NCOA – Physiological Assessment – Part II

1. NCOA – Physiological Assessment – Part II Chapter 14 (4th ed.) Pati Cox, RN, BSN, M.Ed.

2. Cardiac System • History • Risk factors • Smoking • Exercise • Dypsnea – when • Chest pain – when, where, pain description, what relieves it

3. Cardiac System • Inspection • Lying down, sitting up, & standing up • Observe for palpations in neck • You may note pulsations in neck & chest if emaciated • Cough, SOB, venous or abdominal distention • Cyanosis – mucosa & nail beds • Edema – legs, ankles, feet

4. Cardiac System • Palpation • Feel front of chest over heart for: • Thrill – a palpable vibration • Lift or heave – pulsation that is more forceful than anticipated • Minimal changes in pulse when older adult changes positions • Capillary refill –longer than 2-3 sec. = abnormal • Skin temp • Blood pressure-orthostatic hypotension is common

5. Cardiac System • Auscultation • Assess heart rate • Typical faster heart rate • Less detectable or distinct • Atrial Fibrillation common • Note irregularities, intensity, rhythm – REPORT • Lay on Left side if difficult hearing • Murmur – clicking or humming sound - REPORT

6. Respiratory System Environmental concerns: Air pollution TB, TB Skin Test Chest x-ray Pneumovax Influenza Vaccine • History • Dypsnea, Activity or rest? • Cough, dry or productive, color & consistency • Lung Disease, pneumonia, CHF, anemia • O2 use

7. Respiratory System KYPHOSIS • Inspection • Barrel chest, sl. Use of intercostal muscles and sl. Prolonged respirations =normal • 12-24 breaths/min = normal • >24 = tachypnea; <12 = bradypnea (dec. consciousness, confusion, lethargy) • Nasal flaring and accessory muscles • Assess character or respirations (normal = even & unlabored) • Skin, lips & nail color for cyanosis • Posture – affects ability to breathe

8. Cyanosis

9. Barrel Chest

10. TriPod Position Patients with COPD – Emphysema will sit up Right with hands on Knees leaning forward resembling a Tripod

11. Respiratory System • Palpation • Anterior & Posterior Chest • Masses • Tenderness • Trachea • Deviation from midline

12. Respiratory System • Auscultation • Rem to avoid hyperventilation; ask to breathe normal in between deep breaths – dizziness • Should hear softer sounds and diminished sounds in lower bases • Listen for adventitious sounds

13. RESPIRATORY SYSTEM

14. Gastrointestinal System • History • Focus = Nutritional Status, bowel habits, & medications • 24 hour recall of diet • Fluids? (2000-3000 mL per day) • Tolerate diet, fluids? • Fiber intake • Sensations when eating, difficulty swallowing • Injury, infection • Laxative use • Pain – location • RLQ – Appendicitis • LLQ – Diverticulosis • Tenderness @ base of Xiphoid process – stomach pain, hiatal hernia, or referred pain from aorta

15. Gastrointestinal • The order of physical examination is: • Inspection • Auscultation • Need to listen to bowel sounds first before palpation • Palpation may elicit pain or a change in bowel sounds – want older adult relaxed • Palpation

16. Gastrointestinal

17. Gastrointestinal

18. Gastrointestinal - Auscultation

19. Gastrointestinal - Ascites

20. Gastrointestinal - Hepatomegaly

21. Gastrointestinal - Gallbladder

22. Gastrointestinal – Umbilical Hernia

23. Integumentary System • History • Most important aspect of assessment • Most common complaints • Pruritus • Pain • Parasthesia • Dermatitis • Sun exposure, environmental allergens, infectious diseases • Skin care regimen, medications – allergic reactions, soaps, etc

24. Inspection Complete in well lit room Scalp, skin folds, behind ears, Fingernails, toenails, genitalia, buttocks and face Skin color, odor Uniformity Petechiae Ecchymosis Pallor Cyanosis, dusky, gray Jaundice Pressure points over bony prominences Braden Scale Skin lesions- see text Palpate Skin turgor – forehead or anterior chest Skin texture Skin temperature – with back of hand Integumentary System

25. Integumentary System – Braden Scale

26. Integumentary System – Braden Scale

27. Integumentary System – Skin lesions • TEXT (3RD EDITION) PAGE 169 • TEXT (4TH EDITION) PAGE 234

28. History Complaints = Pain Stiffness Redness Limitation of movement Joint deformity Assess Pain Sudden onset of low backpain = compressionfx. REPORT Inspection If possible – ADL’s & IADL’S Expect some general decline in ROM Gait, endurance Ability to operate wheelchair Shoes Transfer Symmetry of movement Lesions on feet REPORT all abnormalities Musculoskeletal

29. History Sexual function Self breast exam Breast cancer - Hx Nipple discharge, pain, lumps, skin discoloration, change in breast shape HRT or other meds such as Digitalis, Thyroid or Antihypertensives Pap smears Vaginal dryness, bleeding Inspection External genitalia Skin or mucous membranes – lesions, rashes, discoloration, hair loss Inflammation, discharge Asymmetry Reproductive - Woman

30. History BPH (Benign Prostatic Hypertrophy or Hyperplasia) Change in urine stream Nocturia Medications Diuretics, Antihypertensives make BPH worse Breast exam Inspection External Genitalia Skin, mucous membranes Lesions Rashes Discoloration Hair loss Inflammation Discharge Asymmetry Circumcision Reproductive - Male

31. Urinary System • History • Question chief complaint • Most common c/o = • Urgency to void • Leakage upon position changes • Frequency of urination • Voiding small amounts • Incontinence – embarrassed • UTI – most common cause of fever and disorientation in the elderly • Pressure Ulcer formation • Normal urinary & bowel habits • Medical History – children, surgeries, diabetes • Medications – diuretics, antiparkinsonian • Immobility • Dehydration

32. Inspection Assess Ua. Amount Color Sediment Incontinence Pressure ulcers Palpation Distention Masses Pelvic Discomfort Urinary System

33. Functional Assessment • Holistic approach to evaluating the older adult • Physical • Cognitive • Social • As important as physiological assessment • What the O.A. can (strength) and cannot do (deficit) • Assists in setting realistic goals to maximize functional strengths, compensate for deficits and maintain optimal independence

34. Functional Assessment • Physical • Individuals current health status • How well he/she performs ADL’s & IADL’s • Cognitive • Individuals memory, judgment, thinking abilities • Social • Psychosocial approach to determine how the individual interacts with the environment and others

35. Functional Assessment • Cure is not a goal – focus is to set realistic goals • Maximize functional strengths • Compensate for functional deficits • Achieve and maintain optimal independence in function • Older adult has to many chronic illnesses that are irreversible • Nurses • Monitor for changes • Utilize resources • Validate • Communicate with team members

36. ADL’s Performed while taking care of oneself Bathing Dressing Toileting Feeding Ambulating & transferring Continence Katz Scale –tool utilized to determine overall ability of person Page 172 (3RD ED) Page 238 (4th ED) IADL’s (Instrumental ADL) Activities that support independent living Telephone Cook Shop Laundry Manage finances Take meds Prepare meals Lawton’s Scale – tool utilized to determine ability Page 173 (3rd ED) Page 239 (4th ED) Functional Assessment

37. Functional Assessment • Social Function • How older adult interacts with self, environment, & others • How person functions as a member of the community • Must consider: culture, socioeconomic status • Self Concept – affects older adult’s ability to perform self-care activities; psychological intervention may be necessary to improve self concept