America’s elderly population is expected to rise from 34 million in 2000 to approximately 70 million by 2030. To ensure optimal health outcomes for older adults, nurses in all settings should be familiar with geriatric health problems and demonstrate proficiency in providing care. Assessing the health needs of elderly patients can reduce their hospitalization rate and enhance their quality of life and independence. Information you obtain from an accurate assessment serves as the foundation for age-appropriate nursing care.
The nursing process addresses the full range of human experiences and responses to health. To become proficient in geriatric assessment, you need to understand the physiologic changes unique to this population, as well as the differences between normal aging-related changes and health alterations caused by illnesses and social changes.
This article highlights essential skills to use when assessing geriatric patients in any clinical setting. After describing how to assess the integumentary system, head, neck face, and musculoskeletal system, it explains how to evaluate the older adult’s functional status.
Obtaining the health history
Before the physical assessment begins, collect the health history by interviewing the patient [and family members, if needed]. The data you gather will help you focus on particular areas of concern during the physical examination. [See the box below.] Review the health history you’ve obtained before you start the physical examination.
Interviewing the geriatric patient
To promote an efficient information exchange and enhance rapport with the patient, minimize distractions and speak clearly. Put the patient at ease by explaining the reason for the interview and giving a brief overview of how you’ll proceed.
A systematic collection of subjective data, the health history includes both current and past health status. Elicit the chief complaint by asking why the patient is seeking health care. Find out when the present illness or symptom began. Ask about past illnesses that required medical attention, as well as hospitalizations and other procedures. Find out if the patient has a history of cardiovascular, respiratory, renal, or neurologic disorders; diabetes mellitus; cancer; injuries; or falls. Be sure to document all prescription and nonprescription medications the patient takes, including names, dosages, and frequency.
Integumentary system
Most aging-related integumentary changes are easy to see—for instance, graying hair and wrinkled skin. Nonetheless, these changes aren’t always related solely to aging; some may stem at least in part from lifestyle and environmental factors.
Assessing the skin
Wrinkled skin results from loss of elasticity and turgor. With age, the skin gradually thins and loses density, making it more susceptible to bruising and tears. Inspect the skin for lesions and moles. When examining moles, look for irregular shapes; ask the patient if any moles have gotten bigger or changed color. Positive findings indicate the need for further evaluation by a primary care provider or dermatologist. Keep in mind that excessive sun exposure exacerbates aging-related changes and may lead to skin cancers such as melanoma.
Check for pressure ulcers. According to the National Pressure Ulcer Advisory Panel, pressure ulcer rates in hospitals range from 10% to 18%; in long-term care facilities, 2.3% to 28%; and in home-care settings, 0% to 29%. Pressure ulcers are most common on the sacrum, heels, and trochanters. Most experts believe they are preventable and stem primarily from decreased mobility and activity, insufficient caloric intake, and incontinence. The Centers for Medicare & Medicaid Services [CMS] no longer reimburses for care related to hospital-acquired pressure ulcers, so clinicians must be able to quickly identify at-risk patients and implement preventive strategies.
Assessing the hair
An aging-related decline in melanin production makes the hair less vibrant in color, leading to graying. Also, the hair thins; many older adults lose their hair altogether. Dermal vascular beds diminish with age as well, altering hair distribution patterns. Some men are genetically predisposed to baldness and may experience hair loss at younger ages.
Assessing the nails
Regardless of the patient’s age, nail surfaces normally are flat or slightly curved. Note their color, length, and cleanliness. Check for abnormalities. For instance, clubbing may indicate a cardiac or pulmonary disorder; pitting and transverse groves may signify peripheral vascular disease, arterial insufficiency, or diabetes. Brittleness may stem from decreased vascular supply, whereas yellow or brown nails may signal a fungal infection.
Head, neck, and face
The essential purpose of the skull is to protect the brain and other sensory organs from direct injury. Note the general size and shape of the patient’s head; are they appropriate to body size?
The head rests on the seven flexible vertebrae of the neck; the neck gives the head maximum mobility. Limited range of motion [ROM], as from arthritis or muscle weakness, can cause pain and discomfort in older adults. As you evaluate neck ROM, stay alert for reports of pain or dizziness or jerky or abnormal movements; these may be clues to health problems, such as fractured vertebrae, Parkinson’s disease, a transient ischemic attack, or stroke.
Assessing the face
Each individual has unique facial features, but environmental, racial, genetic, emotional, and nutritional factors greatly affect facial appearance and functioning. Note whether the patient’s eyes, eyebrows, nose, and mouth are centered and symmetrical. Asymmetrical features suggest a stroke. Look for appropriateness of affect and behavior.
Check facial skin for dryness, sagging, looseness, and wrinkling, which result from aging-related decreases in elasticity, subcutaneous fat, and moisture. [See the box below for tips on assessing vision and hearing.]