Chapter I THE NURSING PROCESS AND
GERIATRIC ASSESSMENT
THE NURSING PROCESS
ASSESSMENT:
In the assessment process, data about the person, the family, the group, or the situation are obtained. This assessment is accomplished by means of astute observations and examination. Also used in assessment are: purposeful communication and the use of special skills and techniques. This data gathered by the nurse and other health team members can be used to gain a broader perspective about the elderly person. The objective and subjective data are critically analyzed, interrelated and interpreted through the use of inference, knowledge, personal or health care team experience, records and a variety of other sources as indicated. Nursing judgments are made based on this extensive assessment information (Beland 1975).
First level assessment is done on initial contact with the elderly person or family to determine the perceived health threat, the ability to adapt to the threat and immediate necessary actions. Second-level assessment continues throughout the time of contact with the person. It adds depth and breadth to understanding of physical, emotional, mental, spiritual, family, social, cultural characteristics and needs. This more comprehensive view of the person enables you to plan and give care better suited to the whole individual or situation (Bower 1972).
A nursing history form or assessment tool is an organized method of recording the information obtained in the first and second-level assessments. It is distinct from the medical history in that it focuses on the meaning of illness and health care to the person instead of primarily on pathology. The form serves as a guide to obtain information that does not repeat data collected by other health care team members, although it may include, aspects of the medical or social history that is pertinent to nursing care.
The nursing assessment including the nursing history provides a composite picture of the patient. Other health care team members may use this as an introduction to the patient.
Although the form used, and the kind of information collected must be adapted to your individual work setting and your clientele, Bower states that the nursing history should include the following information:
- Previous experience with illness, hospitalization, health agencies, nurses and nursing (also the meaning of these experiences).
- Intellectual understanding and interpretation of health problems, diagnostic regimen, treatment regimen, specific questions or concerns.
- Educational level and intellectual capacity.
- Language usage and communication pattern.
- Usual patterns of living, health, religion and recreation pursuits
- Occupational and social roles and responsibilities.
- Developmental status and level of behavior
- Usual behavior patterns in the presence of stress or crisis
- Close relationships with others; ability to help in this situation.
- Expectations, goals and needs related to health care.
The nursing history should also include daily preferences and idiosyncratic patterns of living. For example, many elderly persons drink prune juice or a glass of water on arising each morning. If this pattern is not continued after admission to the hospital or residence, the person may feel a sense of loss. He or she may become irritable or depressed. Adhering to their established pattern may promote their wellness, physically, and their feeling of being cared for. Such preferences, minor to us, can only be obtained through a carefully obtained nursing history.
You may think that obtaining a lengthy assessment and nursing history is too time-consuming and is impractical. However, it is a vital activity for the purpose of individualizing patient care. A nurse-patient relationship is begun during the assessment process. Assessment conveys interest and concern to the patient. It also establishes a sense of trust from the patient. A nursing diagnosis and realistic care objectives cannot be formulated without information obtained in a nursing history or without patient involvement.
In addition, the last step of the nursing process evaluation will be difficult to complete unless there is baseline patient data. Every nursing unit should have a formal guide for performing a nursing assessment and history. All of the nurses should be involved in the development of the tool. Development of the assessment and history tool includes trial usage and revisions so that the tool will be useful in daily practice. (See assessment guide at the end of this section.)
Good communications skills will help you to obtain assessment and nursing history data. Use open-ended statements. Indicate your observation of the senior’s behavior. Indicate your level of understanding of their implied communication. Silence may also be therapeutic. Let the senior elaborate on answers. Be attentive to the non-verbal communication and its possible meaning(s).
These behaviors on the part of the nurse can help to add to the total amount of information gathered in the interview process. Do not ask a barrage of direct questions. Many direct and pointed questions will tend to stifle the senior’s expression, resulting in superficial and brief answers. The interviewer who is too active obtains less pertinent data. An assessment tool is not meant to be used as a probe.
Ask questions related to what the senior is saying in order to fill in the gaps of needed information. In this way, you may obtain information that was not anticipated, but might turn out to be significant. Some information might better be collected by direct observation of the senior. Information such as their interpretation of reality might be observed. Their ability to abstract might be observed in real-life situations. You will probably not be able to fill in all the spaces on the form on the first interview with the client or the family. You will probably get more accurate information if you use the assessment tool as a guide over a period of several visits.
In several visits, you will be better able to determine patterns of behavior and the usual health-illness status of the senior. Drawing conclusions on the first interview data may not be very accurate. Several interviews will add reliability and completeness to the data collected. In addition, the more skillful you are as a communicator, the more reliable your data will be as the basis for continued care.
Cultural Perspectives on Aging (Gioiella 1985)
Black Americans
There are several different cultural groups represented with Black Americans. The population descended from Africans brought to the U.S. as slaves is different from the more recent immigrants from Africa and the Caribbean Islands. Not all studies differentiate among these groups. In general, the Black American reports more illnesses than White Americans and puts off getting care, especially care of the teeth and eyes. The Black American equates health or wellness with being able to labor productively.
