Nursing Care of The Older Adult Chapter 14 (4 th ed.) Physiological Assessment- Part 1 Pati Cox, RN, BSN, M.Ed.

Normal Age Related Changes Refer to Chapter 2 – pages Class Activity

Outline Physical Assessment History Head to Toe Assessment Functional Assessment

Physical Assessment Not an all inclusive list of assessment techniques All systems will be approached with the IPA method – Inspection – Palpation – Auscultation – Percussion ( another means of assessment) History

Exercise Plan Eating Patterns Weight loss/gain Alcohol, caffeine Water Smoking habits Stress management Sexual Activity Medications –Rx/OTC

Head, Neck, & Face HistoryInspectionPalpation Head injury Inc. level of stress Thyroid dysfunction Neck injury infection Size shape & symmetry of head Evaluate Hair distribution Facial muscles/expressions Skin on face & neck Lesions Size of neck, symmetry of neck, trachea position, venous distention ROM of neck Trachea Carotid pulses x) Crepitus (Not normal) Edema of face/neck Involuntary facial movements Tenderness Lack of symmetry

Nose and Sinuses HistoryInspectionPalpation Any problems with nose/sinuses Nosebleeds? (Epitaxis) (more common in O.A. than younger adults) Size, shape, color of nose Flaring of nostrils Nasal drainage Nasal cavity – drainage, swelling, polyps, bleeding Nasal mucosa – moist/dark pink Men – inc. nasal hair Assess movement of air through each nares (nose) Smell (should be the same in each nares) provide some common smells Tenderness or masses Abnormal findings Swelling of mucosa Bleeding, swelling of mucosa, deviated septum Discharge Perforation Polyps Infection Crusting Dryness blockage

Eyes History – Vision changes, pain, blurring, tearing, discharge, cataracts, infection, diplopia, glasses, last exam? Inspection – Position & alignment – Symmetry of eyes, brows, eyelashes, pupils & irises – Redness, swelling, discharge – Pupils = reactive to light – may be slower, round, equal in size & smooth – Check glasses – Snellen Chart for distant vision= 20/40 or less should be referred (make sure person can read- if not use directional chart) – Read a newspaper for presbyopia

Ears History – Effect of hearing loss on quality of life – Hearing aids, etc? – Pain, dizziness – when, how long, what relieved it – Drainage, color, consistency, odor – Sudden rapid change in hearing, what were you doing, does it come and go? Inspection – Observe in conversation – Lean forward or cup a hand to ear – Loud voice used, request repetition? – Directional loss – Symmetry, size, shape, redness, inflammation, swelling, discharge & lesions Palpation – Smooth texture – Tenderness or pain is present

Mouth and Throat History – Dental complaints – Pain/discomfort? – Teeth sensitive to hot/cold – Swelling in mouth/throat – Difficulty chewing or swallowing – Food tastes? Mouth dry? – Dentures /cleaning – Sores/lesions – How often brush/floss teeth – Last exam/results Inspection & Palpation – Do both concurrently – Use gloves, inspect, remove dentures – Any lesions, sores, etc – dentures are malaligned, do they fit, any rough places – Examine teeth, mucous membranes – pink & moist – Check uvula(midline & red), hard (pale)& soft palate (pink), tongue (white coating, patchy = thrush) – Check lips – pink,moist, cracks in corners = cheilosis - thrush

Neurological System History – Headaches – Shaking, trembling, tremors – Seizures, existing disorder, treatment, circumstances

Neurological System Inspection – Level of orientation (LOO) Place, time, person – Alert, lethargic, unresponsive – Observe face – symmetry of movement – Appearance, grooming, behavior – Strength of extremities – squeeze hands, push against hands with feet – Observe gait, balance, coordination & ask about weakness during ambulation (as appropriate)

Peripheral Vascular HistoryInspectionPalpationAuscultation Ask about pre-existing diseases (diabetes) Garters, girdles, ankle, knee, or thigh high hose? Panty hose? Tight shoes? Are there any indentions in your legs that take a few minutes or awhile to go away? Tingling, numbness, pain What makes it worse or better Color of extremities, hair loss Swelling – when? Always compare 1 side to another Skin color lying down Chronic Venous insufficiency Arterial insufficiency Edema of hands & feet Measure girth of feet & legs Stasis ulcers = rare with varicose veins but occur with deep vein insufficiency Skin temp Peripheral pulses Check for symmetry for pulses Check pulse one at a time Mark it with a pen if difficult to find Listen to neck veins (carotid) for bruit

Peripheral Vascular Chronic Venous Insufficiency – Common in elderly – Legs are cyanotic-dk blue/purple when dependent – Petechiae may be present – Distended tortuous veins – Hair loss – Hyperpigmentation- hemosiderin – Cool or normal skin temp – Pretibial or pedal edema – worse during day than noc – When in dependent position – gravity is working against an already ineffective blood return Chronic Arterial Insufficiency – Legs are pale when elevated and dk. Red when dependent – Thin, shiny atrophic skin; – Hair loss over feet and toes – Thick and rigid toenails – Cool skin – When in dependent position – gravity enhances – arterioles dilate & deliver blood to starved tissues Measure girth of extremity when edematous – mark so measurement can be made at same location each time

Venous Stasis Ulcers Usually on side of ankle Rare with varicose veins Found with deep vein insufficiency

Venous Insufficiency Hemosiderin

Venous Insufficiency

Arterial Stasis Ulcer Usually involves toes or places where the skin has been bumped or bruised Pale when elevated

Arterial Insufficiency

Vascular Stasis Ulcers (Continued) m#section~pictures m#section~pictures ia/ulcers/content.html ia/ulcers/content.html

Gangrene Eschar

Cellulitis

Wound Quiz & More Pictures s/content.html