NCOA

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
• gt24 tachypnea lt12 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 _at_ 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
Inspection Auscultation Palpation
Skin rashes, lesions, constrictive clothing marks Rigidity bowel obstruction - REPORT Bulges hernia Divide abdomen into 4 quads Bowel Sounds may have to listen for 5 min. if no sounds audible due to dec. gastric motility in o.a. Have the o.a. relax May be difficult if obese Firmness, soft Masses Diverticulosis, fecal impaction, cancer, mesenteric thrombosis
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
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

25
Integumentary System Braden Scale
26
Integumentary System Braden Scale
27
Integumentary System Skin lesions
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

• TEXT (3RD EDITION) PAGE 169
• TEXT (4TH EDITION) PAGE 234

28
Musculoskeletal

• History
• Complaints
• Pain
• Stiffness
• Redness
• Limitation of movement
• Joint deformity
• Assess Pain
• Sudden onset of low backpain compression fx.
  REPORT

• Inspection
• If possible ADLs IADLS
• Expect some general decline in ROM
• Gait, endurance
• Ability to operate wheelchair
• Shoes
• Transfer
• Symmetry of movement
• Lesions on feet
• REPORT all abnormalities

29
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

30
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

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
Urinary System

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

• Palpation
• Distention
• Masses
• Pelvic Discomfort

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 ADLs IADLs
• 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
Functional Assessment

• ADLs
• 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)

• IADLs (Instrumental ADL)
• Activities that support independent living
• Telephone
• Cook
• Shop
• Laundry
• Manage finances
• Take meds
• Prepare meals
• Lawtons Scale tool utilized to determine
  ability
• Page 173 (3rd ED)
• Page 239 (4th ED)

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 adults ability to
  perform self-care activities psychological
  intervention may be necessary to improve self
  concept