A study of dietary patterns of urban elderly revealed that Blacks had significantly poorer nutrition. Males had a significantly poorer diet than females regardless of race. The same researchers found that even though elderly Blacks had poorer nutrition and lower income than elderly Whites, they found no differences in life-satisfaction. Both groups (and elderly Mexican-Americans) reported the same satisfaction with their lives.
Another study on physical function in White and Black elderly revealed that Blacks had greater decreases in mobility and self-care capacity than Whites. Black women had more limitations than Black men. Blacks also had twice as much time spent in bed due to illness than the White elderly subjects.
Hispanics
This cultural group includes both Mexican-Americans and Puerto Ricans. Many values and beliefs are similar in both cultures. Some Hispanics view illness as having social, spiritual and physical origins and wellness as a holistic balance and equilibrium between the individual and the universe. Illness may be due to fright, a punishment, or supernatural influences. Rituals, prayers and magic to deal with the evil eye are used in healing by the espiritualista or the curandero.
The Hispanic may also use herbs, massage and warm baths to restore balance between hot and cold, dry and moist. Illnesses, foods and treatments are described as hot, cold, or moist and must be combined appropriately by the caregiver.
The Grandparent or Godparent roll is important in the Hispanic culture and often is an important role for the elderly family member. The extended family is also more common in this group, although, erosion of this family structure is a growing phenomenon in younger generations of Hispanics.
Chinese-Americans
The Chinese and to some degree, other Asians, have a system of beliefs about health, illness and the practice of medicine that differs greatly from Western beliefs and practices. Emphasis in the East is on prevention, maintaining a balance between energy systems in the body, the Yang and the Yin.
The Chinese have their own diagnostic techniques, avoid intrusive procedures that they believe affect the wholeness of the system and avoid drawing blood if possible. Herbs, acupuncture, meditation, massage and diet are all used to treat illness. Healers play an important role in health care.
The elderly have an important role and great respect in Asian cultures. Children are expected to care for their elders. Some of this tradition is present in Asian immigrants in the United States. However, the elderly may expect more than their more westernized children or grandchildren are prepared to give.
Native Americans
Health beliefs and practices of Native Americans vary from tribe to tribe. Healers are important in many, especially if the tribe relates illness to evil spirits. In general, Native Americans believe that health is God-given and reflects living in harmony with the universe. Many traditional treatments including diet, massage, herbs and rituals are used.
In some Native American tribes the elderly are considered a source of wisdom for the younger generation. Direct questioning or asking the individual to repeat information is considered a mark of disrespect.
White Ethnic Americans
Very little is known about the health beliefs and practices of the elderly who continue to identify with Irish, Italian, Polish, German or other European cultures. Cross-cultural studies do reveal differences in expression of pain, differences in diet, differences in life-style and differences in perception of importance of certain symptoms. Another study looked at the use of formal social support systems by white ethnic aged. It found that use in this group was generally low. Family, friends and church groups were more likely to be used for assistance.
Implications of Culture
Many clients may retain folk health practices as links to their cultural heritage in an effort to maintain identity. Most nurses in the U.S. are socialized into the scientific model of health care. A conflict of beliefs and practices may, therefore, arise between client and nurse. Certainly nurses should not abandon their own respect for science; however, respect for the alternative healing methods and traditional health practices should be maintained.
To overcome cultural barriers to health care, use of ethnic providers, ethnic organizations, native languages and foods should be considered by the nurse in providing care.
STATEMENT OF NURSING DIAGNOSIS:
Once a sufficient amount of information has been collected, the information can be analyzed and interpreted. Next, the nurse can formulate an explicit statement about the presenting problem or unmet needs. These unmet needs can then be addressed by nursing care.
The term diagnosis means to state a decision or opinion after careful examination and analysis of facts in a situation or condition. The term diagnosis is not limited to medical conditions. The Nursing Diagnosis is a description of behavior at variance with the desired state of health, a commonly recurring condition. It also means unmet needs that interfere with health and adaption, or the present or anticipated problem or difficulty experienced by the person or family which is amenable to nursing intervention.
The diagnostic statement or label provides a guideline for intervention and indicates prognosis, potential, or desired outcome (Murray 1980). Nursing diagnoses do not label medical entities. They refer to conditions that can be helped by nursing action. Nursing diagnoses that may be applicable to the psychological and physical status of the elderly are listed next in this section.
Nursing Diagnoses applicable to the psychological and physical status:
- Anxiety or agitation
- Confusion
- Emotional or social deprivation
- Disengagement
- Mourning
- Impaired adjustment to crisis, stress or the aging process
- Maladaptive family process
- Altered level of consciousness (lethargy, stupor, coma)
- Lack of understanding
- Non-compliance with treatment
- Pain
- Altered ability to perform activities of daily living (self care)
- Impaired mobility
- Impaired nutrition-hydration status
- Impaired integrity of the skin
- Impaired sensory processes (blindness, deafness, paresthesias)
- Negative self-concept
- Impaired verbal communication (aphasic, mute, asocial)
- Suspicion
- Withdrawal
- Insomnia
INTERVENTION
Intervention refers to all of the actions that you engage in, as well as the approach you use, to promote the patient’s well-being.
