17 Assessment of Special Populations

Learning Objectives

At the end of this chapter, the learner will:

  1. Identify age-related variations in conducting a health assessment.
  2. Discuss the involvement of caregivers/guardians in the assessment process.
  3. Complete the Activity of Daily Living Assessment for geriatric patients.
  4. Discuss abuse and neglect for at-risk populations.

I. Overview of the Special Populations

In prior chapters, the essential knowledge of health assessment was laid out to prepare the nurse to assess adult patients in a clinical setting. Information on comprehensive assessment and focused assessments were also presented, with the aim of preparing the nurse to use clinical reasoning to choose the appropriate assessment for each clinical situation presented. Examples of special populations include obstetric examination during pregnancy, labor and delivery, and the postpartum period, newborn assessment, pediatric assessment, and geriatric assessment. This chapter will demonstrate how the health assessment is adapted for the pediatric and geriatric populations.

Growth and Development

Growth and development is an ongoing process that begins at conception and continues through the remainder of our lives. There is a broad spectrum of physical and psychological changes that are part of the maturation and life of the individual.

Growth is a physical change that can be weighed and measured. Development is psychological and social changes to the individual such as behaviors and thinking patterns. Growth and development are two complementary processes that together make up the individual.

The rate of development and growth is dependent on many factors such as age and genetic disposition…

The newborn’s specific assessment findings:

  • The Apgar score is a measure of a newborn’s transition from the womb during the first ten minutes of life.APGAR score.jpg

The chart above is the work of Dr. Vijaya Chandar:https://commons.wikimedia.org/wiki/Category:Apgar_score#/media/File:APGAR_score.jpg

Some of the main assessment tools used to assess children are the Milestone and growth charts. Developmental Milestones are used to help ensure that each child is behaving and appropriate growth is occurring intellectually, cognitively, emotionally, and socially. The growth in all capacities is influenced by culture, social norms, and institutions in the child and family’s life. Growth charts are used to assess how well a child is growing and how that growth compares to other children in the country.

Assessment findings of the newborn include assessing different body systems. See below:

  • A newborn’s skin is grayish to dusky blue in color until the baby starts breathing at which time the baby’s skin will return to the appropriate color and tone. The baby is also wet, covered in streaks of blood, and coated with a white substance known as vernix caseosa. The newborn may also have Mongolian spots, birthmarks, or peeling skin, particularly at the wrists, hands, ankles, and feet.
  • The newborn’s body dimensions include narrow shoulders and hips, a slightly protruding abdomen, and relatively short upper and lower extremities.
  • The baby will weigh between 5-10 pounds and measure between 14-20 inches (35.6-50.8 cm)
  • The head is large in the proportion to the rest of the body and the cranium is large compared to the rest of the face., and the fontanels will still be open. The head may also be misshapen from coming through the birth canal this will resolve within days or weeks.
  • The skin may be covered with lanugo, a fine downy body hair for a few weeks.
  • The newborn’s genitals are swollen and reddened, with male infants having an unusually large scrotum.
  • All babies will have enlarged breasts with possible milk secretions that range from clear to milky to bloody. These findings are due to the mother’s hormones.
  • The umbilical cord will dry and fall off in 3 weeks.

Below are links to Growth charts from 0-24 months for male and female children from the Center for Disease Control and Prevention: https://www.cdc.gov/growthcharts/who_charts.htm

Growth Charts for girls 0-24 months

Growth Charts for boys 0-24 months

Here is an example. Many items are measured this way to ensure that children meet wellness goals. Items include height, length, weight, and in babies head and chest circumference. Growth charts were noted until age 12.

Milestones:
The first year of life is a year of rapid growth and body changes/functions. the nurse will assess the patient according to developmental stages. The first stage would be 0 months-1 year. Toddlers 1-3 years, Pre-Schoolers 3-6, School ager 6-12-year-old also called middle childhood, 12-18-year-old Adolescence.

The 5-year-old child old realizes what is real and what is not, is aware of gender, and starts to create a social group, grows in independence, speaks clearly, and has improved balance and activity tolerance. The five-year-old is in or getting ready for pre-school.

The twelve-year-old child has hobbies, dexterity, becomes independent with Activities of Daily Living, can tell time, understands complex commands, and enjoys using the telephone, plays with friends of the same gender, and by 10 years old starts playing with the other sex, enjoys talking to others. See the link below for further details: https://www.stanfordchildrens.org/en/topic/default?id=the-growing-child-school-age-6-to-12-years-90-P02278

The 12-18-year-old-Adolescents rapid growth with changes to the body’s composition, height, and weight. Sexual maturity occurs. Changes also occur to the respiratory and cardiac systems. There is improved ability to think including improvement to attention span, memory, processing speed, organization, and Metacognition. Metacognition is necessary for social cognition and results in increased introspection, self-consciousness, and intellectualization. Risk-taking behavior occurs because of continued brain development especially the frontal lobe. There is rapid cognitive growth also that interacts with experience, knowledge, and social demands.

