When doing an overall assessment of a patient, the nurse is able to utilize findings and do what?

Assessment tools cannot substitute for good clinical skills and judgements. As clinicians we need to be aware that assessment tools can tell us more than just a score.

Assessment involves collecting information that gets to know the patient in detail, evaluates their risks and the nature of problems to be identified.

Assessment should integrate all the relevant issues. It should explore the medical, physiological, social and psychological function of the older person.

The assessment process encourages us to be curious and to consider the best possible interventions that we can employ to minimise risks and maximise our patient’s quality of life. This can ultimately involve balancing some risks with some gains and working with our team and the older person and their family to make an informed choice about this.

Assessment supports us to:

• treat the condition that caused the admission (such as shortness of breath)
• detect and quantify additional conditions or psychosocial issues that contribute to or complicate the admission and respond to them as able both during the admission and when planning for discharge. For example
  • depression - consider if the person needs a medical review
  • poor nutrition - consider what can be done to optimise the person’s intake
  • social isolation, or risk of loneliness - consider how you can encourage the person to participate in their care by harnessing their personal and social connections, and consider linking them to supports that are meaningful to them on discharge
• use strategies to prevent conditions that often emerge during hospital stays but can be avoided (such as delirium and falls).

We can gather information as part of the assessment process from multiple sources, and these may vary at the stages of a hospital admission.

The four main sources of information are:

1. Older people themselves - self report.
2. Others who know the older person well - informant report.
3. Observation of the person undertaking various activities - direct observation.
4. Various secondary written or verbal sources - including hospital records, medical reports, investigation results, communication from community care providers.

Unless there are reasons to suspect otherwise the older person is considered the best source of information about their own health1. Direct observation is the best source of information about physical function; however, we should consider how the environment or setting where observations take place may impact on the older person’s performance.

Assessment tools can be focussed on exploring one particular condition such as pain, pressure injury or nutrition. They can also be more comprehensive and encompass a broader focus beyond one particular issue. Examples of these types of tools include:

• InterRAI Comprehensive Assessment Tool: Acute
• Systematic Evaluation and Intervention for Seniors At Risk (SEISAR) - a short, standardised, comprehensive tool for the evaluation of active geriatric problems in seniors in the emergency department.

The assessment tool or scale should enable collection of useful patient data that supports interpretation of the holistic health status, identifies patient needs, and informs care planning and interventions to restore health and wellbeing.

Selecting an assessment tool

Consider the following factors when selecting an assessment tool include:

• A standardised tool can reduce variation in practices and interpretation of findings and allow comparison across assessments.
• A validated assessment tool ensures the right data is captured to evaluate the patient and their progress.
• Is a specific tools mandated for specific circumstances or settings? See the individual topics for examples.
• Does the tool cater for cultural or language differences?
• Is the tool appropriate for the physiology of ageing?

The format used will also depend on the discipline, skill and expertise of the clinician, the context and setting of the assessment, the time available and the number of assessors involved. The assessment can be:

• unstructured – if the professional expertise of the assessor is high
• semi-structured – incorporates specific tools and checklists
• structured and standardised – using global assessment instruments.

Comprehensive Geriatric Assessment

There is no gold standard for assessment of older people; however, a Comprehensive Geriatric Assessment is highly recommended to understand the multidimensional complex care needs of frail older people and to determine both short and long term care needs.

A Comprehensive Geriatric Assessment can be undertaken by any member of the interdisciplinary healthcare team who has the required knowledge and skills. Multiple team members with specific skills may need to be involved depending on the patient’s needs.

Ideally, the assessment should be completed within the patient’s first 24 hours in hospital and communicated to all team members, the patient and informal carers.

Conducting assessments

We also need to be aware of the following when conducting assessments of older people:

• At all times, it is vital that we maintain an understanding the older person’s perspective.
• In acute hospital settings, circumstances may mean older people are not able or willing to be actively involved when health professionals assess them.
• Older people may take more time to complete tools than younger people, so allow for rests during formal assessments.
• Ensure that any needs for communication assistances are met. These may include use of interpreters, ensuring the older person is wearing their glasses and/or hearing aids if they are used routinely.
• Do not assume older people know why they are being assessed. Explain why certain questions or tests are being undertaken.
• Establish cognitive status as early as possible in an assessment. Do not assume older people are able to hear, comprehend what is said or are capable of accurate, intelligible responses (for example if they are acutely unwell).
• Note that appearing ‘flat’, minimal eye contact and being non-committal responses may indicate depressive symptoms are present. Depressed older people can give the appearance of being cognitively impaired.
• Consider the need for an interpreter for those with limited English proficiency. The interpreter can also assist with cultural care delivery.
• Consider specific cultural issues and seek assistance necessary from cultural liaison officers or Indigenous health workers.

