UNIT 3: Assessment & Documentation
Assessment of Older Adults
Assessment in older adults is more complex and detailed than in younger adults. It takes
longer, requires special skills, and must be paced according to the client’s stamina.
Key nursing approaches:
• Listen patiently and allow pauses
• Ask questions not often asked (sensitive but important topics)
• Obtain data from all sources (client, family, caregivers, records)
• Know normal vs abnormal aging changes (Review chart given in class)
Components of Comprehensive Geriatric Assessment
Assessment includes biological, psychosocial, functional, cultural, and spiritual data:
• Cognitive abilities and mood
• Psychological well-being (depression, anxiety)
• Caregiver stress or burden
• Health care utilization patterns
• Advanced care preferences
• Geriatric syndromes (falls, delirium, frailty, UI, sleep disorders, pressure injuries)
• Sexual function, STI risk
• Hearing loss, oral health, environmental safety
Collecting Assessment Data
Approaches include:
• Self-report
• Proxy report (family/caregiver)
• Observation of behavior, affect, and function
Evidence-Based Assessment Tools
Cognition tools:
• Mini-Mental State Examination (MMSE) – cognitive status
• Clock Drawing Test - dementia
• Mini-Cog (3-word recall + clock test)
• Global Deterioration Scale
, Mood tool:
• Geriatric Depression Scale (GDS)
Functional Assessment
Functional status determines independence and safety. Nurses assess both ADLs and IADLs.
ADLs (basic self-care): eating, toileting, bathing, dressing, grooming, ambulation.
IADLs (complex tasks): shopping, cooking, managing money, transportation, medication
management.
FANCAPES & SPICES Frameworks
FANCAPES for frail/complex clients:
• Fluids – state of hydration
• Aeration – respiratory function
• Nutrition – type/amount of food
• Communication - ability
• Activity – ability to meet basic needs
• Pain – physical, psychological, or spiritual
• Elimination – bladder or bowel
• Socialization – ability to give and receive love/friendship