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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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nursing care of the older adult

Nursing Care of The Older Adult

Chapter 14 (4th ed.)

Physiological Assessment-Part 1

Pati Cox, RN, BSN, M.Ed.

normal age related changes
Normal Age Related Changes
  • Refer to Chapter 2 – pages 22-28
  • Class Activity
outline
Outline
  • Physical Assessment
  • History
  • Head to Toe Assessment
  • Functional Assessment
physical 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
history
History
  • Exercise Plan
  • Eating Patterns
  • Weight loss/gain
  • Alcohol, caffeine Water
  • Smoking habits
  • Stress management
  • Sexual Activity
  • Medications –Rx/OTC
slide8
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
slide9
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

Mouth and Throat
neurological system
Neurological System
  • History
    • Headaches
    • Shaking, trembling, tremors
    • Seizures, existing disorder, treatment, circumstances
neurological system1
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 vascular1
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

Peripheral Vascular

Measure girth of extremity when edematous – mark so measurement can be made at same location each time

venous stasis ulcers
Venous Stasis Ulcers
  • Usually on side of ankle
  • Rare with varicose veins
  • Found with deep vein insufficiency
arterial stasis ulcer
Arterial Stasis Ulcer
  • Usually involves toes or places where the skin has been bumped or bruised
  • Pale when elevated
vascular stasis ulcers continued
Vascular Stasis Ulcers (Continued)
  • http://www.medicaledu.com/venous.htm
  • http://www.emedicine.com/plastic/topic467.htm#section~pictures
  • http://www.podiatry.curtin.edu.au/encyclopedia/ulcers/content.html
gangrene
Gangrene

Eschar

wound quiz more pictures
Wound Quiz & More Pictures

http://woundcare.org/newsvol2n2/ar8.htm

http://www.podiatry.curtin.edu.au/encyclopedia/ulcers/content.html