257 Exam 2 Study GuidE
Unit 3 Key Concept Chp 8
Three approaches for obtaining assessment data (pg. 93)
Self-rapport, report-by-proxy, observation
Self-rapport: in this format either the questions are asked directly, or the person is expected to respond about
his or her health status.
Report By Proxy: When assessment information is obtained indirectly (report by proxy), the nurse asks another
person to report his or her observation. This is used for cognitively impaired patient.
Observation: In this approach, the nurse collects and records objective and subjective data using parameters
considered to be objective for performance based functional assessment (Ex: Distance the person walk).
Considerations of Common Changes in Late Life During the Physical Assessment (Table 8.1 pg.97)
Height & · Monitor for changes in weight.
Weight · Weight gain: Especially important if the person has any heart disease; be
alert for early signs of heart failure.
· Weight loss: Be alert for indications of malnutrition from dental problems,
depression, or cancer. Check for mouth lesions from ill-fitting dentures.
Temperature · Even a low-grade fever could be an indication of a serious illness.
Temperatures as low as 100° F may indicate pending sepsis.
Blood Pressure · Positional blood pressure readings should be obtained because of the high
occurrence of orthostatic hypotension. Both arms should be checked (at
heart level) and the arm with the highest measurement should be
recorded. Isolated systolic hypertension is common.
Skin · Check for indications of solar damage, especially among persons who
worked outdoors or live-in sunny climates. Because of thinning of skin,
“tenting” cannot be used as a measure of hydration status.
Ears · Cerumen impactions are common. These must be removed before hearing
can be adequately assessed or tympanic membrane visualized.
Hearing · High-frequency hearing loss (presbycusis) is common. The person often
complains that he or she can hear but not understand because some, but
not all, sounds are lost. The person with severe but unrecognized hearing
loss may be incorrectly thought to have dementia.
Eyes · Lids sag and position of lids may change. Reduced pupillary responsiveness
(miosis) occurs (normal if equal bilaterally). Gray ring around the iris (arcus
senilis) may develop.
Vision · Person exhibits increased glare sensitivity, decreased contrast sensitivity,
and need for more light to see and read. Ensure that waiting rooms,
hallways, and exam rooms are adequately lit. Decreased color
discrimination may affect ability to self-administer medications safely.
Mouth · Excessive dryness is common and exacerbated by many medications.
Cannot use mouth moisture to estimate hydration status. Periodontal
disease is common. Decreased sense of taste occurs. Tooth surface may be
abraded.
Neck · Because of loss of subcutaneous fat it may appear that carotid arteries are
enlarged when they are not.
Chest · Any kyphosis will alter the location of the lobes, making careful
assessment more important.
· Risk for aspiration pneumonia is increased, increasing the importance of
, the lateral exam and the need for measurement of oxygen saturation.
· Evidence of pneumonia may not be evident if the person is dehydrated.
· Third heart sound indicative of pathology.
Heart · Listen carefully for third and fourth heart sounds. Faint fourth heart sounds may
be heard. Determine if this was present in the past or is new. Up to 50% of
persons have a heart murmur.
Extremities · Dorsalis pedis and posterior tibial pulses are very difficult or impossible to
palpate. Must look for other indications of vascular integrity.
Abdomen · Because of deposition of fat in the abdomen, auscultation of bowel sounds
may be difficult.
Musculoskeletal · Osteoarthritis is very common and pain is often undertreated. Ask about
pain and function in joints. Conduct very gentle passive range of motion if
active range of motion not possible. Do not push past comfort level.
Observe for gait disorders. Observe the person get in and out of chair in
order to assess independent function and fall risk.
Neurological · Although there is a gradual decrease in muscle strength, it still should
remain equal bilaterally. Greatly diminished or absent ankle jerk (Achilles)
tendon reflex is common and normal. Decreased or absent vibratory sense
of the lower extremities is common, making testing unnecessary.
Genitourinary: · Men have pendulous scrotum with less rugae. Have thin and graying pubic
Male hair
Genitourinary: · Women have nonpalpable ovaries; short, dryer vagina; decreased size of
Female labia and clitoris; sparse pubic hair. NOTE: Use utmost care with exam to
avoid trauma to the tissues.
Consider what nursing interventions to employ with these changes.
FANCAPES (pg. 96)
Ø Fluids: “State of hydration”. Oral hydration is the first TX approach for dehydration.
