The health status of middle-aged and elderly people is often evaluated by asking medical history, physical examination, laboratory examination and functional evaluation.
I. Medical history
The medical history of middle-aged and elderly patients should be collected mainly from social history, past history and physical system status of middle-aged and elderly people. The collection of social history is very important to understand the comprehensive situation of middle-aged and elderly people, which is often ignored in the past medical history. The social resources of middle-aged and elderly people, such as interpersonal relationships, social participation and religious beliefs, socio-economic conditions, living environment, demand for social services, and who provides care, play a very important role in nursing the elderly.
1. Past medical history should be collected: ① history of surgery ② history of major diseases ③ history of drug treatment ④ history of drug allergy ⑤ medication compliance.
⑥ Drug efficacy and adverse reactions, etc. ⑦ Past history ⑧ Family history
2. Review the key symptoms of the system and understand the functional status of various systems in the body: ① dyspnea and intractable cough in the respiratory system;
(2) Sitting breathing, edema, angina pectoris, palpitation, syncope and claudication of cardiovascular system; ③ Dysmastication, dysphagia, abdominal pain and changes in defecation habits of digestive system;
④ Frequent micturition, urgency, nocturia, hematuria, urinary incontinence and vaginal bleeding in the urogenital system; ⑤ local or extensive pain or weakness in skeletal muscle system;
⑥ Visual impairment of nervous system (temporary or permanent), progressive hearing loss, unstable walking or wrestling, and transient local symptoms;
All landowners key symptoms of the mental system, such as depression, anxiety or uneasiness, paranoia, forgetfulness or insanity.
3. Current medical history:
① onset and course of disease ② main symptom characteristics ③ development and evolution of illness ④ accompanying symptoms.
⑤ Diagnosis, treatment and nursing process ⑤ Overview
⑦ Living habits and living conditions ⑧ Other relevant materials.
The ability of the elderly to participate in daily activities and social activities. The influence of current diseases on daily life and social activities. Two. Physical examination of the elderly
On the basis of the physiological changes of the normal aging of the elderly, there are often many pathological changes overlapping, which complicates the interpretation of many signs found in physical examination. Physical examination of the elderly should consider age changes, especially pay attention to vital signs. Need to check are:
① Blood pressure ② Pulse ③ Breathing ④ Weight ⑥ Appearance and behavior ⑥ Body surface modification ⑥ Thinking and speaking.
8 The skin is completely loose; Pet-name ruby audio-visual function.
Indications: oral and dental health and tooth loss 1 1 thoracic morphology and lung murmur 12 cardiovascular system 13 heartbeat frequency and rhythm 14 extra heart sounds 15 cardiovascular murmur.
16 Distal Pulse Weakening 17 Abdominal Abdominal Aortic Pulse 18 Urogenital System Changes
19 limbs, including joint pain, joint movement and edema.
Neuropsychiatric changes, including abnormal mental state, weakness, abnormal sensation, abnormal reflex, abnormal posture and gait, etc.
Three. Laboratory examination
Determine the laboratory examination items according to the physical health status of the elderly. Due to the decline of organ function, the laboratory examination results of elderly patients often change abnormally (compared with the normal laboratory examination results of young and middle-aged people). If we don't understand the normal changes related to aging, there will be abnormal findings, which will either be regarded as aging changes or lead to misdiagnosis and wrong treatment and nursing. Therefore, when evaluating the results of laboratory tests, we should not only consider the changes of diseases, but also consider the changes of aging.
① the slight increase of ESR in the elderly may be the change of aging; ② Impaired glucose tolerance test in the elderly;
③ The creatinine is higher than normal or slightly higher, which is related to renal insufficiency; ④ The average albumin value of the elderly decreased;
⑤ Normal elderly people may have slightly increased alkaline phosphatase, but the pathological state (liver disease or senile disease); Medium height should be considered;
⑥ The decrease of serum iron and iron binding force has nothing to do with age;
⑦ There are S-T segment and T wave changes, atrial or ventricular arrhythmia and conduction block in ECG of the elderly. If there are no symptoms, no special evaluation or treatment is needed.
Four. Functional evaluation
The evaluation of functional status is multidimensional, and the commonly used evaluation fields and scales are summarized as follows: (1) Self-evaluation of health status:: Frequently asked questions: 1. Height 2. Weight 3. Intelligence 4. Consciousness.
5. Body surface:
① Skin ② Hair ③ Nail 6. Head and face:
① Eyes and eyesight ② Ears and hearing ③ Nose and smell ④ Tongue and smell, teeth 7. Neck 8. Chest:
① Thoracic lung ② Heart ③ Breast 9. Abdomen 10. Spinal limbs 1 1. Urinary system 12. Nerve reflex
(2) Assessment of daily life function
Mini Mental State Examination Scale (MMSE)
Name: Gender: Age: Education: Total score:
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(4) Social function evaluation
Mainly evaluate social skills, such as vision, hearing, understanding and dialogue skills; Social resources, such as relatives and friends; Social support refers to the accessibility and availability of social resources.
(5) Evaluation criteria of mental health
The elderly should fully realize their physical strength, mental state and social participation potential in the whole life process. Even very old people can contribute to their families, society and country, and increase their sense of happiness and belonging. Such as cooking, cleaning and so on. , contribute to the family, is the performance of mental health.
The mental state of the elderly can be evaluated by the Geriatric Depression Scale (GDS). * * * 15, total score 15.
Specific topic:
1. Are you basically satisfied with your life? (65438+ no answer 0); 2. Did you lose a lot of activities or interests? (The answer is1); 3. Do you feel that life is empty? (The answer is1); 4. Do you often feel bored? (The answer is1); 5. Are you energetic most of the time? (65438+ no answer 0);
6. Are you afraid that something bad will happen to you? (The answer is1); Do you feel happy most of the time? (65438+ no answer 0); 8. Do you often feel helpless? (The answer is1);
9. Would you rather stay at home than go out and do something new? (The answer is1); 10, do you think there is a prominent memory problem? (The answer is1);
1 1. Do you think your current life is wonderful? (65438+ no answer 0);
12, do you think your present lifestyle is worthless? (The answer is1); 13, are you energetic? (65438+ no answer 0);
14, do you think your situation is hopeless? (The answer is1); Health standard for middle-aged people 1. Health standard 1: strong heart 2. Health standard 2: Good eyesight 3. Health standard 3: Happy laughter 4. Health standard 4: Blood sugar is stable.
5. Health standard 5: acute hearing 6. Health standard 6: close friends 7. Health standard 7: Hard bones 8. Health standard 8: flexible balance 9. Health standard 9: Vaccinate regularly.