Nursing Care of The Older Adult

Chapter 14 (4th 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

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

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

Head, Neck, & Face

History Inspection PalpationHead 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 PalpationAny problems with nose/sinusesNosebleeds?

(Epitaxis)

(more common in O.A. than younger adults)

Size, shape, color of noseFlaring of nostrilsNasal drainageNasal cavity – drainage, swelling, polyps, bleedingNasal mucosa – moist/dark pinkMen – inc. nasal hairAssess movement of air through each nares (nose)Smell (should be the same in each nares) provide some common smells

Tenderness or massesAbnormal findingsSwelling of mucosaBleeding, swelling of mucosa, deviated septumDischargePerforationPolypsInfectionCrustingDrynessblockage

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

History Inspection Palpation Auscultation

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, painWhat makes it worse or betterColor of extremities, hair lossSwelling – when?

Always compare 1 side to anotherSkin color lying downChronic Venous insufficiencyArterial insufficiencyEdema of hands & feetMeasure girth of feet & legsStasis ulcers = rare with varicose veins but occur with deep vein insufficiency

Skin tempPeripheral pulsesCheck for symmetry for pulsesCheck pulse one at a timeMark 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)

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/ulcers/content.html