Transcript Nursing Care of The Older Adult

Nursing Care of The Older Adult
Chapter 14 (4th ed.)
Physiological AssessmentPart 1
Pati Cox, RN, BSN, M.Ed.
Normal Age Related Changes
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Refer to Chapter 2 – pages 22-28
Class Activity
Outline
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Physical Assessment
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History
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Head to Toe Assessment
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Functional Assessment
Physical Assessment
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Not an all inclusive list of assessment
techniques
All systems will be approached with the IPA
method
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Inspection
Palpation
Auscultation
Percussion (another means of assessment)
History
History
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Exercise Plan
Eating Patterns
Weight loss/gain
Alcohol, caffeine Water
Smoking habits
Stress management
Sexual Activity
Medications –Rx/OTC
Head, Neck, & Face
History
Inspection
Palpation
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 (1 @ x)
Crepitus (Not normal)
Edema of face/neck
Involuntary facial
movements
Tenderness
Lack of symmetry
Nose and Sinuses
History
Inspection
Palpation
Any
Size,
Tenderness
problems
with
nose/sinuses
Nosebleeds?
(Epitaxis)
(more common
in O.A. than
younger adults)
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
or masses
Abnormal findings
Swelling of mucosa
Bleeding, swelling of
mucosa, deviated
septum
Discharge
Perforation
Polyps
Infection
Crusting
Dryness
blockage
Eyes
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History
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Vision changes, pain, blurring,
tearing, discharge, cataracts,
infection, diplopia, glasses, last
exam?
Inspection
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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
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History
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Inspection
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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?
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
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Smooth texture
Tenderness or pain is present
Mouth and Throat
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History
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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
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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
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History
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Headaches
Shaking, trembling, tremors
Seizures, existing disorder, treatment,
circumstances
Neurological System
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Inspection
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Level of orientation (LOO)
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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
History
Inspection
Palpation
Auscultation
Ask
Always
Skin
Listen
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?
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
temp
Peripheral pulses
Check for symmetry
for pulses
Check pulse one at a
time
Mark it with a pen if
difficult to find
to neck
veins (carotid) for
bruit
Peripheral Vascular
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Chronic Venous Insufficiency
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Common in elderly
Legs are cyanotic-dk
blue/purple when dependent
Petechiae may be present
Distended tortuous veins
Hair loss
Hyperpigmentationhemosiderin
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
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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
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Usually on side of ankle
Rare with varicose veins
Found with deep vein
insufficiency
Venous Insufficiency
Hemosiderin
Venous Insufficiency
Arterial Stasis Ulcer
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Usually involves toes
or places where the
skin has been
bumped or bruised
Pale when elevated
Arterial Insufficiency
Vascular Stasis Ulcers (Continued)
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http://www.medicaledu.com/venous.htm
http://www.emedicine.com/plastic/topic467.ht
m#section~pictures
http://www.podiatry.curtin.edu.au/encyclopedi
a/ulcers/content.html
Gangrene
Eschar
Cellulitis
Wound Quiz & More Pictures
http://woundcare.org/newsvol2n2/ar8.htm
http://www.podiatry.curtin.edu.au/encyclopedia/ulcer
s/content.html