Major client factors requiring special
consideration while the nurse elicits the
health history:
• Sensory-perceptual deficits
• Anxiety
• Reduced energy level
• Pain
• Multiple and interrelate health problems
• Tendency to reminisce
• In obtaining history, begin with the less threatening “get acquainted
type” of questioning, which eases the tension and anxiety and builds
trust. The nurse then gradually moves to the more personal and
sensitive questions
• When possible, refer to old records to obtain information that will
lessen the time required of both the client and the interviewer
I. Client Profile/ Biographic Data
II. Family Profile
III. Occupational Profile
IV. Living Environment Profile
V. Recreation/Leisure Profile
VI. Resources/Support Systems Used
VII. Description of Typical Day
VIII. Present health Status
 PHYSICAL
ASSESSMENT OF
THE OLDER
ADULT
 Inspection

• The most commonly used method of

physical assessment in which the
senses of vision, smell, and hearing are
used to collect data
 Inspection

• General inspection is used to detect the

need for more specific inspection
• Used when assessing the overall level
of function, as well as when looking for
specific areas of need within any
particular area of function
 Palpation

• Uses the sense of touch in the fingers

and hands to obtain data
 Palpation

• Used for evaluation in many parts of a

physical assessment, including pulses,
temperature and texture of the skin, texture
and condition of the hair, presence and
consistency of tumors or masses under the
skin, distention of the urinary bladder, and
presence of pain or tenderness
 Auscultation

• Uses the sense of hearing to detect

sounds produced within the body
• Heart, lung, and bowel sounds are
typically assessed using auscultation
 Auscultation

• Involves the use of a stethoscope or

other sound amplifier (such as a
Doppler) to make the sounds louder and
more easily heard
• Sounds are described according to their
quality, pitch, intensity, and duration
 Percussion

• A technique in which the size, position,

and density of structures under the skin
are assessed by tapping the area and
listening to the resonance of the sound
• Depending on the amount of vibration
(sound) heard, the presence of masses,
fluid, or air can be determined
 ASSESSING
VITAL SIGNS IN
OLDER ADULTS
 Temperature

• Oral (sublingual) route

– Used most commonly for temperature
assessment
– Either an electronic thermometer or a glass
thermometer that does not contain mercury
can be used to take an oral temperature
 Temperature

• Rectal route
– Should be used with caution
– Should not be used in older persons who
have undergone rectal surgery or have
rectal bleeding
 Temperature

• Axillary route
– Not generally used for older adults
– Time-consuming; the accuracy of
temperature readings may be affected by
environmental conditions
 Pulse

• Position should be consistent (e.g.,

lying, sitting, standing) each time the
pulse is checked
 Pulse

• Can be assessed at various sites on the

body, including the temporal, carotid,
brachial, radial, femoral, popliteal, posterior
tibial, and dorsalis pedis arteries, as well as
at the apex of the heart
• The normal pulse rate in adults ranges from
60 to 90 beats per minute
Figure 8-2; Page 136
 Respirations

• The aging person should be placed in a

comfortable position to maximize ease
of breathing
• The rate, depth, and ease of breathing
must be assessed
 Respirations

• A range of 12 to 20 breaths per minute

is considered normal
• Slightly irregular breathing rhythms are
not unusual in the aging population
Figure 8-3; Page 137
 Blood Pressure

• To obtain the most accurate readings, the

patient should be positioned so that the
upper arm is at the level of the heart
• Cuff selection should be based on the
patient’s upper arm size
• Aging individuals are susceptible to
posture-related changes in blood pressure
 Sensory Assessment of
Older Adults

• Simple assessments of vision and

hearing ability are based on empiric
data (the way the individual responds to
visual or auditory clues)
 Sensory Assessment of
Older Adults

• Nurses should observe whether the person is

able to read or do close work that requires
good central vision or whether he or she
participates in television viewing or other
sight-related activities
• Talking with older adults can reveal the
presence or absence of hearing
PSYCHOSOCIAL
ASSESSMENT OF
OLDER ADULTS
 Mini-Mental State
Examination
(MMSE)

• Standardized psychological assessment

tool
• Performing this assessment requires little
time and only a pencil and blank sheet of
paper
• Scoring of this tool is simple and self-
explanatory
Minimum Data Set (MDS) 2.0

• This tool was designed not only to help

assess residents, but also to help
caregivers identify problems, develop
intervention plans, and monitor
outcomes
Minimum Data Set (MDS) 2.0

• All health care agencies that receive

federal funding are mandated to use the
computerized MDS and must be
capable of transmitting the results to
state and federal agencies
• A comprehensive assessment tool that
assesses core areas of function
Minimum Data Set (MDS) 2.0

• All health care agencies that receive

federal funding are mandated to use the
computerized MDS and must be
capable of transmitting the results to
state and federal agencies
• A comprehensive assessment tool that
assesses core areas of function
Figure 8-5; Pages 142-150
B. Nursing
Diagnosis
Diagnosing

• the process of reasoning or the clinical act

of identifying problems

Purpose: To identify health care needs and

prepare a Nursing Diagnosis.

