Functional Assessment Of The Elderly

Aging Positively

Abstract

A functional assessment of the elderly involves a multi-dimensional diagnostic process designed to evaluate an elderly individual in terms of functional capabilities, disabilities, medical and psychological characteristics. These assessment tools provide objective data to detect potential impairments among our aging populations. With these tools we are able to evaluate how elderly individuals are aging, what assistance is need, how to make sure their environment are safe and their insight on what aging positively or successfully means.

M.B. is a sixty five year old Christian woman who is five feet and two inches tall and weighs one hundred and seventy pounds. M.B. was born in Aguilla, PR on July 13, 1947
and was the sixth child out of ten children. When M.B. was nine months old her father died. M.B. does not know why her biological father passed away. When she was two years old her mother remarried and had four more children with her new husband. M.B. and her family were not allowed to talk about her father due to respecting their step-father. M.B. also never met her paternal grandparents or family members because the step-father did not allow them to have contact. Her step-father was a landscaper and her mother was a housewife until 1986 when she died of a rupture peptic ulcer in her stomach.
M.B. married at the age of fifteen and bore six children with her husband. M.B. has five daughters and one son. Two of M.B. daughters are deaf-mute; one of them still resides with her. The other married a man that is deaf-mute and they bore two daughters, neither of their girls was born with any visual or hearing impairments. In 1973 M.B., her children and her husband left Puerto Rico and moved to Bethlehem, PA so that he can find better employment to support their family. Her husband worked at Bethlehem steel’s while she was a housewife. M.B. became a widow ten years ago; he died after his second stroke and had a history of hypertension and diabetes mellitus type 2. He was a smoker and enjoyed having a case of beer daily.
M.B.
states that while she was married she does not recall any enjoyment in her marriage. Her husband was very controlling, mentally and physically abusive. He did not allow her to obtain any form of education, M.B. only made it to six grade. He also did not allow her to work even after he was unable, due to his first stroke. M.B. also states that her love of GOD and her children is what kept her hopeful that life will get better. M.B. stated that life at first after her husband passing was difficult financially. She had to learn how to pay bills and become responsible in all aspect of finances. She was able to learn quickly due to her children who are grown, independent and supportive of her needs. M.B. lives on a fixed income that is provided by her husband social security benefits. Her daughter that resides with her helps her financially; with her social security benefits that she receives because she has a disability. M.B. has Pennsylvania state government health insurance that covers all of her medical and prescription
needs.
M.B. describes a typical day for the student nurse from the moment she wakes up to right before she falls asleep. M.B. gets up about 7:30 every morning. M.B. gets out of bed slowly to decrease the occurrence of postural hypotension. Postural hypotension is a decline in blood pressure when the older person changes position very quickly. It can occur when you go from lying down position to either sitting or standing position quickly. Postural hypotension can make you feel dizzy, lightheaded and may even faint. M.B. describes her symptoms as only feeling dizzy for less than three minutes if she changes position quickly, usually no treatment is required. Postural hypotension can be occurred due to side effects of antihypertensive agents, NSAIDs and other medications that affect blood pressure (Gulanick & Myers, 2007). Patients are usually taught to change positions slowly and increase water intake if not on a fluid restriction to decrease signs and symptoms of postural hypotension (Tabloski, 2010).
M.B. sits on the edge of the bed for a few minutes puts on her non-slip slippers and then makes her bed. M.B. states that she only has footwear that has slip resistance to decrease her risk of falls. M.B. does not have a recent history of falls but does recall falling once because she was pushed by her late husband and since then has a slight fear of falling and hurting herself. M.B. has carpet in her bedroom and is looking into having them removed and replaced with hardwood flooring. The student nurse suggested that this was a great idea to help decrease her risk for falls or injury. M.B. then goes into the bathroom which is next door to her bedroom; to use the toilet and brush her teeth. She then states she heads back to her room and sits by the window to read a passage from the bible. After reading the passage she states she feels refreshed to start her day. M.B. takes her clothes out of the closet and dresser drawers for the day and places them on bed before getting in the shower. M.B. does not have a walk in shower, no chair to sit down or support or grab bars to hold on to. M.B. tells the student nurse that one of her daughters did purchase grab bars but is waiting on her grandson to hang them up. She also mentioned that her son stated he is going to purchase a sliding shower chair when he comes down to visit. The student nurse then asked M.B. when her son was coming to visit and she state sometime in May. After her shower, M.B. gets dressed and combs her hair. M.B. denies any incontinence issues and any difficulties or limitations with self care.