Applying clinical skills to assessment

Good clinical skills, observation, listening, interpreting and clinical judgement are all vital in decision-making.

When we assess older patients, we use tools and draw on our clinical reasoning skills. The reasoning cycle2 sets out the elements of effective clinical decision-making:

• Consider the patient situation
• Collect cues and information – through observation, questions
• Process the information – what does it mean?
• Identify problems and issues – what does the information indicate?
• Establish goals – what actions need to be taken?
• Take actions
• Evaluate outcomes
• Reflect on process and new learning.

1. Levett-Jones, T. (2013). Clinical Reasoning: Learning to think like a nurse. Frenchs Forest: Pearson Australia

2. Dorevitch 2004 p 229 in Nay, R., Garratt, S., & Fetherstonhaugh, D. (2013). Older People: Issues and Innovations in Care (4th ed.). Australia: Churchill Livingstone Australia

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If you are a nurse, you know that a comprehensive patient health assessment is an important first step in developing a plan to deliver the best patient care. Health assessments are a key part of a nurse's role and responsibility. The assessment is a tool to learn about your patient's concerns, symptoms and overall health.

"It is a critical step because this is where comprehensive data including physiological, psychological, socioeconomic, social determinants of health, spiritual and lifestyle information is gathered to help determine nursing diagnoses, which are used to develop nursing care plans that aim to improve health outcomes," says U.S. Public Health Service Commander Derrick Wyatt, MSN, RN-BC, a health scientist administrator for the Agency for Healthcare Research and Quality (AHRQ).

During the assessment, nurses may notice signs of potential or underlying health issues that need to be addressed, as well.

"I am reminded of how law enforcement officers gather detailed information using interviews, physical evidence and observations to help solve cases. Nurses use the information gathered during the comprehensive health assessment to achieve similar goals for solving complex problems with the interdisciplinary team," says Wyatt.

There are many components to a comprehensive health assessment. Before beginning the assessment, nurses should try to develop a rapport with their patients, introducing themselves, explaining what they will be doing during the assessment, and why. Depending on the setting or reason for the visit, the patient may be anxious, and establishing a rapport can help put the person at ease. Social, cultural and behavioral factors influencing the patient's health are also important to keep in mind.

A comprehensive health assessment usually begins with a health history, which includes information about the patient's past illnesses or injuries (including childhood illnesses and immunizations), hospitalizations, surgeries, allergies and chronic illnesses. It also includes finding out about diseases that run in the patient's family.

During the health history component of an assessment, the patient is asked to describe his or her symptoms, when they started, and how they developed before moving on to the physical exam. The physical exam begins with a complete set of vital signs (blood pressure, heart rate, respiratory rate and temperature).

With the increase in chronic conditions and the growing elderly population, learning how to be in tune with unique patient characteristics is an important component of an RN to BSN program.

Wyatt says the approach to conducting a comprehensive health assessment will remain the same no matter the age or health status of a patient; however, "It is essential for students to understand and address nuances when conducting assessments on different populations, such as pediatric and geriatric patients or with patients with specific disease processes and family dynamics."

Once the comprehensive health assessment has been performed, the next step is to put all of the information together, analyzing the objective and subjective data and developing a care plan. Those critical thinking skills are part of the training for a BSN degree, and they will be needed more than ever in the future.

"I think complex medical conditions, the shift to value-based care, and the industry changing to a proactive care model, will place an emphasis on health assessments to identify opportunities to screen for preventative care and promote healthier lifestyles in the elderly population." says Wyatt.

The online program that Texas A&M International University (TAMIU) offers is affordable, flexible, and designed to deepen your knowledge and skills to conduct comprehensive health assessments through the life span for patients of different ages and with specific health conditions. The ACEN-accredited program at TAMIU also covers nursing research, cultural determinants of health behavior, nursing history, global health nursing, community nursing and more.

The RN to BSN curriculum also helps nurses advance to leadership roles and sharpen their skills in critical thinking, effective communication, ethical and legal handling of issues, conflict resolution, quality improvement, and change initiation.

Learn more about TAMIU's online RN to BSN program.

Sources:

Nurse.org: How to Conduct a Head-to-Toe Assessment

University of New England Center for Excellence: Center for Excellence in Health Innovation

Agency for Healthcare Research and Quality (AHRQ)

Derrick Wyatt, MSN, RN-BC, health science administrator for AHRQ (email interview Nov. 30, 2018)

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