report-nsg process of older adult
TRANSCRIPT
-
8/8/2019 Report-nsg Process of Older Adult
1/71
NURSING PROCESS
and the OLDERADULT
-
8/8/2019 Report-nsg Process of Older Adult
2/71
A. Special AssessmentGuidelines for Elderlyof Older Adults
-
8/8/2019 Report-nsg Process of Older Adult
3/71
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.
-
8/8/2019 Report-nsg Process of Older Adult
4/71
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
-
8/8/2019 Report-nsg Process of Older Adult
5/71
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
-
8/8/2019 Report-nsg Process of Older Adult
6/71
Health Assessments
Subjective data
Information gathered from the older
persons point of view
Best described in the individuals own
words
-
8/8/2019 Report-nsg Process of Older Adult
7/71
INTERVIEWING
OLDER ADULTS
-
8/8/2019 Report-nsg Process of Older Adult
8/71
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.
-
8/8/2019 Report-nsg Process of Older Adult
9/71
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
-
8/8/2019 Report-nsg Process of Older Adult
10/71
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
-
8/8/2019 Report-nsg Process of Older Adult
11/71
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
-
8/8/2019 Report-nsg Process of Older Adult
12/71
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
-
8/8/2019 Report-nsg Process of Older Adult
13/71
-
8/8/2019 Report-nsg Process of Older Adult
14/71
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
-
8/8/2019 Report-nsg Process of Older Adult
15/71
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
-
8/8/2019 Report-nsg Process of Older Adult
16/71
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
-
8/8/2019 Report-nsg Process of Older Adult
17/71
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.
-
8/8/2019 Report-nsg Process of Older Adult
18/71
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
-
8/8/2019 Report-nsg Process of Older Adult
19/71
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
-
8/8/2019 Report-nsg Process of Older Adult
20/71
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
-
8/8/2019 Report-nsg Process of Older Adult
21/71
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
-
8/8/2019 Report-nsg Process of Older Adult
22/71
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
-
8/8/2019 Report-nsg Process of Older Adult
23/71
PHYSICAL
ASSESSMENT OFTHE OLDERADULT
-
8/8/2019 Report-nsg Process of Older Adult
24/71
Inspection
The most commonly used method of
physical assessment in which the
senses of vision, smell, and hearing are
used to collect data
-
8/8/2019 Report-nsg Process of Older Adult
25/71
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
-
8/8/2019 Report-nsg Process of Older Adult
26/71
Palpation
Uses the sense of touch in the fingers
and hands to obtain data
-
8/8/2019 Report-nsg Process of Older Adult
27/71
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
-
8/8/2019 Report-nsg Process of Older Adult
28/71
Auscultation
Uses the sense of hearing to detect
sounds produced within the body
Heart, lung, and bowel sounds are
typically assessed using auscultation
-
8/8/2019 Report-nsg Process of Older Adult
29/71
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
-
8/8/2019 Report-nsg Process of Older Adult
30/71
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
-
8/8/2019 Report-nsg Process of Older Adult
31/71
ASSESSINGVITAL SIGNS INOLDER ADULTS
-
8/8/2019 Report-nsg Process of Older Adult
32/71
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
-
8/8/2019 Report-nsg Process of Older Adult
33/71
-
8/8/2019 Report-nsg Process of Older Adult
34/71
Temperature
Axillary route
Not generally used for older adults
Time-consuming; the accuracy of
temperature readings may be affected by
environmental conditions
-
8/8/2019 Report-nsg Process of Older Adult
35/71
Pulse
Position should be consistent (e.g.,
lying, sitting, standing) each time thepulse is checked
-
8/8/2019 Report-nsg Process of Older Adult
36/71
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
-
8/8/2019 Report-nsg Process of Older Adult
37/71
Figure 8-2; Page 136
-
8/8/2019 Report-nsg Process of Older Adult
38/71
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
-
8/8/2019 Report-nsg Process of Older Adult
39/71
Respirations
A range of 12 to 20 breaths per minute
is considered normal
Slightly irregular breathing rhythms are
not unusual in the aging population
-
8/8/2019 Report-nsg Process of Older Adult
40/71
Figure 8-3; Page 137
-
8/8/2019 Report-nsg Process of Older Adult
41/71
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
-
8/8/2019 Report-nsg Process of Older Adult
42/71
-
8/8/2019 Report-nsg Process of Older Adult
43/71
-
8/8/2019 Report-nsg Process of Older Adult
44/71
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)
-
8/8/2019 Report-nsg Process of Older Adult
45/71
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
-
8/8/2019 Report-nsg Process of Older Adult
46/71
PSYCHOSOCIAL
ASSESSMENT OFOLDER ADULTS
-
8/8/2019 Report-nsg Process of Older Adult
47/71
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
-
8/8/2019 Report-nsg Process of Older Adult
48/71
-
8/8/2019 Report-nsg Process of Older Adult
49/71
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
-
8/8/2019 Report-nsg Process of Older Adult
50/71
Minimum Data Set (MDS) 2.0
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
-
8/8/2019 Report-nsg Process of Older Adult
51/71
Minimum Data Set (MDS) 2.0
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
-
8/8/2019 Report-nsg Process of Older Adult
52/71
Figure 8-5; Pages 142-150
-
8/8/2019 Report-nsg Process of Older Adult
53/71
B. Nursing
Diagnosis
-
8/8/2019 Report-nsg Process of Older Adult
54/71
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.
-
8/8/2019 Report-nsg Process of Older Adult
55/71
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.
-
8/8/2019 Report-nsg Process of Older Adult
56/71
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
-
8/8/2019 Report-nsg Process of Older Adult
57/71
C. Outcome
Identificationand Planning
-
8/8/2019 Report-nsg Process of Older Adult
58/71
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
-
8/8/2019 Report-nsg Process of Older Adult
59/71
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.
-
8/8/2019 Report-nsg Process of Older Adult
60/71
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
-
8/8/2019 Report-nsg Process of Older Adult
61/71
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.
-
8/8/2019 Report-nsg Process of Older Adult
62/71
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.
-
8/8/2019 Report-nsg Process of Older Adult
63/71
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.
-
8/8/2019 Report-nsg Process of Older Adult
64/71
D. Implementation
-
8/8/2019 Report-nsg Process of Older Adult
65/71
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.
-
8/8/2019 Report-nsg Process of Older Adult
66/71
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.
-
8/8/2019 Report-nsg Process of Older Adult
67/71
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
-
8/8/2019 Report-nsg Process of Older Adult
68/71
E. Evaluation
-
8/8/2019 Report-nsg Process of Older Adult
69/71
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.
-
8/8/2019 Report-nsg Process of Older Adult
70/71
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.
-
8/8/2019 Report-nsg Process of Older Adult
71/71
The End
Thank You!