Introduction

Chapter I: The Nursing Process: Geriatric Assessment

Chapter II: Psychological Assessment

Chapter III: Physical Assessment and Recording the Findings

Chapter VI: Drug Therapies for the Elderly Client

References

Chapter II: PSYCHOLOGICAL ASSESSMENT

PSYCHOLOGICAL ASSESSMENT
(For use on admission to the hospital, nursing home or residence for senior citizens)

I. Identifying Data:

 II. Health History:

1. Have you had previous admissions to the hospital?
   To another nursing home or residence?
   
   
2. Describe significant aspects of your health history.
   
   
3. What does it mean to you to be in the hospital or nursing home?
   
   
4. What is your usual source of health care?
   
   
5. How accessible are health services?
   Is transportation readily available?
   Do you have some form of health insurance?
   
   
6. What medications do you currently use?
   
   
7. Describe any drug allergies.
   
   
8. What do you consider your major present problem or area of concern?
   
   
9. When did the problem begin?
   
   
10. Was the onset sudden or gradual?
    
    
11. What does this problem or illness mean to you?
    
    
12. What do you consider the stressful event triggering your problem?
    
    
13. Have you ever experienced a similar problem?
    If you have, what was the problem?
    How did you handle the problem?
    Were your coping patterns successful?

III. Life-Style Patterns:

1. What is your usual pattern of living?
   Are you able to care for your own ADL’s? (Activities of Daily Living.)
   What time of the day do you feel the most alert?
2. What is your present living situation and environment?
   Are there any hazards to health or development?
3. How do present circumstances differ from usual pattern of living?
4. Have things changed with your aging or illness or disability?  If so, how?

IV. Perceptual Ability:

1. Describe your sensory ability or any impairment related to:
   Sight                            Taste
   Hearing                        Smell
   Touch                          Balance
   
   Pain or unusual body perceptions:
   
   
2. Do bright lights or loud noises bother you?
   
   
3. If you are more sensitive to light or noise now, is it related to your illness or to conditions existing in the hospital or residence?
   
   
4. Do you have special visions? 
   If so, describe them and when and where they occur.
   
   
5. Do you hear voices?
   If so, what do they say and are you able to converse with them?
   
   
6. What are your food preferences?
   What foods are not tasteful or enjoyable to you?
   
   
7. What kinds of feelings do you have in various body parts?
   Are you especially aware of any body part or function?
   
   
8. What situations require assistance to maintain balance/mobility?
   What kind of assistance do you need?

V.    Emotional Status:

Self concept:

How would you describe yourself?
How do you feel you handle yourself and your life?    
What would you describe as your attitude toward life?
What are the most important values to you?
What do you like best about yourself?
If it were possible, what is the primary aspect of yourself that you would like to change?
Do you prefer doing things alone or with others?

Ego ideal:
What goals or aspirations do you presently have?
Do you feel you have managed to achieve your goals in life?

Super ego:
Which of the following comes first for you?
1.  Pleasure
2.  Your goals
3.  Essential tasks

How do you respond to situations that require you to do something you are reluctant to do?
1.  Do you ignore the task?
2.  Do you plunge in and complete it as soon as possible?
3.  Do you delay the task as long as possible?

What rules or customs are difficult for you to follow?

What do you consider the most important teachings that were given to you by your parents or family?

That you have lived by?
What causes you to feel guilty?

Relations to others:

Do you share your feelings with another with ease or with difficulty? 
With whom do you share your feelings?
Who can you trust to help you in time of need?
Who or what do you care about the most in your life?
Who do you think cares most about you?
How do you see your life fitting into the lives of others?
How dependent or independent of family or friends are you?

Sense of autonomy:

What does the term “fate” mean to you?
What do you feel has control over what is happening to you?
How much control do you exert over others?

How has aging or illness or hospitalization or admission to nursing home or residence affected your feelings of control or lack of control?

Reaction and coping with situations:

What situations or persons cause you to feel calm, secure and happy?
What situations or persons cause you to feel upset, embarrassed, anxious or anger?
What usually results from your behavior?