To diagnose in nursing: it means to analyze

assessment information and derive meaning
from this analysis.
Nursing Diagnosis

• is a statement of a client’s potential or actual health

problem resulting from analysis of data.
• A statement that describes a client’s actual or potential
health problems that a nurse can identify and for which
she can order nursing interventions to maintain the
health status, to reduce, eliminate or prevent
alterations/changes.
• It uses the critical-thinking skills analysis and
synthesis in order to identify client strengths & health
problems that can be resolved/prevented by
collaborative and independent nursing interventions.
Activities during diagnosis:
• Compare data against standards
• Cluster or group data
• Data analysis after comparing with standards
• Identify gaps and inconsistencies in data
• Determine the client’s health problems, health
risks, strengths
• Formulate Nursing Diagnosis – prioritize
nursing diagnosis based on what problem
endangers the client’s life
 C. Outcome
Identification
and Planning
• PLANNING
- involves determining before and the strategies or
course of actions to be taken before implementation of
nursing care. To be effective, the client and his family
should be involved in planning.

Purpose:
• To determine the goals of care and the course of
actions to be undertaken during the implementation
phase.
• To promote continuity of care.
• To focus charting requirements.
• To allow for delegation of specific activities
1. Establish/Set priorities
Priority – is something that takes precedence in position,
and considered the most important among several items. It
is a decision making process that ranks the order of
nursing diagnosis in terms of importance to the client.

Guideline for setting priorities:

1. Life-threatening situations should be given highest
priority.
2. Use the principle of ABC’s (airway, breathing, circulation
3. Use Maslow’s hierarchy of needs.
4. Consider something that is very important to the client.
5. Actual problems take precedence over potential
concerns.
6. Clients with unstable condition should be given
priority over those with stable conditions. Ex: attend
to client with fever before attending to client who is
scheduled for physical therapy in the afternoon.
7. Consider the amount of time, materials, equipment
required to care for clients. Ex: attend to client who
requires dressing change for postop wound before
attending to client who requires health teachings & is
ready to be discharged late in the afternoon.
8. Attend to client before equipment. Ex: assess the
client before checking IV fluids, urinary catheter,
drainage tube
2. Plan nursing interventions/nursing orders to direct
activities to be carried out in the implementation
phase.

Nursing interventions
• any treatment, based upon clinical judgment and
knowledge, that a nurse performs to enhance client
outcomes.
• they are used to monitor health status; prevent,
resolve or control a problem; assist with activities of
daily living; or promote optimum health and
independence.
• They maybe independent, dependent and
independent/collaborative activities that a nurses
carry out to provide client care.
– Independent Nursing Intervention – those activities
that the nurse is licensed to initiate as a result of
the nurse’s own knowledge and skills.

– Dependent Nursing Intervention – those activities

carried out on the order of a physician, under a
physician’s supervision, or according to specific
routines.

– Interdependent/Collaborative – those activities the

nurse carries out in collaboration or in relation with
other members of the health care team.
3. Write a Nursing Care Plan
NCP
• a written summary of the care that a client is to receive.
• it is the“blueprint” of the nursing process.
• It is nursing centered in that the nurse remains in the scope of nursing
practice domain in treating human responses to actual or potential
health problems.
• It is s step-by-step process as evidence by
1.Sufficient data are collected to substantiate nursing diagnosis.
2.At least one goal must be stated for each nursing diagnosis.
3. Outcome criteria must be identified for each goal.
4. Nursing interventions must be specifically designed to meet the
identified goal.
5. Each intervention should be supported by a scientific rationale, which
is the justification or reason for carrying out the intervention.
6. Evaluation must address whether each goal was completely met,
partially met or completely unmet.
D. Implementation
IMPLEMENTATION
• is putting the nursing care plan into
action.

Purpose: To carry out planned

nursing interventions to help the
client attain goals and achieve
optimal level of health.
Activities:
1. Reassessing – to ensure prompt attention to
emerging problems.
2. Set priorities – to determine the order in
which nursing interventions are carried out.
3.Perform nursing interventions – these may be
independent, dependent or collaborative
measures.
4.Record actions – to complete nursing
interventions, relevant documentation should
be done. Remember: Something that is NOT
written is considered as NOT done at all.
Requirements of Implementation:
1. Knowledge – include intellectual skills like
problem-solving, decision-making and
teaching.
2. Technical skills – to carry out treatment and
procedures.
3.Communication skills – use of verbal and non-
verbal communication to carry out planned
nursing interventions.
4. Therapeutic use of self – is being willing and
being able to care
E. Evaluation
EVALUATION

• is assessment the client’s response to

nursing interventions and then comparing that
response to predetermined standards or
outcome criteria.

Purpose: To appraise the extent to which goals

and outcome criteria of nursing care have
been achieved.
Activities:
1. Collect data about the client’s response
2. Compare the client’s response to goals and
outcome criteria.
3. The four possible judgments that may be made
are as follows:
– The goal was completely met.
– The goal was partially met.
– The goal was completely unmet.
– New problems & nursing diagnosis have
developed.
4. Analyze the reasons for the outcomes.
5. Modify plan of care as needed.
 The End
Thank You!