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Nursing Care of The Older Adult

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

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  1. Nursing Care of The Older Adult Chapter 14 (4th ed.) Physiological Assessment-Part 1 Pati Cox, RN, BSN, M.Ed.

  2. Normal Age Related Changes • Refer to Chapter 2 – pages 22-28 • Class Activity

  3. Outline • Physical Assessment • History • Head to Toe Assessment • Functional Assessment

  4. 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

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

  6. Head, Neck, & Face

  7. Nose and Sinuses

  8. 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

  9. 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

  10. 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

  11. Neurological System • History • Headaches • Shaking, trembling, tremors • Seizures, existing disorder, treatment, circumstances

  12. 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)

  13. Peripheral Vascular

  14. 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

  15. Venous Stasis Ulcers • Usually on side of ankle • Rare with varicose veins • Found with deep vein insufficiency

  16. Venous Insufficiency Hemosiderin

  17. Venous Insufficiency

  18. Arterial Stasis Ulcer • Usually involves toes or places where the skin has been bumped or bruised • Pale when elevated

  19. Arterial Insufficiency

  20. 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

  21. Gangrene Eschar

  22. Cellulitis

  23. Wound Quiz & More Pictures http://woundcare.org/newsvol2n2/ar8.htm http://www.podiatry.curtin.edu.au/encyclopedia/ulcers/content.html

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