Intervention includes:
- Verbal and nonverbal communications.
- Aid recovery of the client.
- Your approach and reactions to the person as you promote and maintain biopsychosocial health.
- Visible actions.
- Comfort, protection, enhanced stability.
Intervention occurs when you prevent harm or further dysfunction or assist the senior to function as effectively as possible within the limits imposed by his condition. Many tasks done unwittingly are nursing interventions and should be defined as such to the patient. The scientific rational for performing the nursing activity should also be explained to the person or family. Nursing interventions with the elderly or family include:
- Giving sickness care including intensive care or daily care such as feeding, bathing, range of motion, turning.
- Enabling the senior to perform his or her own hygiene and grooming.
- Implementing medical procedures and treatments as ordered by the physician.
- Encouraging the senior to use energy-saving devices.
- Adapting procedures or techniques to the home situation.
- Encouraging a regimen of activity or rehabilitation to reduce disengagement.
- Maintaining communication with the senior, for example, by listening to him reminisce.
- Reduce sensory and emotional immobility, i.e., visiting with an elderly couple or bring them a bouquet of flowers.
- Meeting spiritual needs by calling the minister, read passage from the Bible, say a prayer at their request.
- Maintaining communication with the family or significant others.
- Teaching and counseling the person or family to help them become more adaptive or independent.
- Reducing anxiety by being supportive and available to the person and family experiencing death.
- Referring the elderly person or family to health, social and welfare agencies as indicated.
The list could go on and on. Through nursing interventions, you help the person or family meet the needs that cannot be met by the self.
To summarize, nursing interventions include:
- Helping the person/family cope with actual or potential stressor.
- Eliminating a source of stress.
- Helping the senior develop new behavior, strengthen an existing one or modify or diminish a present behavior.
- Supporting the senior in his or her present behavior.
- Preventing further injury or complications.
- Manipulating the environment to promote adaption (Bower 1972).
The elderly person may have many needs to be met – physical, social, emotion and spiritual. Often the following basic needs are overlooked. However, they can be met with little extra effort on the part of the nurse. Remember that the elderly person desires to:
- Be recognized as a person and not regarded as a room number, a disease, a problem, “grandma”, or less of a person because of age.
- Be listened to
- Be comforted, to have distress recognized, perceive that health care workers are making efforts to make him or her physically and emotionally comfortable; the aged person can tolerate pain if he or she is not being neglected.
- Be remembered: The person fears being overlooked and forgotten.
- Learn what is causing health problems or distress in terminology that he or she can understand.
- Know what treatment and care is planned, length of treatment and what can be expected as an end result.
- Receive quality care.
- Have some self-determination about what activities he or she will take part in so long as he or she does not injure self or others.
Family members of the patient often have basic needs that are overlooked. The family members may also be aged. However, they deserve the same consideration as the patient. They should not be treated as infants or as incompetents. Family members also need to be comforted emotionally, and sometimes physically, when they feel guilty or worried.
The family needs to be informed as fully as possible about the situation and expected results of the treatment and care. Family members also need encouragement and support as they encounter the stress of illness in the loved one and work to restore and maintain well-being and prevent further complications in the patient.
Intervention includes the INDEPENDENT FUNCTIONS of:
- Doing all hygiene and comfort measures.
- Planning and creating an environment conducive to wholeness and safety from injury and risk.
- Teaching and counseling, either formally or informally.
- Offering of self to impart strength and courage to another as he or she copes with problems.
- Socializing in a purposeful manner.
- Making a referral to another agency when indicated.
Intervention includes the DEPENDENT FUNCTIONS of:
- Doing all the ministrations or procedures that implement the medical regimen outlined by the physician.
- Doing all the ministrations or procedures that implement the regimen by other health care team members.
Intervention also includes:
- Coordinating care given by other health team members.
- Collaborating with others to provide continuity of care.
- Directing others, including the family, to give care to the elderly person.
Bower classifies intervention into three nursing actions:
- Supportive
- Generative
- Protective
Supportive nursing actions provide comfort, treatment and restoration. These measures augment the person’s present adaptive capacity, help him or her cope more effectively with stress and prevent further health problems. In addition, supportive interventions maximize the person’s or family’s strengths and provide guidance, encouragement or relief to enable the person to regain health.
Generative nursing actions are innovative and rehabilitative. They help the person or family develop different approaches to coping with stress or crisis and are especially used when assisting another with struggles involved in roll changes or identity crisis.
Protective nursing actions are measures that promote health and prevent disease. They improve or correct situations. Examples are immunizations, health teaching or anticipatory guidance; or preventing complications and disease sequelae (Bower 1972).
Next: Chapter II: THE NURSING PROCESS AND GERIATRIC ASSESSMENT CONTINUED |