Health Assessment and Screening in the Older Adult

Performing health assessments and health screenings provide information about a patient’s health status and identify those in need of further assessment and care. As the nurse caring for older adult patients, you’ll use this information to provide patient-centered care.

Now, during a health assessment, you’ll collect comprehensive health information, which typically includes gathering a health history and conducting a physical examination. Health information can be categorized as either subjective or objective data. Subjective data refers to information the patient states or recounts, such as pain level or sleep quality, and tends to be obtained during a health history. On the other hand, objective data is collected during the physical assessment, and includes tangible information that’s observed or measured, like presence of a skin rash or blood pressure readings.

Alright, starting with health history, this is where you’ll interview your patient to obtain subjective data about their perceived health and factors impacting their health. Begin by asking about basic identifying information, like name and date of birth.

Next, move on to specific data like past medical and surgical history, such as previous hospitalizations and surgeries, current medications, and personal health habits like diet, physical activity, and sleep patterns.

Then you’ll discuss the patient’s current health status and any pressing health concerns, as needed. Keep in mind that the patient is the preferred information source; however, a family member or caregiver can provide information if your patient has limited ability to recall or communicate, like those with dementia or aphasia.

During the health history, remember to do your best to avoid the use of medical jargon. For example, instead of saying hypertension, say high blood pressure. Also, since word recall and response time can slow with age, be sure to speak slowly and clearly, and provide your patient with enough time to answer your questions.

Next up is the physical assessment, where you’ll use inspection, percussion, palpation, and auscultation to collect objective data about your patient’s health status, and validate subjective information gathered from the health history. Typically, the physical examination is conducted in a head-to-toe approach, meaning it starts with the head and then moves systematically down the body.

Now, before starting the examination, gather your assessment equipment and ensure the examination room is set up for privacy and comfort. Also, keep in mind that older adults may present with atypical signs and symptoms, such as confusion in the presence of an acute infection, or vague symptoms like fatigue and nausea rather than chest pain during a myocardial infarction.