Adaptive pattern:

What is your usual pattern of relating to those close to you?
To a group situation?
How much does another’s reaction or behavior influence how you will act?
How important is another person’s behavior or feelings to you?
What is your reaction to frustration?  To success?
Which of the following are you likely to do?
Go along with the person or situation to keep peace?
Blame others if something goes wrong for you?
Consider yourself the cause if something goes wrong?
Feel more angry than is warranted by the situation?
Let others know abruptly of your feelings?
Say little about your feelings, hoping the other person will guess how you are feeling?
Feel reluctant to act in an unfamiliar situation without permission or encouragement
from someone?
Feel confident in unfamiliar situations and take charge of things if it is indicated?
Encourage others to do their best work possible?
Consider that others are unlikely to do the job as well as yourself?

What do you find best relieves your tension – eating, smoking, drinking, drubs, sleep, activity etc?

VI.    Use of Leisure:

1. What activities do you enjoy for recreation or relaxation?
2. How often do you engage in these activities?
3. How do these activities affect your health?

VII.    Communication Pattern: (Observe and listen for)

1. Ability to express thoughts and feelings (talks freely or hesitancy, writes, draws, uses
   nonverbal behavior primarily).
2. Describes vocabulary (variety of words used, repetition of words, slang or correct grammar).
3. Enunciation of words.
4. Rate of expression of speech (how quickly answers, rapidity in flow of speech, hesitations,
   smooth vs. uneven rate, urgency of speech).
5. Ability to express his ideas (coherent, logical, confused, circumstantial, tangential, poverty
   of ideation).

VIII.   Cognitive Status:  (Observe and listen for)

1. Level of consciousness (alert, lethargic, confused, stuporous or comatose).
2. Orientation to time, place, person.
3. Education level.
4. Ability to recall far past, immediate past and present events (what brought you into the
   hospital or residence?  Tell me about the events that led you to your hospitalization or
   admission to nursing home or residence.  Tell me MAJOR things about yourself and your past life).
5. Attention span (attends to immediate stimuli; length of concentration or attention span; is
   not distracted by external stimuli; how capable of following train of thought, what stimuli
   distracts, how long interview proceeded before person showed signs of fatigue, preoccupied
   with self or some event).
6. Speed of response to verbal stimuli (answers immediately, quickly or slowly, hesitates,
   ignores certain statements).
7. Remains in reverie state or in primary process (daydreams, fantasizes, talks about material
   that seems nonsensical or is difficult to follow).
8. Ability to grasp ideas to follow directions.
9. Ability to do logical thinking or problem solving (or unable to do cause-effect associations,
   states loose, magical or nonsensical logic).
10. Ability to abstract (answers questions literally, is able to elaborate or explain, can give
    meanings for behavior situations).
11. Presence of delusions or degree of reality in belief system.
12. Apparent insight into problem or situation:
    What have you been told about your illness?
    What do you think is the cause of your problem?
    Why do you think you have been admitted to hospital or nursing home or residence?
13. Aware of need for more knowledge about illness situation:
    What questions or concerns do you have about your illness, hospital stay, admission
    to nursing home or residence?

IX.        Ego Functions:

Interviewer should note the following during the interview:

• What was the primary emotion?  Was it appropriate to the situation?
• During the interview, what nonverbal behavior accompanied statements?
• What questions elicited behavioral manifestations of discomfort or anxiety?
• Was there accentuated use of any one pattern of behavior during the interview?
• Did the person use “they” instead of “I” when responding to questions?
• Was he/she aware of body parts and functions without excessive preoccupation
  with him or herself.
• Was the person realistic or did he/she show disturbed reality twisting?
  • For example – Is the person adapting to reality?
  • Does he/she show poor judgment?
  • Does he/she understand the consequences of his/her behavior?
  • Does reality interfere with creative behavior?
  • Presence of delusions?  Hallucinations?
• Has the person learned the socially acceptable method of dealing with drives and
  feelings?
• What defense mechanisms are apparently commonly used?
• What defense mechanisms were used during the interview?
• Does behavior appear over-controlled, under-controlled or without control?  Describe.
• Does the person appear able to have the various aspects of his personality integrated?
• What aspects of his behavior appear fragmented or lacking in unity or autonomy?

Summary of impressions
(Note:  Any discrepancies between patient’s or client’s perception and that of interviewer or caregiver.)

A.  Intrapersonal Factors:

1.  Physical (appearance; posture; faces; dress; hygiene; range of body functions; physical
findings that evidence anxiety).