M.B. states that she comes down to her main living area which is on the second floor around 8:30 a.m. M.B. has to walk down fifteen flight of uncarpeted and no non-skid step treads. M.B. resides in half a double three bedroom home in which her first floor is a laundry, sun and bathroom. Her main living area which consists of her kitchen, living and dining room is on the second floor. M.B. bedroom and second bathroom is on the third floor. The student nurse noticed that M.B. only has one sided railing for each staircase. The student nurse explains that having railing on each side of the staircase will decrease her risk for falls and injury.
Once M.B is down stairs in her main living area she starts to gather her daily morning medication regimen and prepares breakfast for herself. M.B. has to walk across a narrow area from steps to living room and thru her dining room into her kitchen which is clutter free. The kitchen has wood flooring with adequate lighting. M.B. does have two throw rugs in her kitchen; one is placed in front of her sink and the other in front of her stove. The student nurse explains that having throw rugs especially without non-skid backing increase her risk for falls and injury (Gulanick & Myers, 2007). M.B. tells the student nurse that she is aware of the risk but these throw rugs are the only ones she found to match her kitchen decor.
M.B. breakfast consist veggie omelet, whole wheat toast, sometimes turkey bacon, and a cup of decaffeinated coffee as well as water for her medications. Certain morning M.B. states that if she does not want to cook or is in a hurry will make instant oatmeal with a fresh fruit. M.B. keeps her plates and bowls on the lower shelf of her top cabinet and cups and glasses on the lower shelf of another top cabinet. M.B. top kitchen cabinets were placed low by her grandson so she does not have to reach up to get plates and bowls. M.B. keeps her pots and pans inside the oven and has to bend down to get them. M.B. keeps most of her can goods in a three self pantry closet that one of her daughters purchased for her. The student nurse observed M.B. kitchen to see what other things and their placements can increase risk for falls and injuries. The student nurses noticed the throw rugs and the bending down to get her pots and pans are risk factors.
M.B. takes her morning medication regimen at 9 every morning with a glass of water. M.B. keeps her medications in the original containers given from the pharmacy. She stated that she does not need to divide her ten different medications. M.B. stated that she knows the names of her medication and their indications. The student nurse notice that the labels on the medication container also had hand writing to indicate usage in Spanish; for example: insulin, hypertension, ASA, and cholesterol. M.B. has a past medical history of HTN, Hyperlipidemia, Diabetes Mellitus type 2 and a Stroke in “06. M.B. is currently taking two medications for hypertension: Lisinopril which is an ACE inhibitor that treats high blood pressure by preventing the conversion of angiotension I into II that results in vasodilatation decreasing the blood pressure. Metoprolol is a beta-blocker that treats or prevents MI and decreases heart rate and blood pressure, by stimulating the beta¹ receptors. M.B. is also taking two lowering-lipid agents: Zetia is used to treat high cholesterol along with low-fat, low-cholesterol diet. Works by inhibiting absorption of cholesterol in the small intestine leads to lowering of cholesterol. Simvastatin lowering-lipid agent used to lower total and LDL (bad) cholesterol and triglycerides in the blood and also used for prevention of cardiovascular events especially in patient’s with DM, PAD or CVA. M.B. also takes three antidiabetics agents: Janumet is an oral diabetes medicine that helps control blood sugar levels. This medication is a combination of metformin and sitagliptin and does not treat DM type 1. Metformin works by decreasing glucose production in the liver and decreasing absorption of glucose by the intestines. Sitagliptin works by regulating the levels of insulin your body produces after a meal. M.B. also takes two subcut insulin: Lantus is a long-acting and has no peak and controls blood sugar in patients with type1 and type 2 DM; works by inhibiting hepatic glucose production by stimulating glucose uptake in the skeletal muscle and fat. Apidra works the same and has the same indication as Lantus only difference is that Apidra is rapid acting works within fifteen minutes and peaks in an hour compared to Lantus. M.B. also takes baby aspirin daily which is used to lower risk of MI or CVA. Aspirin inhibits clots formation by inhibiting prostaglandins. M.B. also takes Calcium and Vitamin D daily to treat calcium deficiency. Calcium is a mineral found in naturally in foods; it is used for many normal functions of our body especially bone formation and maintenance. Vitamin D is important for the absorption of calcium from the stomach and for the functioning of calcium in the body.