Please use this link to review the milestones that are expected and guide the assessment in children 1 month to 6 years. https://depts.washington.edu/dbpeds/Screening%20Tools/Devt%20Milestones%20Table%20(B-6y)%20PIR%20(Jan2016).msg.pdf

Please use this link to review the milestones that are expected and guide the assessment in children  6-12 years old.  https://www.stanfordchildrens.org/en/topic/default?id=the-growing-child-school-age-6-to-12-years-90-P02278

Please use this link to review the milestones that are expected and guide the assessment in Adolescents. https://courses.lumenlearning.com/boundless-psychology/chapter/adolescence/

Now that the milestones and growth charts have been discussed please review the video below which presents a comprehensive approach to the assessment of children:

Geriatric Assessment: 

Geriatrics refers to the medical care of older adults which normally refers to adults over 65 years old. Aging is the irreversible, inevitable decline in organ function (Merck Manual). The decline is gradual and occurs over a period of time. The speed of aging is determined through genetics, environmental and other factors. This decline will occur even if the patient is healthy. Illness, environmental risks, or poor lifestyle choices may speed up aging. The body systems that age first and profoundly affect homeostasis are the cardiovascular, renal, and central nervous. Therefore, when assessing these systems take the time to be thorough even if the patient seems healthy as initially the baseline function of these organs will not be affected. Please click on this link to review the Physiological Age-related changes Selected Physiologic Age-Related Changes

When diseases interact with the normal decline in organ function geriatric-specific complications, now called geriatric syndromes, occur. An example would be an older adult having undiagnosed Pneumonia and the first manifestation of pneumonia is delirium. This presentation is because of the decline in organ function. Whereby minor illnesses are paired with unusual and unlikely signs of illness. Aging organs are also more susceptible to injury; eg, intracranial hemorrhage is more common and is triggered by less clinically important injury in older adults. Other life-changing medical diagnoses like a Cerebral Vascular Accident occur with minimal injury. The nurse should also monitor the older adult closely for debilitating diseases like Alzheimer’s disease and Atrial fibrillation.

Assessment of the older adult will need more time and attention, especially for the very old or frail patients.  Obtaining needed information from a health history and the physical exam itself may need to occur on two separate occasions because of fatigue. The second reason for needing more time to complete the assessment is that many older adults have either or both an increased number of health care disorders or increased complexity in the diagnosed disorders. The third reason for added time is to ensure that polypharmacy does not occur. Please click on the link to review the medications that older adults should not be taking, Potentially Inappropriate Drugs in Older Adults

The Healthcare team’s duty is to address and maintain patient function, prevent falls, and improve the quality of health, encourage exercise and healthy eating, and give the older adults a voice in their care. The geriatric assessment has four components:

  • Functional ability: Ability to do activities of daily living (ADLs) and instrumental ADLs (IADLs) are assessed. ADLs include eating, dressing, bathing, transferring between the bed and a chair, using the toilet, and controlling bladder and bowel. IADLs enable people to live independently and include preparing meals, doing housework, taking drugs, going on errands, managing finances, and using a telephone (Merck Manual).

    Physical Assessment: This section will be different as it should have a problem-based approach that addresses both current and possible future medical disorders/diseases including problems with vision, hearing, ambulation-gait, balance, and incontinence.

    Cognition and mental health: Several validated screening tests for cognitive dysfunction (eg, mental status examination ) and for depression (eg, Geriatric Depression Scale, Hamilton Depression Scale) can be used. (Merck Manual)

    Socio-environmental situation: The nurse should assess the patient’s: social support system, the utilization of services that will enable hobbies, living independently, and being a satisfied member of a community. Services should address any disabilities, special needs, or home safety,  and may need social work involved in the plan of care.

The health history for a geriatric patient should include all aspects of the normal adult health history with the following questions added:
  • Do you have difficulty performing functional tasks and need if assistance is needed how much? An example of a functional task is getting out of a chair without using the arms.
  • Have you ever fallen and if so how many times? How has the fall affected your self-esteem, independence, mobility, and socialization?
  • Do you have urinary and/or fecal incontinence? If yes what have you done to manage the condition> Have you spoken to your primary care provider about the incontinence? What appliance are you using? Can you afford the appliances?
  • Do you have any Pain? Where is it located and how long have you had it? How is the pain managed at home?
  • What sources of social support, particularly family or friends do you have? How often do you see them? How far away do they live? What interactions or activities are completed together.
  • Depressive symptoms- Use the tools provided by the facility and linked above.
  • Vision or hearing difficulties, Have you been prescribed glasses or a hearing aid? Are you using glasses or a hearing aid. If yes how are they cleaned? if no then why? Is the vision or hearing loss affecting your functioning or activity of daily living?
  • Whether the patient has specified a ‘lasting power of attorney for healthcare. If there is a power of attorney then does the power of attorney know and respect your wishes.
  • Below is a video example of a Geriatric assessment:

