NCOA – Physiological Assessment – Part II

Chapter 14 (4th ed.)

Pati Cox, RN, BSN, M.Ed.

Cardiac System

History– Risk factors– Smoking – Exercise– Dypsnea – when– Chest pain – when,

where, pain description, what relieves it

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

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

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

Respiratory System

History– Dypsnea, Activity or rest? – Cough, dry or productive, color &

consistency– Lung Disease, pneumonia, CHF, anemia– O2 use

Environmental concerns:

Air pollutionTB, TB Skin TestChest x-rayPneumovaxInfluenza Vaccine

Respiratory System

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

KYPHOSIS

Cyanosis

Barrel Chest

TriPod Position

Patients with COPD –Emphysema will sit upRight with hands onKnees leaning forward resembling aTripod

Respiratory System

Palpation– Anterior & Posterior

Chest Masses Tenderness

– Trachea Deviation from midline

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

RESPIRATORY SYSTEM

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

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

Gastrointestinal

Gastrointestinal

Inspection Auscultation Palpation

1. Skin – rashes, lesions, constrictive clothing marks

2. Rigidity = bowel obstruction - REPORT

3. Bulges = hernia

1. Divide abdomen into 4 quads

2. Bowel Sounds – may have to listen for 5 min. if no sounds audible due to dec. gastric motility in o.a.

1. Have the o.a. relax

2. May be difficult if obese

3. Firmness, soft

4. Masses =

5. Diverticulosis, fecal impaction, cancer, mesenteric thrombosis

Gastrointestinal - Auscultation

Gastrointestinal - Ascites

Gastrointestinal - Hepatomegaly

Gastrointestinal - Gallbladder

Gastrointestinal – Umbilical Hernia

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

Integumentary System

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 – Braden Scale

Integumentary System – Braden Scale

Integumentary System – Skin lesions

TEXT (3RD EDITION) PAGE 169

TEXT (4TH EDITION) PAGE 234

Normal Abnormal

Seborrheic Keratosis

Senile or Actinic keratosis

Senile purpura Squamous cell carcinoma

Cherry angioma

Sebaceous

Hyperplasia

Basal Cell epithelioma

Malignant Melanoma

Lentigo maligna

melanoma

Musculoskeletal

History– Complaints =

Pain Stiffness Redness Limitation of movement Joint deformity

– Assess Pain– Sudden onset of low

backpain = compression fx. 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

Reproductive - Woman

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 - Male

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

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

Urinary System

Inspection– Assess Ua. Amount– Color– Sediment– Incontinence– Pressure ulcers

Palpation– Distention– Masses– Pelvic Discomfort

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

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

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

Functional Assessment

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

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