Geriatric assessment: Essential skills for nurses

Issue Date: July 2011 Vol. 6 No. 7

Author: Michael Cary, MSN, RN, and Courtney H. Lyder, ND, GNP, FAAN
Americas 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 adults 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 youve 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
youll 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 seefor instance,
graying hair and wrinkled skin. Nonetheless, these changes arent 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 patients 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 patients
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, Parkinsons 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 patients 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.)
Vision and hearing assessment
Vision can deteriorate with age. Older adults should have 20/40 vision or
better. Such conditions as changing eye shape (presbyopia), cataracts, and
glaucoma typically worsen with age. Because of structural changes in the
eye, older adults may be more sensitive to glare; as a result, shiny surfaces
may increase the risk of falls and result in injury. Encourage adults to get
annual eye exams.

Hearing loss is common in older adults and usually affects both ears. In
general, older adults have more trouble hearing high-frequency sounds, such
as consonants (especially p, s, and t) than low-frequency sounds, such as
vowels. Refer patients with hearing difficulty to an audiologist.
Musculoskeletal system and functional status
Investigate for abnormalities suggested by the health history data, such as
loss of balance, gait disorders, postural abnormalities, or inability to transfer
from a chair to a standing position. If the patient is weak, with poor
coordination, you may need to allot additional time for the functional
examination.
Evaluate muscle groups for atrophy, tremors, and involuntary movements.
ROM tests in older adults are similar to those used in other age-groups.
However, inflamed joints may limit ROM in older adults. Inspect joints of the
hands, wrists, knees, hips, and shouldersareas more prone to arthritis.
Note warmth, swelling, tenderness, crepitus, and deformities.
Maintaining independent functioning as long as possible improves quality of
lifea fundamental principle of geriatric nursing. Assess the patients ability
to perform activities of daily living (ADLs), including bathing, dressing,
toileting transfer, continence, and feeding. You may want to use such tools
as the Katz Index of independence in ADLs or the Barthel Index for functional
evaluation.
Also assess more complex functioning skills such as those needed to perform
instrumental ADLs (IADLs). These are activities that enable an individual to
live independently, such as the ability to use the telephone, travel, shop,
prepare meals, do housework, take medication appropriately, and manage
money. Using the Lawton IADL assessment model can help you evaluate
these activities and develop an appropriate plan of care.
Evaluating the patients fall risk
Conditions such as osteoporosis can increase an older adults risk of falling.
Falls may lead to injuries with devastating effects, including decreased
function, fractures, and sometimes even death. When assessing the patients
fall risk, use a valid and reliable tool, such as the Morse Fall Scale or Tinetti
Gait and Balance Assessment. With CMS no longer reimbursing for care
related to patient falls, fall risk assessment and appropriate interventions are
especially important.
Next steps

Use your assessment findings to develop an effective plan of care that

focuses on geriatric-appropriate interventions and support services. Ongoing
monitoring through routine follow-up gives you the chance to modify the plan
as needed. If the patients assessment findings are abnormal, consider
consulting a geriatric nurse practitioner or geriatrician.