Geriatric Head to Toe and Functional Assessment by the Multi-disciplinary team. Please click the link if the video is not visible.https://youtu.be/-eHPugoC5sE

https://youtu.be/-eHPugoC5sE

Geriatric Head to Toe and Functional Assessment by the nurse. Please click the link if the video is not visible:https://youtu.be/s7LSCrGWCys

Knowledge check

 

II. Anatomy and Physiology

Click the link below to review how the anatomy and physiology of the baby, toddler, school-age child, and adolescent differs from an adult. In the assessment process, you will need to apply your knowledge of how age changes both the landmarks used to assess a patient and what are considered normal findings/values.

Physiology from birth through death

III.  Medical Terminology

Apgar scores                                       A tool that uses points to determine a newborn infant’s health status.

Glasgow coma scale                          Used to assess and interpret the degree of consciousness.

Fontanels                                            The soft spot on the baby’s head caused by the incomplete closure of the infant’s skull.

Developmental Milestones              These are specific findings/activities that a child does within a certain age range.

Growth Charts                                   The child’s new height and weight are plotted on a graph and compared to previous measurements taken.

The curve of the child’s graph is then compared to the graft of the “Healthy child

Growth and Development                Human growth from birth through adolescence and development of all body systems

enabling Psychomotor growth and maturity.

Premature                                           Babies born prior to 37 weeks of gestation.

Aging                                                   The process of growing older is independent of chronological age.

Gerontology                                       “Is the scientific study of the process of Aging.”

Geriatric                                              This is the term used to describe the medical care of older adults.

Gerontological  Nursing                    The nurse that specializes in caring for older adults.

Longevity                                             The length of an individual’s life.

Demography                                       “The statistical study of human populations collectively, including geographic changes and.

trends in births, marriages, diseases, and deaths.

Frailty                                                    Is associated with aging and is caused by internal and external factors that affect homeostasis.

Sarcopenia                                           Muscle tissue is lost as part of age-related changes.

 
Functionality

Knowledge check

IV. Step by Step Assessment

  • Perform hand hygiene.
  • Check room for contact precautions.
  • Introduce yourself to the patient.
  • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
  • Explain the process to the patient.
  • Assemble equipment prior to starting the exam.
  • Be organized and systematic in your assessment.
  • Use appropriate listening and questioning skills.
  • Listen and attend to patient cues.
  • Ensure patient’s privacy and dignity.
  • Apply principles of asepsis and safety.
  • Use age-appropriate methods to Check Vital Signs.






Steps


Additional Information




1. Conduct a focused interview that will address all five dimensions of man for the pediatric and geriatric patient.
Obtain the following:


    

  1. Name, gender, age, date of birth, race, culture.
    2. 

  2. Reason for the visit.
    3. 

  3. Past medical, surgical, family, and social histories
    4. 

  4. History of the present illness.
    5. 

  5. Are there any growth and development delays or problems-not completing developmental tasks on time?
    6. 

  6. Are there changes in eating, physical movement, or engagement/socialization?
    7. 

  7. Any new changes in personality?
    8. 

  8. Who are the primary caregivers?
    9. 

  9. Where does the patient live and with whom?
    10. 



For the Geriatric patient:


    

  1. Who is part of the support system network?
    2. 

  2. What is the functional status of the patient?
    3. 

  3. Can the older adult complete activities of daily living (ADLs)
    4. 



The link below contains a health history checklist:


https://opentextbc.ca/clinicalskills/chapter/2-4-health-history-subjective-assessment/





1b. Complete the body system review focusing on the body systems related to the reason for the visit and current illnesses.
Please open the link below to obtain a sample of a Review of System form. https://docs.google.com/document/d/1cw1THqBpHKi7_IggH3FoiVy3HidVzoO1dWpzupkLL1M/edit


A Functional assessment is needed for older adults or children with physical or psychological impairments.


Please see an example of a questionnaire that can be used to obtain the information needed during a functional assessment at the end of this article: 2.8 FUNCTIONAL HEALTH AND ACTIVITIES OF DAILY LIVING  https://wtcs.pressbooks.pub/nursingskills/chapter/2-8-functional-health-and-activities-of-daily-living/





2. Inspection
Complete a Head-to-Toe inspection of the body during the Head to Toe assessment. Pay special attention to markers of nutritional deficits which can affect behavior and affect skin integrity. Inspect for circulatory problems which can affect balance and energy levels in the older adult. Also, inspect for scoliosis in children and Kyphosis in older adults.


