Which type of question is used when starting the assessment of a client?

Assessment tools cannot substitute for good clinical skills and judgements. As clinicians we need to be aware that assessment tools can tell us more than just a score.

Assessment involves collecting information that gets to know the patient in detail, evaluates their risks and the nature of problems to be identified.

Assessment should integrate all the relevant issues. It should explore the medical, physiological, social and psychological function of the older person.

The assessment process encourages us to be curious and to consider the best possible interventions that we can employ to minimise risks and maximise our patient’s quality of life. This can ultimately involve balancing some risks with some gains and working with our team and the older person and their family to make an informed choice about this.

Assessment supports us to:

• treat the condition that caused the admission (such as shortness of breath)
• detect and quantify additional conditions or psychosocial issues that contribute to or complicate the admission and respond to them as able both during the admission and when planning for discharge. For example
  • depression - consider if the person needs a medical review
  • poor nutrition - consider what can be done to optimise the person’s intake
  • social isolation, or risk of loneliness - consider how you can encourage the person to participate in their care by harnessing their personal and social connections, and consider linking them to supports that are meaningful to them on discharge
• use strategies to prevent conditions that often emerge during hospital stays but can be avoided (such as delirium and falls).

We can gather information as part of the assessment process from multiple sources, and these may vary at the stages of a hospital admission.

The four main sources of information are:

1. Older people themselves - self report.
2. Others who know the older person well - informant report.
3. Observation of the person undertaking various activities - direct observation.
4. Various secondary written or verbal sources - including hospital records, medical reports, investigation results, communication from community care providers.

Unless there are reasons to suspect otherwise the older person is considered the best source of information about their own health1. Direct observation is the best source of information about physical function; however, we should consider how the environment or setting where observations take place may impact on the older person’s performance.

Assessment tools can be focussed on exploring one particular condition such as pain, pressure injury or nutrition. They can also be more comprehensive and encompass a broader focus beyond one particular issue. Examples of these types of tools include:

• InterRAI Comprehensive Assessment Tool: Acute
• Systematic Evaluation and Intervention for Seniors At Risk (SEISAR) - a short, standardised, comprehensive tool for the evaluation of active geriatric problems in seniors in the emergency department.

The assessment tool or scale should enable collection of useful patient data that supports interpretation of the holistic health status, identifies patient needs, and informs care planning and interventions to restore health and wellbeing.

Selecting an assessment tool

Consider the following factors when selecting an assessment tool include:

• A standardised tool can reduce variation in practices and interpretation of findings and allow comparison across assessments.
• A validated assessment tool ensures the right data is captured to evaluate the patient and their progress.
• Is a specific tools mandated for specific circumstances or settings? See the individual topics for examples.
• Does the tool cater for cultural or language differences?
• Is the tool appropriate for the physiology of ageing?

The format used will also depend on the discipline, skill and expertise of the clinician, the context and setting of the assessment, the time available and the number of assessors involved. The assessment can be:

• unstructured – if the professional expertise of the assessor is high
• semi-structured – incorporates specific tools and checklists
• structured and standardised – using global assessment instruments.

Comprehensive Geriatric Assessment

There is no gold standard for assessment of older people; however, a Comprehensive Geriatric Assessment is highly recommended to understand the multidimensional complex care needs of frail older people and to determine both short and long term care needs.

A Comprehensive Geriatric Assessment can be undertaken by any member of the interdisciplinary healthcare team who has the required knowledge and skills. Multiple team members with specific skills may need to be involved depending on the patient’s needs.

Ideally, the assessment should be completed within the patient’s first 24 hours in hospital and communicated to all team members, the patient and informal carers.

Conducting assessments

We also need to be aware of the following when conducting assessments of older people:

• At all times, it is vital that we maintain an understanding the older person’s perspective.
• In acute hospital settings, circumstances may mean older people are not able or willing to be actively involved when health professionals assess them.
• Older people may take more time to complete tools than younger people, so allow for rests during formal assessments.
• Ensure that any needs for communication assistances are met. These may include use of interpreters, ensuring the older person is wearing their glasses and/or hearing aids if they are used routinely.
• Do not assume older people know why they are being assessed. Explain why certain questions or tests are being undertaken.
• Establish cognitive status as early as possible in an assessment. Do not assume older people are able to hear, comprehend what is said or are capable of accurate, intelligible responses (for example if they are acutely unwell).
• Note that appearing ‘flat’, minimal eye contact and being non-committal responses may indicate depressive symptoms are present. Depressed older people can give the appearance of being cognitively impaired.
• Consider the need for an interpreter for those with limited English proficiency. The interpreter can also assist with cultural care delivery.
• Consider specific cultural issues and seek assistance necessary from cultural liaison officers or Indigenous health workers.

Applying clinical skills to assessment

Good clinical skills, observation, listening, interpreting and clinical judgement are all vital in decision-making.

When we assess older patients, we use tools and draw on our clinical reasoning skills. The reasoning cycle2 sets out the elements of effective clinical decision-making:

• Consider the patient situation
• Collect cues and information – through observation, questions
• Process the information – what does it mean?
• Identify problems and issues – what does the information indicate?
• Establish goals – what actions need to be taken?
• Take actions
• Evaluate outcomes
• Reflect on process and new learning.

