19.3 Applying the Nursing Process

Applying the Nursing Process: Assessment

When performing a comprehensive assessment on an older adult, the findings are used to establish their baseline status of physical, cognitive, psychosocial, and spiritual well-being. It is appropriate to consider the potential impact of declining strength and physical functioning on their psychological status using Erikson’s developmental stage of “Integrity versus Despair.” It is also important to consider the impact of chronic disease on their ability to function and complete Activities of Daily Living (ADLs). Many older adults who are able to perform ADLs without assistance consider themselves healthy.

When performing an assessment on an older adult, modification of communication techniques may be required, as discussed in the “Sensory Impairments” and “Cognitive Impairments” chapters. It is important to allow adequate time for older individuals to reply to questions thoughtfully and to move through the requests contained in a physical assessment comfortably.

It is helpful to use an evidence-based tool to assess for frequent needs of older adults, such as the Fulmer SPICES tool. The SPICES tool focuses on areas of common problems for aging individuals and can lead to early intervention and treatment. The SPICES tool includes assessment of the following:

S: Sleep Disorders

P: Problems with Eating or Feeding

I:  Incontinence

C: Confusion

E: Evidence of Falls

S: Skin Breakdown[1]

Read more details about using the SPICES tool.

Several free assessment tools for common issues in older adults are located at The Hartford Institute of Geriatric Nursing website. Use the box below to explore available tools.

Download free assessment tools from the “Try This: Series” at the Hartford Institute of Geriatric Nursing.[2]

Unexpected Findings

While cognitive impairment and memory deficits are not considered normal aspects of aging, there are common expected physiological changes that occur with aging. Nurses should be familiar with these expected findings so that deviations from the expected can be adequately addressed. See Table 19.3 for a comparison of expected versus unexpected findings in an older adult that require notification of the health care provider.[3]

Table 19.3 Expected Versus Unexpected Findings[4]

Assessment  Expected Findings New Unexpected Findings to Report to the Health Care Provider 
Cardiovascular system
  • Walls of blood vessels thicken; vessels narrow and lose elasticity
  • Valves become less efficient; calcification is noted
  • Peripheral circulation decreases and systolic blood pressure increases
  • Cardiac output decreases
  • Decreased sensitivity of baroreceptors
  • New hypertension
  • Orthostatic hypotension
  • Vital signs out of normal ranges

*CRITICAL CONDITIONS requiring immediate notification or contact of emergency services: Chest pain; symptomatic hypotension or hypertension; new onset or changes in oxygenation

Respiratory system
  • Decreased cough reflex
  • Increased chest wall rigidity
  • Decreased lung compliance
  • Fewer alveoli
  • Vital signs out of normal ranges

*CRITICAL CONDITIONS requiring immediate notification or contact of emergency services: Hemoptysis; decreased oxygen saturation levels not responding to treatments; labored breathing

Musculoskeletal system
  • Loss of muscle mass and strength
  • Increased subcutaneous tissue deposits
  • Joint changes (degeneration)
  • Loss of bone density
  • Decreased proprioception
  • New changes in strength or mobility
  • Falls

*CRITICAL CONDITIONS requiring immediate notification or contact of emergency services: Sudden onset of unilateral weakness, facial drooping, or slurred speech; falls with suspected injury

Genitourinary system
  • Decreased renal perfusion; fewer nephrons
  • Decreased bladder capacity
  • Female: reduction in sphincter tone
  • Male: prostate enlargement
  • New difficulties with urination (frequency, urgency, incontinence, hesitation, retention, pain)

*CRITICAL CONDITIONS requiring immediate notification or contact of emergency services: Urine output less than 30 mL/hour

Gastrointestinal system
  • Decreased salivary and gastric secretions
  • Decreased gut motility
  • Reduced production of intrinsic factor
  • Hemorrhoids
  • Impaired rectal sensation
  • Constipation
  • Black stool
  • Blood in stool
  • Liquid seepage of stool
  • Nausea
  • Vomiting
  • Diarrhea
  • Loss of appetite
  • Unintended weight loss

*CRITICAL CONDITIONS requiring immediate notification or contact of emergency services: Absent bowel sounds or rigid, distended abdomen