2.  Psychological (cognitive and perceptual abilities; thought process; emotional status; ego
functions; adaptive or defensive mechanisms used; feelings about self and body image;
values; attitudes; needs; expectations; aspirations; behavior patterns; creative expressions;
needs; strengths; limits).

3.   Developmental (degree of apparent normalcy; apparent stage of behavior and coping or
defensive mechanisms; past learning history; perception of environment and family values;
goals and ideas and the influence of these; how current level of functioning and life-style
relate to culture or ethnicity; age, and sex of person).

4.  Social (super ego functions; behavior or socialization pattern; use of language and
communications skills; activities of daily living; perception of relations to others; value
system; customs; taboos or superstitions; understanding of own roles and roles of others).

5.  Interpersonal factors (family structures; relationship with family, friends and others;
communication ability; socialization level; expectations of family, friends, care-givers and      
others in present situation; ability to anticipate consequences of behavior; resources).

6.   Extra-personal factors (cultural factors; social class level; occupation; work related resources; environmental or work related stresses; residence and geographical location; financial resources; relationship to community; community resources; effective of time of day,
temperature and weather on behavior; use of space and privacy).

B.    Recommendations:
Short-term goals:                   Long-term goals:

*This tool could be adapted by the nurse who is working in the home health agency.

ATTITUDES TOWARD AGING

Communicating with an elderly patient may challenge you to confront your personal attitudes and prejudices about aging.  Examine these feelings before taking the patient’s history, and decide in advance how you will handle them.  Any prejudices you reveal will probably interfere with your efforts to communicate, since elderly patients are especially sensitive to others’ reactions and can easily detect negative attitudes and impatience.

Then consider your patient’s attitude toward his or her body and health.  An elderly patient may have a distorted perception of his or her health problems; may dwell on them needlessly or dismiss them as normal signs of aging.  A patient may ignore a serious problem because he or she doesn’t want these fears confirmed.  If your patient is seriously ill, the subjects of dying and death may arise during the health history interview.  Listen carefully to any remarks your patient makes about dying.  Be sure to ask about his religious affiliation and spiritual needs.  Many elderly patients find comfort in their religious beliefs and practices.  You should also inquire tactfully about the matter of a living will (Health Assessment Handbook 1992).

THE NEED FOR PATIENCE

Patience is the key to communicating with an elderly patient.  He or she may respond slowly to your questions.  Do not confuse patience with patronizing behavior.  Your patient will easily perceive such behavior and may interpret it as a lack of genuine concern for him or her.  Keep your questions concise, rephrase those he/she doesn’t understand and use non-verbal techniques in a meaningful way.

To further foster your elderly patient’s cooperation, take a little extra time to help him or her see the relevance of your questions.  You may need to repeat this explanation several times as the interview progresses.  However, do not repeat questions unnecessarily.  Ask only for information that is relevant to the condition.  For example, you would not obtain a detailed obstetric history from a 75 year old woman who does not have a gynecological problem.

Once you have obtained an elderly patient’s cooperation, you may have some trouble getting him or her to keep the story brief.  He or she has a great deal of history to relate and may reminisce during the interview.  Try to find time for this.  Let the patient talk.  You may obtain valuable clues about the current physical, mental and spiritual health.  If you must keep the history brief, let him or her know prior to beginning the interview.  Let him or her know the exact time limits.  Offer to come back at another time in order to chat with him or her informally (Health Assessment handbook 1987).

THE ELDERLY PATIENT’S PAST HISTORY

Pay special attention to your elderly patient’s medication history.  He or she is probably taking some type of medication routinely.  Find out the names of all current and past medications whether over-the-counter or prescription drugs.  Find out the dosage and frequency of each drug and the purpose for taking the drug.  Ask to see a sample of each drug, if possible, (Health Assessment Handbook 1987).

THE ELDERLY PATIENT’S PHYCHOLOGICAL HISTORY

If your patient does not have a family or any friends on whom he/she can depend for support, record this in the psychological history for possible later referral of the patient to a social worker.  Record the names of the next of kin.  Without your intervention here, loneliness may discourage the elderly patient from getting well.

If your patient is employed, inquire about his or her job in order to find out if the current health problems will interfere with their return to work.  Talk with the patient concerning plans for retirement.  If they have any such plans, also explore their attitudes toward the retirement phase of life.

If your patient expresses financial concerns, explore them further in a financial history.  Remember to ask your elderly patient if he or she receives any pensions or Social Security payments.