The student nurse asked about M.B.
afternoon routine and she stated that it depends on the day and the activity she signed up for through her church. M.B. did state that she does have lunch usually something small. She sometimes has half a turkey on wheat bread sandwich with an activa yogurt, a cup of juice and a cup of water for her noon medications, if she is home. When she is out with the church she will eat out with church members but does limit fast food menus by going to diners. M.B. eats dinner no later than 6 pm which usually consist of rice and beans and baked chicken, pork chops or steak, salad and a cup of decaffeinated coffee. From 7-9 pm M.B. sits in her living room and watches Spanish soaps except on Wednesday and Fridays because she is at church till 9 pm. At 10 pm M.B. get herself ready for bed, she usually goes down to the first floor to make sure the windows and doors are locked, then she goes back to the second floor make sure everything is off like lights, stove and etc. At this time she takes her bedtime medication with a cup of water, grabs a water bottle and starts to head up to her bedroom which is located on the third floor. M.B. did state to the student nurse that she does turn on the staircase light while she goes up the steps. Once in her room she goes to bathroom, takes a shower, brushes her teeth and changes into her night gown. Then heads over to her chair by the window in her room to read a passage from the bible, she then prays and
climbs into bed. M.B. stated that she usually goes to sleep by midnight and sleep through the night without any disruptions.
The student nurse did a Mini-Mental Status Examination (Appendix A) on M.B. which tests for orientation, attention, calculation, recall, motor skills and language. M.B. scored a 3 on recalling which indicates classification of non-demented because she was able to recall all three words. The student nurse instructed M.B. to fill in the face of the clock within the circle provided by the SN, then to draw the hands on the clock to indicate twenty to four. M.B. did this without any assistance, the way she fill in the numbers was a little weird for the SN. M.B. first fill in the three hour intervals and then fill in the number starting at eleven counter clockwise. The SN said to M.B. once done that it was a neat way, in filling in the clock; M.B. stated that she wanted to make sure the hours were in exact placement, and then she laughed. The SN did checked M.B. vision because she used her glasses to draw the face on the clock. The SN did not have a Snellen chart “which is used to test distant visual acuity” (Weber & Kelley, 2007); instead M.B. read from a Spanish literature on diabetes she had on her table. M.B. did not have any problems reading the fine print in the literature. The SN also tested her hearing by doing the whisper test which screens for hearing impairments (Tabloski 2010). M.B. was able to recall all three words in both ears.
The student nurses did a Katz Index assessment (Appendix B) on M.B. and she scored a total of six points which indicates that she is fully independent. M.B. is able to do all of her ADL’s without any assistance. The SN also did the IADL Scale (Appendix C) on M.B. and she scored an 8 which means that she is high function, independent. M.B. does not drive but has reliable transportation from family and friends. The SN felt no need to do a depression assessment because she does not live alone and her children live near by and church members are very supportive. The SN used a Tinetti Assessment Tool (Appendix D) to assess M.B. balance and gait. She scored a total score of 25/28 which indicates she does not have a fall risk but should still practice fall preventions.
The SN asked M.B. if she has any long term plans or a living will. M.B. stated she has discussed her wishes with her children but has nothing in writing. The SN explained the importance of having Advance directives such as a living will, provides instructions for care in the event that she is unable to communicate her wishes (Smeltzer, Bare, Hinkle, & Cheever, 2010). M.B. made it very clear that in the event that doctors say she need to be on life support for her children to let her go. The SN informed M.B. that she is able to obtain Advance directive through her health insurance. M.B. stated that she will contact her medical insurance and ask them to mail her the forms.
The SN did a Mini Nutritional Assessment (Appendix E) and M.B. scored a total of 25 which indicates a risk of malnutrition. M.B. seems to eat health meals with proportion control; she weighs 170 lbs and BMI is 31.1 which indicate that she is overweight. The SN asked M.B. if she has an exercise regimen she stated that she walks for thirty minutes daily. Also that she is consistently moving around either doing house chores, activities within the church and she volunteers at nursing homes, jail or senior community centers to talk about the word of GOD. M.B. stated that she attends all of her appointments with her primary doctor. She also does yearly physical examinations and immunizations to prevent any other complication with her health. The SN checked M.B.’s blood pressure with a wrist blood pressure monitor she owns; her blood pressure was 132/65. Her lungs were clear and no signs extra heart sound or murmur also no edema in extremities. M.B. states that she is very compliant with her daily medication regimen.
M.B. has plenty of support from family, friends and her church community. Her children and grandchildren constantly call and visit her on a daily basis. She has a daughter that lives with her and another that resides a block away and the other live in the same town. M.B. son is the only one that does not reside near due to his employment he lives in California but visits about three times a year and calls often within the week. M.B. stated that she is very happy with her life and this is all due to the love she has for GOD. Some say that having a spiritual and religious faith can have a positive impact on health (Smeltzer, Bare, Hinkle, & Cheever, 2010). M.B. states that despite her medical issues that she is very happy and grateful because she is active and does not feel limited. She also states that she is living life to the fullest and living life the way GOD has intended. M.B. state that she was able to make it through her difficulties she has encounter in her life by staying positive and the love and support from her family and her faith. The SN asked the M.B. if she feels she is aging successfully, she replied by saying “of course” that she serving GOD and is still able to do everything at a slower pace without any assistance. She states to have no regrets in her life and will be ready when GOD is ready for her. Research on aging has demonstrated that many individuals can age successfully, and that this “success” is realized in different ways by different individuals (Ferri, James & Pruchno,2009).
