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Geriatric Assessment Skills for Nurses

This document outlines essential skills for nurses in assessing geriatric patients, including obtaining a health history through interviewing the patient and family members, assessing various body systems like skin, hair, nails, head and neck, vision and hearing, and the musculoskeletal system. It emphasizes evaluating the patient's functional status using tools like the Katz Index of Activities of Daily Living or Barthel Index, as well as assessing fall risk using the Morse Fall Scale or Tinetti Gait and Balance Assessment.

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MIKE ANDERSEN
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91 views13 pages

Geriatric Assessment Skills for Nurses

This document outlines essential skills for nurses in assessing geriatric patients, including obtaining a health history through interviewing the patient and family members, assessing various body systems like skin, hair, nails, head and neck, vision and hearing, and the musculoskeletal system. It emphasizes evaluating the patient's functional status using tools like the Katz Index of Activities of Daily Living or Barthel Index, as well as assessing fall risk using the Morse Fall Scale or Tinetti Gait and Balance Assessment.

Uploaded by

MIKE ANDERSEN
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
  • Geriatric Assessment
  • Obtaining the Health History
  • Interviewing the Geriatric Patient
  • Assessing the Skin
  • Assessing the Hair and Nails
  • Assessing the Head and Neck
  • Assessing the Face
  • Assessing Vision and Hearing
  • Musculoskeletal System and Functional Status
  • Evaluating the Patient's Fall Risk
  • Assessment Tools
  • Selected References

Geriatric

assessment
ESSENTIAL SKILLS FOR NURSES
Obtaining the Health History

interview the patient


(and family members,
if needed)
Interviewing the Geriatric Patient

minimize explain the


distractions and reason for the
speak clearly interview

CHIEF
HEALTH HISTORY
COMPLAINT- ask
- includes both
why the patient
current and past
is seeking health
health status
care ; Use PQRST
Assessing the skin

Inspect the skin for


lesions and moles.

Check for pressure


ulcers.
Assessing the hair and nails

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,

yellow or brown nails - may signal a fungal infection.


Assessing the Head and neck
Note the general size and shape of the patient’s
head; are they appropriate to body size?

Observe for Limited range of motion (ROM)

stay alert for reports of pain or dizziness or jerky or


abnormal movements
Assessing the face

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.
Assessing Vision and Hearing

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.

Encourage adults to get annual eye exams.

Hearing loss is common in older adults and usually


affects both ears.
Musculoskeletal system and
functional status

Investigate for abnormalities suggested by the health history data

Evaluate muscle groups

ROM tests in older adults are similar to those used in other age-groups.

However, inflamed joints may limit ROM in older adults.

Note warmth, swelling, tenderness, crepitus, and deformities.


Musculoskeletal system and
functional status

Assess the patient’s ability to


perform activities of daily living
(ADLs)

Use Katz Index of independence


in ADLs or the Barthel Index for
functional evaluation.
Evaluating the patient’s fall risk

Conditions such as
osteoporosis

Morse Fall Scale or Tinetti Gait


and Balance Assessment.
Selected references:
 Conroy S. Emergency room geriatric assessment—urgent, important or both? Age
Ageing. 2008;37(6):612-613.
 Gallo JJ, Fulmer T, Paveza GJ, Reichel W. Functional assessment. In: Gallo JJ, Bogner
HR, Fulmer T, Paveza GJ, eds. Handbook of Geriatric Assessment. Sudbury, MA: Jones
& Bartlett; 2000:109-110.
 Hauer KA, Kempen GI, Schwenk M, et al. Validity and sensitivity to change of the Falls
Efficacy Scales International to assess fear of falling in older adults with and without
cognitive impairment. Gerontology. 2010;22:1-11.
 Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffee MW. Studies of illness in the aged.
The index of ADL: a standardized measure of biological and psychosocial
function. JAMA. 1963;185:914-919.
 Linos E, Swetter SM, Cockburn MG, Colditz GA, Clarke A. Increasing burden of
melanoma in the United States. J Invest Dermatol. 2009;129(7):1666-1674.
 Lyder CH, Ayello EA. Pressure ulcers: a patient safety Issue. In: Hughes RG, ed. Patient
Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency
for Healthcare Research and Quality; 2008.
 Mauk KL. Gerontological Nursing: Competencies for Care. 2nd ed. Sudbury, MA:
Jones & Bartlett; 2009.

Geriatric assessment ESSENTIAL SKILLS FOR NURSES
Obtaining the Health History interview the patient (and family members, if needed)
Interviewing the Geriatric Patient minimize distractions and speak clearly explain the reason for the interview HEALTH HI
Assessing the skin Inspect the skin for lesions and moles. Check for pressure ulcers.
Assessing the hair and nails Note their color, length, and cleanliness. Check for abnormalities. For instance: clubbing - may
Assessing the Head and neck Note the general size and shape of the patient’s head; are they appropriate to body size? Observ
Assessing the face Note whether the patient’s eyes, eyebrows, nose, and mouth are centered and symmetrical. Asymmetrical f
Assessing Vision and Hearing Vision can deteriorate with age. Older adults should have 20/40 vision or better. Such conditio
Musculoskeletal system and functional status Investigate for abnormalities suggested by the health history data Evaluate mus
Musculoskeletal system and functional status Assess the patient’s ability to perform activities of daily living (ADLs) Use

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