When appropriate, inquire about the patient’s sex life.  Do not ignore it because of a patient’s age.  Approach this aspect of the psychosocial history with the same sensitivity and respect for privacy that you would show with younger patients.  If the patient is reluctant to discuss this part of their life, do not press for the information.

GERIATRIC ACTIVITIES OF DAILY LIVING

Your geriatric patient’s activities of daily living may affect his/her health.  In turn, his/her health problems may threaten his/her independence.  Ask him/her to describe a typical day at home.  Have them include activities, sleep patterns and eating habits (Table I).  His/her eating habits may suggest other significant lines of questioning.  Find out how much of an appetite he/she usually has.  Find out how they prepare food and how much fluid is normally consumed.  You can put this information into a chart showing which foods the patient eats at which times during the day.

Ask about matters related to the patient’s mobility.  Is he/she able to move around at home easily and safely?  Can he/she supply the basic needs; food, clothing and shelter?  Does he/she drive to the supermarket or does a friend drive them?  Does he/she use public transportation?  Ask if he/she expects to be able to continue with his/her normal routine after discharge from the hospital.  If necessary, consult with a social worker to discuss what you have learned about the patient’s activities of daily living (Health Assessment Handbook 1987)

Geriatric care is hindered by disabilities often associated with the elderly client.  The elderly person is much less likely to report legitimate symptoms of disease in its early stages.  This is a phenomenon that has been noted by many authorities.  For whatever reasons, the elderly tend to wait until the disease has progressed until the symptoms are reported and they seek help.  Even in countries that have completely free medical care, under-reporting is prevalent in the elderly.

Frequently found problems in the elderly are decompensated heart failure, correctable hearing problems, correctable vision problems, active tuberculosis, severe anemia, chronic respiratory insufficiency, uncontrolled diabetes, foot disease, dementia, depression and others.  The following reasons are common reasons that these conditions are under-reported:  (1) The stigma of reporting disease as a further sign of old age.  (2) Due to depression the person is not interested in returning to optimal heath.  (3) They are often afraid that they will lose their independence if they report conditions.  (4) Intellectual lose in old age could also be a reason for not reporting.  Our health care system relies on people reporting symptoms and seeking treatment.  When the elderly do not report illnesses, it only compounds their overall medical condition.

TABLE I                GERIATRIC ACTIVITIES OF DAILY LIVING

When questioning elderly patients about daily activities, use general questions that will elicit his/her usual habits and whether he/she has problems performing them.  Elderly patients may also have personal concerns, financial or transportation problems that keep him/her from his/her daily routine.  Structure your questions as outlined here.

DIET OR ELIMINATION
What do you eat on a typical day?
Do you feel hungry between meals?
Do you prepare your own meals?
With whom do you eat?
What types of food do you enjoy most?
Do you have any problems eating?
Have you noted any changes in your sense of taste?
Do you snack?  When are your snack times?
What do you usually eat for a snack?
What are your usual bowel habits?
Have you noticed any recent changes in your bowel habits?

EXERCISE/SLEEP
Do you take daily walks?
Do you do your own housework?
Do you have any difficulty moving about?
Has your doctor recently restricted your exercise?
Has your doctor recommended any special exercise programs?
What time to you go to bed at night?
What time to you awaken?
Do you follow any routines that help you sleep?
Do you sleep soundly or wake often?
Do you take a nap during the day?  If so, how long?

RECREATION
Do you belong to social groups such as seniors’ clubs or church groups?
What do you enjoy doing in your leisure time?
How many hours a day to you watch television?
Do you share leisure time with your family?

TOBACCO/ALCOHOL
Do you use tobacco?  If so, do you smoke cigarettes, cigars, pipe?
How long have you smoked?  How much do you smoke each day?
If you quit smoking, when did you quit?
Do you drink alcohol?  How often and how much do you drink?
Do you drink alone or with friends?  Has drinking increased lately?

PERSONAL CONCERNS
Do you wear dentures?  Are they a hindrance when you eat or talk?
Do you wear glasses?
Do you have problems with your vision when you wear your glasses?
Do you hear those around you with no difficulty?
Does poor hearing hinder any of your activities?
What is your source of income?
Do you shop for your own groceries?  If not, who does this for you?

Next: Chapter III PHYSICAL ASSESSMENT AND RECORDING THE FINDINGS