1. Levett-Jones, T. (2013). Clinical Reasoning: Learning to think like a nurse. Frenchs Forest: Pearson Australia

2. Dorevitch 2004 p 229 in Nay, R., Garratt, S., & Fetherstonhaugh, D. (2013). Older People: Issues and Innovations in Care (4th ed.). Australia: Churchill Livingstone Australia

There are many tools to help you further explore a client’s symptoms or signs. A common one follows the mnemonic PQRSTU as illustrated in Figure 2.2, which offers a systematic approach to asking assessment questions without leaving out any details.

Figure 2.2: The PQRSTU assessment mnemonic

The mnemonic is often used to assess pain, but it can also be used to assess many signs and symptoms related to the client’s main health needs, and other signs and symptoms that are discussed during the complete subjective health assessment. Table 2.3 lists examples of prompting questions using this mnemonic.

PQRSTU	Questions Related to Pain	Questions Related to Other Symptoms
Provocative	What makes your pain worse?	What makes your breathing worse?
Palliative	What makes your pain feel better?	What makes your nausea better?
Quality	What does the pain feel like? Note: If the client struggles to answer this question, you can provide suggestions such as “aching,” “stabbing,” “burning.”	What does the itching feel like?
Quantity
Region	Where do you feel the pain? Point to where you feel the pain.	Where exactly do you feel the nausea?
Radiation	Does the pain move around? Do you feel the pain elsewhere?	Do you feel the nausea elsewhere?
Severity (severity scale)	How would you rate your pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain you’ve ever experienced? Note: The severity scale is an important assessment of pain and when used can provide evaluation of a treatment’s effectiveness. After eliciting a baseline, you may provide some sort of pain control intervention and then reassess the pain to see if it was effective.	How would you rate your breathing issues on a scale of 0 to 10, with 0 being no problems and 10 being the worst breathing issues you’ve ever experienced?
Timing	When did the pain start? What were you doing when the pain started? Where were you when the pain started? Is the pain constant or does it come and go? If the pain is intermittent, when did it last occur? How long does the pain last?	When did your breathing issues begin? What were you doing when the itching first started? Where were you when the itching first started? Is the nausea constant or does it come and go? If the nausea is intermittent, when did it last occur? How long did the nausea last?
Treatment	Have you taken anything to help relieve the pain? Have you tried any treatments at home for the pain?	Have you taken anything to relieve the itching better? Have you tried any treatments at home for the itching?
Understanding	What do you think is causing the pain?	What do you think is causing the rash?

Table 2.3: The PQRSTU assessment mnemonic

The order of questions you ask will often depend on the symptom or sign and the flow of the conversation with the client. You will also want to be aware of responses that don’t seem to align. For example, if a client responds to the question about quantity of pain by saying “the pain isn’t too bad,” but then rates the severity of their pain as being 8/10, you should probe further. It is okay to say to the client, “I noticed you rated your pain fairly high, at 8/10, but you said it isn’t too bad. Can you tell me more about that?”

When using the PQRSTU mnemonic for assessment, be sure to apply it comprehensively so that you elicit a full understanding of a particular sign or symptom. See Film Clip 2.2 for effective demonstration of using the PQRSTU mnemonic, and Film Clip 2.3 for ineffective demonstration of using the PQRSTU mnemonic.

Film Clip 2.2: Effective use of the PQRSTU mnemonic

Film Clip 2.3: Ineffective use of the PQRSTU mnemonic

Developmental and Cultural Considerations

Younger children or clients with developmental delays or disabilities, or cognitive impairments, may not be able to answer the types of questions shown in Table 2.3. The care partner might be able to help answer some of these questions, and in that case, you should explore “why” and “how” questions. For example, if the care partner indicates that the infant’s pain started two weeks ago, you should ask “Why or how do you know that it started then?” Or if you are working with a young child, you will need to modify your language to be more understandable (e.g., “Where does it hurt?” “Where is your owie?”).

You can also assess pain in young children using the Wong-Baker FACES Pain Rating Scale (see Figure 2.3). When using this scale, ask the client to choose the face that best depicts the pain they are experiencing. You may need to explain what the faces mean: Face 0 doesn’t hurt at all, Face 2 hurts just a little bit, Face 4 hurts a little bit more, Face 6 hurts even more, Face 8 hurts a whole lot, and Face 10 hurts as much as you can imagine.

Figure 2.3: Wong-Baker FACES® Pain Rating Scale Wong-Baker FACES Foundation (2019). Wong-Baker FACES® Pain Rating Scale. Retrieved May 29, 2019, with permission from http://www.WongBakerFACES.org (see their website for licensing)

Alternative scales exist to assess pain and other symptoms that are more relevant to certain cultures. See Figure 2.4 for an example of a Sun-Cloud-Pain Scale. On this sliding scale, 0 indicates that the client feels very well whereas 5 indicates that the client is feeling very unwell.

Figure 2.4: Sun-Cloud-Pain Scale. Graphic Created Using Icons by Linseed Studio from the Noun Project.

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