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 22-28 Class Activity. Outline. Physical Assessment History Head to Toe Assessment Functional Assessment.
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Chapter 14 (4th ed.)
Physiological Assessment-Part 1
Pati Cox, RN, BSN, M.Ed.
Teeth sensitive to hot/cold
Swelling in mouth/throat
Difficulty chewing or swallowing
Food tastes? Mouth dry?
How often brush/floss teeth
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 - thrushMouth and Throat
Common in elderly
Legs are cyanotic-dk blue/purple when dependent
Petechiae may be present
Distended tortuous veins
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
When in dependent position – gravity enhances – arterioles dilate & deliver blood to starved tissuesPeripheral Vascular
Measure girth of extremity when edematous – mark so measurement can be made at same location each time