File:Vertebral column disorders - Normal Scoliosis Lordosis Kyphosis -- Smart-Servier.jpg


https://commons.wikimedia.org/wiki/File:Vertebral_column_disorders_-_Normal_Scoliosis_Lordosis_Kyphosis_–_Smart-Servier.jpg


 


2.8 FUNCTIONAL HEALTH AND ACTIVITIES OF DAILY LIVING  https://wtcs.pressbooks.pub/nursingskills/chapter/2-8-functional-health-and-activities-of-daily-living/





3. Palpation
Complete Head to Toe assessment focusing on the musculoskeletal system. Assess the muscle growth, strength, and tone in the pediatric patient and muscle retention and tone in the older adult.


Assess for joint tenderness and bone pain in both populations.


In children, it can range from growing pains to Arthritis to an Auto-Immune disease.


In older adults, the most common cause is Osteoarthritis or Rheumatoid Arthritis and both may lead to falls.





4. Auscultation
Complete the cardiopulmonary and GI assessments.




5. Screening
Pediatric:


    

  1. Well-child visits with an assessment of growth charts and milestones.
    2. 

  2. Vaccination schedules.
    3. 

  3. Interaction between child and caregiver.
    4. 

  4. Activity level.
    5. 



How Much Does a Well-Baby Doctor Visit Cost? https://www.howmuchisit.org/how-much-does-a-well-baby-doctor-visit-cost/


 


Geriatric:


    

  1. Annual visit.
    2. 

  2. Needing screening at 45-50: Colonoscopy, bone density, functionality, Blood pressure, Cholesterol and Diabetes Mellitus.
    3. 

  3. Need Vaccinations: Varicella, Flu, Pneumonia vaccines and booster shots for Tetanus and Pertussis.
    4. 



American Cancer Fund-Medical Checkup Check List


https://www.americancancerfund.org/healthy-living/time-for-a-checkup/?gclid=CjwKCAjwlYCHBhAQEiwA4K21m-bIACD7A94y-pd7mE754Qy-3swz0jcvSBSiYK7SrfUcS4zaXWjcGxoC9PoQAvD_BwE


    

  1. Focusing on wellness instead of illness. https://www.frontiersin.org/articles/10.3389/fmed.2021.517226/full
    2. 







5. Report and document assessment findings and related health problems according to agency policy.
Accurate and timely documentation and reporting promotes patient safety.






V. Documentation of Assessment Findings


Please click the link below to see a sample of the narrative documentation for a Head-to-Toe assessment related to an older adult:


https://www.opennotes.org/tools-resources/for-patients/reading-your-notes/






A sample Note






Please click the link below to see a sample of the narrative documentation for a Head-to-Toe assessment related to an older adult:


https://www.opennotes.org/tools-resources/for-patients/reading-your-notes/






 


VI. Related Laboratory and Diagnostic Findings


Blood tests related to the pediatric patient at an outpatient wellness visit will include a complete blood count with differential and possibly a metabolic panel to review electrolytes. The need for further blood and radiology testing will be driven by patient history, current symptoms, signs, and assessment findings. Testing for iron deficiency or vitamin deficiency, diabetes and HIV, and other STDs can be seen in both the pediatric and geriatric populations. Older adults will be tested for cholesterol and triglycerides periodically if at risk for heart disease. Calcium and Vitamin D levels will be checked in older adults if at risk for Osteoporosis.


Some of the commonly ordered radiological tests include the Chest X-ray when the following medical diagnoses are suspected: Asthma, Pneumonia and CardiacMyopathy. X-rays of the arms and legs will be ordered for pediatric patients from fall-related to outdoor activity, sports, or child abuse. In the older adult again, these X-rays are ordered for falls that occur in or out of the home because of sarcopenia, lack of balance, or inactivity which too leads to muscle mass loss.


Cat Scans are used for many reasons including head injuries. In the pediatric setting these injuries are trauma bases and in the geriatric population trauma is one reason but the next reason will be Cerebral Vascular Accidents.


Myocardial Infarctions (MI) are the main cause of death for older adults and as such catherization of the clogged vessel is imperative as soon as possible with an admitting EKG and chest X-ray.






Type your key takeaways here.


    

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VII. Learning Exercises




Knowledge check: Please complete the following activities.




























VIII. Attributions and References



 





					
		
					

						

							
							

								
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Health Assessment Guide for Nurses Copyright © by Ching-Chuen Feng; Michelle Agostini; and Raquel Bertiz is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.
							

														

								
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