The student nurse found two areas of concern during her assessments on M.B. The first concern is risk for falls related to environmental and health factors as evidence by throw rugs without slip-resistant backing, no grab bars in shower, lack of handrails on both sides of the staircase, gender, presence of acute illnesses, medication side effects, polyharmacy. M.B. will ensure that she only use throw rugs have a slip-resistant backing because "loose throw rugs will increase the risk of slipping and falling" (Gulanick, & Myers, 2007). M.B. will install nonslip surface in tubs and shower. Place grab bars near the tub or shower and toilet and consider using a shower chair. "Wet surfaces in the bathroom increase the risk of falls" (Gulanick, & Myers, 2007). M.B. will increase lighting through out the home. "Older adults have poor vision at night and in dimly lit areas" (Gulanick, &, Myers, 2007). M.B. will continue to maintain a daily exercise regimen. "Increase physical conditioning reduces the risk of falls and limits injury that is sustained when a fall occurs" (Gulanick,&, Myers, 2007). The outcome is M.B. will not sustain a fall or injure herself during ambulation inside and outside her home. According to Edelman & Ficorelli (2012) they state “Planning ahead is the key to helping older adults live their lives to the fullest”. Also being able to balance safety and independence depends on the patient individualize decisions and unique situation (Edelman, & Ficorelli, 2012). M.B. also has an increase risk for injury related to increase risk for fall as evidence by environmental and health factors. The SN will identify hazards that can cause falls or injuries with M.B. home. "This increases the patient`s awareness of potential dangers" (Ralph, & Taylor, 2008). Encourage M.B. to make repairs and remove potential safety hazarded from environment (Ralph & Taylor, 2008). "This decreases possibility of injury" (Ralp,h & Taylor, 2008). M.B. will add non slip treads on each step and not use throw rugs. Arranging M.B. environment helps prevent injury (Ralph, & Taylor, 2008). The outcome for M.B. is she will identify and eliminate safety hazards in her surroundings to decrease her risk for falls.
The second concern is impaired verbal communication related to inability to speak dominant language as evidence by English is the second language. The SN will avoid using medical jargon. "Technical terminology used by health care providers can sound like a foreign language to patient and family" (Gulanick, & Myers, 2007). The SN will only ask M.B. one short question at a time. "This allows the patient to stay focused on one thought" (Gulanick, & Myers, 2007). M.B. will need ample time to respond to question. "It may be difficult for patients to respond under pressure; they may need extra time to organize responses, find the correct word, or make necessary language translations" (Gulanick, & Myers, 2007). The SN will listen attentively when M.B. is communicating. "Feedback promotes effective communication by allowing the sender of the message to verify that the message sent was the message received" (Gulanick, & Myers, 2007). M.B. also has deficient knowledge related to English second language as evidence by M.B. statement of not being sure if new medication prescribed is an adjunct or a substitute for her hyperdylipidemia. The SN assessed M.B. primary means of communication and learn by asking her prefer language. "Patients may have skill with many forms of communication, yet they will prefer one method for important information (Gulanick, & Myers, 2007). M.B. will ensure she receives specific instructions by asking questions. "Information enables the patient to better take control in selecting and implementing required changes" (Gulanick, & Myers, 2007). Identifying any misunderstanding due to language barriers by asking M.B. for feedback. Gulanick & Myers (2007) states that knowledge serves to correct faulty ideas. Providing M.B. with clear, thorough information in her native language. "Accurate, clear information provides rational for treatment and aids the patient in assuming responsibility for care at a later time" (Gulanick, & Myers, 2007). According to Oliva (2008) states that patients with English as second language are less likely English speaking patient seeking medical attention. She also stated that she found a report with a survey that showed that "as many as one in five Spanish-speaking Latinos reports not seeking medical care because of the language barriers". The outcome for M.B. is that she will provide health care professionals with her prefer language of learning to have her medical compliance needs met.
In conclusion M.B. is aging positively because she is a very strong christian woman that takes very good care of herself. Staying positive, her faith in God and the love for her family and friends may have helped her age successfully. In M.B. case aging successfully has nothing to do with perfect health or economic situations nor she a person that has not faced hardship in her life. She is a woman that despite it all has vowed to her faith to see the brighter side to life and appreciate what God has given her and her family in her words is “Each other”. The student nurse has learned from M.B. that aging successfully or positively is subjective and it is within reach for all of us.

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