Integumentary system
  • Decreased elasticity of skin
  • Changes in pigmentation
  • Thinning, greying hair
  • Slower nail growth
  • Sweat and oil gland atrophy
  • Lesions associated with aging such as skin tags and seborrheic keratosis
  • Suspicious moles, lesions, or lumps
  • Skin breakdown
  • Rashes
  • Signs of infection in a skin wound
Endocrine system
  • Altered hormone production
  • Reduced ability to adapt to stress
  • Decreased thyroid function
  • Decreased insulin sensitivity
  • Changes in sleep patterns
  • Unintended weight changes
  • Blood glucose levels out of range

*CRITICAL CONDITIONS requiring immediate notification or contact of emergency services: Symptomatic blood glucose less than 50 or greater than 400[5] 

Immune system
  • Decreased core temperature elevation
  • Decreased thymus size
  • Decreased T-cell function
  • Redness, warmth, tenderness, fever, or other signs of infection
  • Change in mental status and confusion suggestive of infection

*CRITICAL CONDITIONS requiring immediate notification or contact of emergency services: Suspected or actual infection with two or more of the following signs indicating possible sepsis: Temperature > 38 C or <36 C, Heart rate > 90 bpm, Respiratory rate > 20 or PaCO2 < 32, WBC > 12,000 or < 4,000 or over 10% immature forms or bands[6]

Reproductive system
  • Females: decreased estrogen levels; atrophy of uterus, vagina, and breasts; vaginal irritation, dryness
  • Males: erectile dysfunction
  • Vaginal bleeding
  • Breast lump

Health Promotion

One of the goals of Healthy People 2030 is to improve the health and well-being for older adults. It is estimated that by 2060 almost a quarter of the U.S. population will be age 65 or older. Older adults are at higher risk for chronic health problems like diabetes, osteoporosis, and Alzheimer’s disease. In addition, 1 in 3 older adults fall each year, with falls being a leading cause of injury for this age group. Older adults are also more likely to go to the hospital for infectious diseases such as pneumonia, which is a leading cause of death for this age group. Nurses can ensure older adults get preventive care, including vaccines to protect against the flu and pneumonia, to help them stay healthy. Other goals for older adults established by Healthy People 2030 include early detection of dementia with appropriate intervention; decreased hospitalization for urinary infections, falls, and pneumonia; decreased incidence of medication-related safety issues; improved physical activity; improved oral health; decreased complications of osteoporosis; and reduced vision loss from macular degeneration.[7]

Nurses can advocate for improved health care for older adults while actively involving them in decisions about their care and promoting their quality of life. Common areas of health promotion for older adults include nutrition, physical activity, safe medication use, and psychosocial well-being.

Nutrition

Heart disease, cancer, chronic lung disease, and stroke are the leading causes of death in older adults. Nurses can provide patient education that focuses on good nutrition, physical activity, smoking cessation, and moderate alcohol use to promote improved health outcomes.[8] However, nutrition can pose special challenges for the older adult. Chewing can be a problem if there are difficulties with dentition. Lack of oral care, missing teeth, or poorly fitting dentures can cause individuals to avoid intake of healthy foods. Regular dental care should be encouraged when working with older adults. Finances often impact nutritional intake when older adults have difficulty meeting their basic needs of housing, food, and health care. Additionally, the inability to plan, shop, and prepare meals because of activity intolerance, cognitive impairments, or physical limitations can impact nutrition. Nurses can initiate referrals to social workers or case managers for assistance with financial or health care concerns, as well as promote community resources such as Meals on Wheels or senior citizen meal site centers. Assisting individuals to meet their nutritional needs is an important aspect of health promotion.

Read more about promoting good nutrition in the “Nutrition” chapter.

Physical Activity

Physical activity is important throughout the life span. Older individuals may be limited in their ability to engage in physical activity due to various factors such as physical limitations, pain, and fear of falling. Musculoskeletal problems, such as impaired balance and arthritis, can impair an individual’s ability to walk or participate in regular exercise. Helping older adults find appropriate ways to maintain activity is an important nursing intervention. Nurses can advocate for the older adult by encouraging them to regularly attend health care checks with their provider and discuss concerns that limit their activity. Older adults should be reassured that pain is not considered a normal part of aging and can be effectively treated so they can maintain physical activity comfortably.

Read more about promoting activity and joint range of motion in the “Mobility” chapter.

