Assessment and Diagnosis · 5 min read
Assessing Medical History
Overview
Assessment is the foundation of gerontological nursing practice. This section covers the systematic collection, analysis, and documentation of data used to identify health problems, establish baselines, and guide care planning for older adults. Competent assessment requires understanding age-related changes, recognizing atypical disease presentations, and using validated tools appropriate for the geriatric population.
Principles of Geriatric History-Taking
Obtaining an accurate medical history from older adults presents unique challenges. Age-related sensory deficits, cognitive impairment, and complex medical backgrounds require modified approaches. The nurse must allow adequate time, minimize environmental distractions, and use clear, simple language.
Components of the Comprehensive Medical History
Chief Complaint and History of Present Illness
Document the primary reason for the encounter using the patient's own words. Older adults often present with vague or nonspecific complaints. A complaint of "not feeling right" may indicate serious underlying pathology. Use open-ended questions initially, then focused questions to clarify onset, duration, location, character, aggravating and alleviating factors, and associated symptoms.
Past Medical History
Obtain a complete list of chronic conditions, previous hospitalizations, surgeries, and significant illnesses. Many older adults have multiple comorbidities that interact and complicate treatment. Document the year of diagnosis and current management status for each condition. Common conditions include hypertension, diabetes mellitus, coronary artery disease, heart failure, chronic obstructive pulmonary disease, arthritis, osteoporosis, and cancer history.
Medication History
Medication reconciliation is critical in geriatric assessment. Obtain a complete list of prescription medications, over-the-counter drugs, vitamins, supplements, and herbal products. Document dose, frequency, route, prescriber, and indication for each medication. Ask about adherence patterns, missed doses, and reasons for nonadherence. Polypharmacy (use of five or more medications) increases risk for adverse drug reactions, drug-drug interactions, and medication errors.
Review the Beers Criteria for potentially inappropriate medications in older adults. Common problematic medications include anticholinergics, benzodiazepines, sedative-hypnotics, first-generation antihistamines, and nonsteroidal anti-inflammatory drugs. Ask specifically about recent medication changes, as alterations within the past 30 days frequently correlate with new symptoms.
Allergies and Adverse Reactions
Differentiate true allergies (immunologic responses) from adverse effects, intolerances, and sensitivities. Document the specific reaction experienced, severity, and timing. True allergies may cause anaphylaxis, urticaria, angioedema, or bronchospasm. Adverse effects such as gastrointestinal upset or headache do not preclude future use of the medication if clinically necessary.
Surgical History
List all surgical procedures with approximate dates. Previous surgeries inform current anatomy, potential complications, and anesthesia considerations. Document any surgical complications, blood transfusions, or anesthesia-related problems.
Family History
Family history provides genetic and hereditary risk information. Focus on first-degree relatives and conditions with genetic components: cardiovascular disease, stroke, diabetes, cancer (specify type), dementia, and psychiatric disorders. Ask about age at diagnosis and age at death for deceased relatives.
Social History
Social history reveals lifestyle factors affecting health and informs discharge planning. Components include:
- Living situation: independent, assisted living, skilled nursing, with family
- Marital status and support systems
Functional History
Assess baseline functional status before the current illness. Document independence or need for assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). ADLs include bathing, dressing, toileting, transferring, continence, and feeding. IADLs include managing finances, transportation, shopping, meal preparation, housekeeping, medication management, and telephone use.
Determine use of assistive devices: cane, walker, wheelchair, hearing aids, glasses. Document recent falls, near-falls, and fear of falling. Identify primary caregiver and extent of caregiver involvement.
Review of Systems
Conduct a systematic review of all body systems. In older adults, pay particular attention to:
Atypical Presentations in Older Adults
Older adults frequently present with atypical symptoms that differ from classic textbook descriptions. This phenomenon results from altered physiologic responses, multiple comorbidities, and polypharmacy.
| Condition | Classic Picture | Common in Older Adults |
|---|---|---|
| Myocardial infarction | Crushing chest pain | Dyspnea, confusion, syncope, weakness, nausea |
| Infection | Fever ≥100.4°F | Rise ≥2°F over baseline, confusion, falls |
| Pneumonia | Cough, fever, sputum | Tachypnea, confusion, functional decline |
| Urinary tract infection | Dysuria, frequency | Confusion, behavior change, falls |
| Acute abdomen | Localized pain, peritoneal signs | Minimal pain, blunted peritoneal signs |
| Hyperthyroidism | Hypermetabolic symptoms | Depression, weight loss, atrial fibrillation |
| Depression | Overt sadness | Somatic complaints, apathy, withdrawal |
Myocardial Infarction
Classic crushing chest pain may be absent. Atypical presentations include dyspnea, confusion, syncope, weakness, nausea, or epigastric discomfort. Silent myocardial infarction is common in diabetic patients due to autonomic neuropathy.
Infection
Fever may be absent or blunted in older adults due to impaired thermoregulation. Baseline temperature in older adults is often lower than 98.6°F. A temperature increase of 2°F above baseline may indicate infection even without reaching 100.4°F. Other atypical presentations include confusion, falls, functional decline, anorexia, or incontinence.
Pneumonia
May present without cough, fever, or productive sputum. Tachypnea, confusion, and functional decline may be the only indicators. Aspiration pneumonia is common due to dysphagia and impaired cough reflex.
Urinary Tract Infection
Classic dysuria and frequency may be absent. Confusion, behavioral changes, falls, and functional decline are common presentations. Asymptomatic bacteriuria is prevalent in older adults and should not be treated unless symptomatic.
Acute Abdomen
Abdominal pain may be minimal or absent despite serious pathology. Peritoneal signs are often diminished. Appendicitis may present with vague discomfort rather than classic right lower quadrant pain. Maintain high suspicion for surgical emergencies.
Hyperthyroidism
Apathetic hyperthyroidism occurs in older adults and presents with depression, weight loss, and atrial fibrillation rather than classic hypermetabolic symptoms.
Depression
May present with somatic complaints, cognitive impairment, apathy, or social withdrawal rather than overt sadness.
Documentation Standards
Document medical history thoroughly and accurately. Use objective language and avoid subjective interpretations. Attribute information to its source. Clearly identify patient-reported versus caregiver-reported data. Note reliability of the historian. Document attempts to obtain information and barriers encountered.
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