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Chapter Fourteen. Physiological Assessment. Pati L.H. Cox, RN, BSN, M.Ed. 1-2008. Holistic Assessment. Holistic assessments go beyond the physical assessment Include all aspects of the older person’s life Used to improve person’s overall health and happiness

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chapter fourteen

Chapter Fourteen

Physiological Assessment

Pati L.H. Cox, RN, BSN, M.Ed.

1-2008

holistic assessment
Holistic Assessment
  • Holistic assessments go beyond the physical assessment
  • Include all aspects of the older person’s life
  • Used to improve person’s overall health and happiness
  • Need to obtain holistic information that consists of general information about the person
holistic assessment3
Holistic Assessment
  • Holistic information
    • Exercise plan; eating pattern; consumption of alcohol, caffeine, and water; sleep patterns; smoking habits; stress management techniques; sexual activity; medication record
physical assessment
Physical Assessment
  • The physical assessment includes a history of any problems related to the system being assessed
  • Actual assessment consists of inspection and palpation
physical assessment5
Physical Assessment
  • Assess by system
  • Head, neck, and face
    • History
      • Thyroid problems, head injury, neck injury
    • Inspection
      • Head– position, shape, size, symmetry, hair pattern
      • Face– facial muscles
      • Neck– venous distention, range of motion
physical assessment6
Physical Assessment
  • Head, neck, and face (cont.)
    • Palpation
      • Trachea, cervical muscles, carotid pulses, edema, tenderness
  • Nose and sinuses
    • History
      • Problems with nose or sinuses
physical assessment7
Physical Assessment
  • Nose and sinuses
    • Inspection
      • Size, shape, color of nose, swelling, drainage, difficulty moving air through nostrils, ability to smell
    • Palpation
      • Tenderness, masses
physical assessment8
Physical Assessment
  • Eyes
    • History
      • Changes in vision, excessive tearing, discharge
    • Inspection
      • Symmetry of eyebrows, pupils
      • Redness, swelling, discharge
      • Perform eye exam using Snellen’s eye chart
      • Check glasses
physical assessment9
Physical Assessment
  • Ears
    • History
      • Hearing loss, corrective devices, pain in ears, dizziness, drainage
    • Inspection
      • Do you have to repeat, size, shape, symmetry, lesions
    • Palpation
      • Pain or tenderness
physical assessment10
Physical Assessment
  • Mouth and throat
    • History
      • Pain, swelling, difficulty swallowing, sensitive teeth, fit of dentures, last dental exam
    • Inspection and palpation
      • Gums pink, moist, smooth
      • Teeth in good repair
      • Dentures fit well
      • Gag reflex and uvula
physical assessment11
Physical Assessment
  • Neurological
    • History
      • Headaches, shaking, trembling, confusion or memory loss, seizure disorder
    • Inspection
      • Level of orientation
      • Strength and symmetry of upper and lower extremities
      • Gait
physical assessment12
Physical Assessment
  • Peripheral vascular
    • History
      • History of diabetes
      • Pain, aches, numbness, or tingling in calves, feet, buttocks, or legs
      • Swelling in legs at end of day
physical assessment13
Physical Assessment
  • Peripheral Vascular
    • Inspection
      • Color of skin in upper and lower extremities
      • Edema in feet and legs
      • Venous stasis ulcers, ulceration on feet
    • Palpation
      • Skin temperature, pulses
physical assessment14
Physical Assessment
  • Cardiac
    • History
      • Shortness of breath, chest pain
      • History of smoking, exercise
    • Inspection
      • Visual pulsations, lifts, heaves
      • Cough, shortness of breath
      • Cyanosis of mucous or nail beds
physical assessment15
Physical Assessment
  • Cardiac (cont.)
    • Palpation
      • Thrills, heaves, lifts
      • Capillary refill
      • Skin temperature
      • Blood pressure
    • Auscultation
      • Irregular heartbeat
      • Murmurs
physical assessment16
Physical Assessment
  • Respiratory
    • History
      • Difficulty breathing, cough, pneumonia, lung disease
      • Oxygen use
      • Vaccinations
    • Inspection
      • Use of accessory muscles, nasal flaring, cyanosis
      • Posture
physical assessment17
Physical Assessment
  • Respiratory (cont.)
    • Palpation
      • Masses and tenderness of ribs
    • Auscultation
      • Abnormal sounds on inspiration and expiration
        • Crackles, wheezing, whistling, pleural

friction rub

physical assessment18
Physical Assessment
  • Gastrointestinal
    • History
      • Nutritional status, bowel habits, medications
      • Difficulty swallowing
    • Inspection
      • Skin lesions on abdomen or in skin folds
physical assessment19
Physical Assessment
  • Gastrointestinal (cont.)
    • Auscultation
      • Listen to all four quadrants for bowel sounds
    • Palpation
      • Ask about possible pain in abdomen
      • Feel for masses or rigidity
physical assessment20
Physical Assessment
  • Integumentary
    • History
      • Skin problems, allergies, skin regimen
    • Inspection
      • Observe entire body, including fingernails and toenails
      • Check for pallor, jaundice, petechiae, cyanosis, erythema
      • Pressure ulcers and other lesions
physical assessment21
Physical Assessment
  • Integumentary (cont.)
    • Palpation
      • Turgor, texture, and temperature
  • Musculoskeletal
    • History
      • Pain in joints and back
    • Inspection
      • Observe gait, range of motion
physical assessment22
Physical Assessment
  • Reproductive—Female
    • History
      • Prior problems with breasts
      • Menopause
      • Last pap smear
      • Sexual activity
physical assessment23
Physical Assessment
  • Reproductive—Female (cont.)
    • Inspection
      • Observe breasts for symmetry, discharge from nipples, lumps, discoloration
      • Observe genitalia for discharge, lesions, rash, discoloration
physical assessment24
Physical Assessment
  • Reproductive—Male
    • History
      • Changes in urinary stream
      • Urinary frequency or urgency
      • Burning on urination
      • Sexual activity
    • Inspection
      • Lesions, rashes, discoloration, discharge, circumcision
physical assessment25
Physical Assessment
  • Urinary
    • History
      • Prior problems with urinary tract
      • Medications affecting urination
      • Surgeries
      • Renal disease
    • Inspection
      • Amount and color of urine
physical assessment26
Physical Assessment
  • Urinary (cont.)
    • Palpation
      • Bladder distention, masses
  • Functional assessment
    • Important as physical assessment
    • Evaluate physical, cognitive, and social function
    • Evaluate strengths and deficits
physical assessment27
Physical Assessment
  • Functional assessment (cont.)
    • Activities of daily living
      • Katz’s ADL scale
      • Direct observation most valid indicator
      • Self-care tasks
    • Instrumental activities of daily living
      • Lawton’s scale for IADLs
      • Home-care tasks
physical assessment28
Physical Assessment
  • Functional assessment (cont.)
    • Social function
      • How person interacts with self, the environment, and others
      • Cultural and economic background