Safe Medication Use

Because of the increased incidence of chronic disease, many older adults take multiple medications to manage their symptoms and conditions. Polypharmacy, the use of many medications, increases a person’s risk of adverse medication effects. Older adults may be prescribed medications by multiple providers, and they can become confused when attempting to safely manage their daily medication use. There are also changes in absorption, distribution, metabolism, and excretion of drugs as an individual ages that impact the safe use of any medications.

The American Geriatrics Society maintains a list of medications to potentially avoid or use with caution in older adults because of the risk for harm. This list is called “AGS Beers Criteria.” Updated reports are published in the Journal of the American Geriatric Society.[9] Use the following box to view the most current report.

Read more about the Beers Criteria with rationale for why the listed medications may be inappropriate for older adults on the American Geriatric Society website.

In addition to cautiously using medications listed on the ABG Beers Criteria list with older adults, nurses can promote other safety strategies with medications. For example, older adults should have all of their medications prescribed from multiple providers filled at the same pharmacy to check for interactions and replications. It is also helpful to use a daily pill dispenser to ensure medications are taken as prescribed.

Nurses should also perform medication reconciliation during all clinic visits and on admission to health care agencies to review the patient’s current use of all medications.

Read more about medication reconciliation in the “Preventing Medication Errors” section of the “Legal/Ethical” chapter in Open RN Nursing Pharmacology.

Psychosocial Well-Being

As individuals age, they often experience loss of significant others, family members, and friends. These losses create increased risk for social isolation and depression. Poor mobility and transportation issues can also add to social isolation. As male older adults experience multiple losses, their risk for suicide increases.[10] Nurses can provide information about community resources and outreach programs to promote social interaction for individuals experiencing isolation.

Older adults are also at risk for other safety issues, such as elder abuse and financial exploitation. Read more about safety considerations for older adults in the “Safety” chapter.

Aging individuals continue to have sexual needs, and this aspect of their overall health should not be ignored. Assessment of these needs allows the nurse to integrate these aspects into the patient’s plan of care and make appropriate referrals when necessary.

Adapting Patient Education

As discussed throughout this chapter, there are many considerations when working with the older adult population and promoting optimal health and quality of life. It is also important to modify patient education methods depending on the individual’s knowledge, skills, and abilities. For example, some older adults readily engage in using electronic technology, but others have low digital literacy or experience difficulty when accessing electronic health resources. Nurses should adapt patient education to the needs of the individual and provide verbal, written, or electronic resources as needed, while considering any sensory, cognitive, or functional impairments. The ultimate goal of health promotion and patient education is to improve their understanding, motivation, and engagement in self-management and promote their quality of life.


  1. Fulmer, T. (2019). Fulmer SPICES: An overall assessment tool for older adults. The Hartford Institute for Geriatric Nursing, New York University, Rory Meyers College of Nursing. https://hign.org/sites/default/files/2020-06/Try%20This%20General%20Assessment%201.pdf
  2. The Hartford Institute for Geriatric Nursing, New York University, Rory Meyers College of Nursing. https://hign.org/consultgeri-resources/try-this-series
  3. Boss, G. R., & Seegmiller, J. E. (1981). Age-related physiological changes and their clinical significance. The Western Journal of Medicine, 135(6), 434–440.
  4. Boss, G. R., & Seegmiller, J. E. (1981). Age-related physiological changes and their clinical significance. The Western Journal of Medicine, 135(6), 434–440.
  5. Patolia, S. (2023). Gluose. Medscape. https://emedicine.medscape.com/article/2087913-overview
  6. Chakraborty, R. K., & Burns, B. (2023). Systemic Inflammatory Response Syndrome. [Updated 2023 May 29]. In: StatPearls [Internet].  https://www.ncbi.nlm.nih.gov/books/NBK547669/
  7. Healthy People 2030. (n.d.). Older adults. https://health.gov/healthypeople/objectives-and-data/browse-objectives/older-adults
  8. Centers for Disease Control and Preventive Medicine. (2021, March 1). Leading causes of death. https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm
  9. American Geriatric Society. (2023). American Geriatric Society updated Beers criteria for potentially inappropriate medication use in older adults. https://geriatricscareonline.org/ProductAbstract/american-geriatrics-society-updated-beers-criteria-for-potentially-inappropriate-medication-use-in-older-adults/CL001
  10. Centers for Disease Control and Prevention (n.d.). Injury prevention and controlhttps://www.cdc.gov/injury/index.html
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