Report-nsg Process of Older Adult

8/8/2019 Report-nsg Process of Older Adult

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NURSING PROCESS

and the OLDERADULT


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A. Special AssessmentGuidelines for Elderlyof Older Adults


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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 anddependence.


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The nurse should collect data based on the following key

principles:

1. Use of an individual, person-centered approach2. A view of clients as participants in health monitoring and

treatment

3. An emphasis on clients functional ability


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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 ordiagnostic tests


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Health Assessments

Subjective data

Information gathered from the older

persons point of view

Best described in the individuals own

words


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INTERVIEWING

OLDER ADULTS


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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.


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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 clients peak energy time

During the assessment the nurse must provide an environment that givesthe older adult the opportunity to demonstrate those abilites. Failure to

do so could result in inaccurate conclusions about the clients 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 andcapabilities; 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


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Interview family, friends, and significant others who are involved in the

clients care to validate assessment data

Use body language, touch, eye contact, and speech to promote the

clients maximum degree of participation

Be aware of the clients emotional state and concerns; fear, anxiety,

and boredom can lead to inaccurate assessment conclusions regarding

funcional ability


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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 individuals first name onlywithout the persons consent is

presumptuous and overly familiar


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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


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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


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Structuring the Interview

A variety of communication techniques

should be used to ensure that the patientaccurately understands the information

The nurse should remain attentive and calmand allow patients to complete their own

sentences The nurse should try not to end an interview

too abruptly


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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 thenfocus 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 clients need to relate what is personallyimportant


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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 thesetting 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.


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Obtaining the History

Starts with basic identifying data,

followed by a history of past health

concerns, and then a review of currenthealth issues

Much will depend on the cognitive level

of the individual and the complexity of

his or her particular medical history


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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 furtherexploration and assessment


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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


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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 andsensitive questions

When possible, referto old records to obtain information that willlessen the time required of both the client and the interviewer


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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


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PHYSICAL

ASSESSMENT OFTHE OLDERADULT


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Inspection

The most commonly used method of

physical assessment in which the

senses of vision, smell, and hearing are

used to collect data


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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 anyparticular area of function


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Palpation

Uses the sense of touch in the fingers

and hands to obtain data


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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, andpresence of pain or tenderness


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Auscultation

Uses the sense of hearing to detect

sounds produced within the body

Heart, lung, and bowel sounds are

typically assessed using auscultation


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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 theirquality, pitch, intensity, and duration


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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


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ASSESSINGVITAL SIGNS INOLDER ADULTS


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Temperature

Oral (sublingual) route

Used most commonly for temperature

assessment

Either an electronic thermometer or a glass

thermometer that does not contain mercurycan be used to take an oral temperature


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Temperature

Axillary route

Not generally used for older adults

Time-consuming; the accuracy of

temperature readings may be affected by

environmental conditions


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Pulse

Position should be consistent (e.g.,

lying, sitting, standing) each time thepulse is checked


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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


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Figure 8-2; Page 136


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Respirations

The aging person should be placed in a

comfortable position to maximize easeof breathing

The rate, depth, and ease of breathing

must be assessed


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Respirations

A range of 12 to 20 breaths per minute

is considered normal

Slightly irregular breathing rhythms are

not unusual in the aging population


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Figure 8-3; Page 137


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Blood Pressure

To obtain the most accurate readings,

the patient should be positioned so thatthe upper arm is at the level of the heart

Cuff selection should be based on the

patients upper arm size Aging individuals are susceptible to

posture-related changes in blood

pressure


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Sensory Assessment of

Older Adults

Simple assessments of vision and

hearing ability are based on empiricdata (the way the individual responds to

visual or auditory clues)


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Sensory Assessment of

Older Adults

Nurses should observe whether the person is

able to read or do close work that requiresgood 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


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PSYCHOSOCIAL

ASSESSMENT OFOLDER ADULTS


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Mini-Mental StateExamination

(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


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Minimum Data Set (MDS) 2.0

This tool was designed not only to help

assess residents, but also to helpcaregivers identify problems, develop

intervention plans, and monitor

outcomes


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All health care agencies that receive

federal funding are mandated to use thecomputerized MDS and must becapable of transmitting the results tostate and federal agencies

A comprehensive assessment tool thatassesses core areas of function


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All health care agencies that receive

federal funding are mandated to use thecomputerized MDS and must becapable of transmitting the results tostate and federal agencies

A comprehensive assessment tool thatassesses core areas of function


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Figure 8-5; Pages 142-150


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B. Nursing

Diagnosis


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Diagnosing

the process of reasoning or the clinical actof identifying problems

Purpose: To identify health care needs andprepare a Nursing Diagnosis.

To diagnose in nursing: it means to analyzeassessment information and derive meaningfrom this analysis.


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Nursing Diagnosis

is a statement of a clients potential or actual healthproblem resulting from analysis of data.

A statement that describes a clients 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 bycollaborative and independent nursing interventions.


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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 clients health problems, health

risks, strengths

Formulate Nursing Diagnosis prioritize

nursing diagnosis based on what problemendangers the clients life


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C. Outcome

Identificationand Planning


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PLANNING

- involves determining before and the strategies or

course of actions to be taken before implementation ofnursing 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


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1. Establish/Set priorities

Priority is something that takes precedence in position,

and considered the most important among several items. Itis 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 ABCs (airway, breathing, circulation

3. Use Maslows hierarchy of needs.

4. Consider something that is very important to the client.

5. Actual problems take precedence over potential

concerns.


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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 isscheduled 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


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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.


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Independent Nursing Intervention those

activities that the nurse is licensed to initiate as a

result of the nurses own knowledge and skills.

Dependent Nursing Intervention those activities

carried out on the order of a physician, under a

physicians supervision, or according to specificroutines.

Interdependent/Collaborative those activities the

nurse carries out in collaboration or in relation with

other members of the health care team.


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3. Write a Nursing Care Plan

NCP

a written summary of the care that a client is to receive.

it is theblueprint 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.


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D. Implementation


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IMPLEMENTATION

is putting the nursing care plan into

action.

Purpose: To carry out plannednursing interventions to help the

client attain goals and achieve

optimal level of health.


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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 beindependent, dependent or collaborative

measures.

4.Record actions to complete nursing

interventions, relevant documentation shouldbe done. Remember: Something that is NOT

written is considered as NOT done at all.


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Requirements of Implementation:

1. Knowledge include intellectual skills like

problem-solving, decision-making andteaching.

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 andbeing able to care


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E. Evaluation


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EVALUATION

is assessment the clients 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.


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Activities:

1. Collect data about the clients response

2. Compare the clients response to goals andoutcome 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 havedeveloped.

4. Analyze the reasons for the outcomes.

5. Modify plan of care as needed.


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The End

Thank You!

Documents

Report-nsg Process of Older Adult