Water is best but depends on the severity the TX may include IV or hypodermoclysis (HDC) approach.
General rule = replace 50% of loss within the first 12 hours or 1L/day in a febrile elder.
Nurse should monitor: S/S of overhydration (Unexplained wt. gain, pedal edema, neck vein distention,
SOB)
PT taking SSRI = monitor their na+ and hydration status due to risk of hyponatremia
Ø Aeration: “Respiratory function”. Intervention is based on stabilizing the disease.
Educate on: smoking cessation, secretion clearance techniques, how to deal with supplemental O2 if
required, parental fluid, BX
It’s not unusual for COPD PT sat rate to be 90%-95%. It’s a concern when it’s below.
Sat rate of 88% is respiratory emergency, PT may be advancing to Respiratory failure.
Measure Sat rate, is O2 required and if so, is the PT able to obtain it.
Check PT respiratory rate and depth at: rest, during activity, talking, walking.
What sound were auscultated and what do they suggest?
Ø Nutrition: “Type and amount of food consumed”.
Intervention: What is PT oral health status, what is the impact of periodontal disease
Has recommended diet been followed and consistent with culture, and affordable.
Collab with interprofessional team (Dietitian, pharmacist, social worker, OT, Speech)
, Does the PT have the ability to bite, chew, swallow?
Ø Communication: “Adequate ability to communicate needs”
Is the PT depending on lip reading or is vision adequate?
Does PT have expressive or receptive aphasia if so is Speech therapist available?
What is PT literacy level?
Ø Activity: “Ability to meet basic needs of toileting, grooming, and meal preparation”
Assess for falling risk, assistive devices need, degree of aerobic exercise to participate.
Interprofessional team (Nurse, PT, personal trainers)
Ø Pain: “Physical, psychological, or spiritual pain”
Are there any cultural barriers that make assessment/expression of pain difficult?
What does PT us for pain relief?
Intervention: Careful listening, positive regard, use of pillow for support, seating mattress, frequent rest
period
Encourage PT to keep diary of highs and lows level of pain.
Ø Elimination: “Difficulty with bladder or bowel elimination are not normal part of aging”
Does the environment interfere with elimination and personal hygiene?
Is high-rise toilet seat, bedside commode available?
How is this affecting the PT social functioning and self-esteem.
Ø Socialization: “Ability to give and receive love and friendship"
The nurse will assess PT ability to deal with loss, interact with others in give-take situations.
Mini-mental State Exam (pg. 99) “MMSE”
Used to screen and monitor orientation, short term memory and attention, calculation ability, language, and
ability to correctly copy a figure.
Geriatric Depression Scale (pg. 102) “GDS”
This has been successful in determining depression because it de-emphasize physical complaints, sex drive,
appetite, and those things affected by medications.
Do not use in PT with Dementia, or cognitive impairment.
Functional assessment (pg.102)
A thorough functional assessment includes the following:
1. Identify areas in which PT need help.
2. Identify changes in PT abilities from one period to another.
Unit 3 Key Concept Chp 8
Three approaches for obtaining assessment data (pg. 93)
Self-rapport, report-by-proxy, observation
Self-rapport: in this format either the questions are asked directly, or the person is expected to respond about
his or her health status.
Report By Proxy: When assessment information is obtained indirectly (report by proxy), the nurse asks another
person to report his or her observation. This is used for cognitively impaired patient.
Observation: In this approach, the nurse collects and records objective and subjective data using parameters
considered to be objective for performance based functional assessment (Ex: Distance the person walk).
Considerations of Common Changes in Late Life During the Physical Assessment (Table 8.1 pg.97)
Height & · Monitor for changes in weight.
Weight · Weight gain: Especially important if the person has any heart disease; be
alert for early signs of heart failure.
· Weight loss: Be alert for indications of malnutrition from dental problems,
depression, or cancer. Check for mouth lesions from ill-fitting dentures.
Temperature · Even a low-grade fever could be an indication of a serious illness.
Temperatures as low as 100° F may indicate pending sepsis.
Blood Pressure · Positional blood pressure readings should be obtained because of the high
occurrence of orthostatic hypotension. Both arms should be checked (at
heart level) and the arm with the highest measurement should be
recorded. Isolated systolic hypertension is common.
Skin · Check for indications of solar damage, especially among persons who
worked outdoors or live-in sunny climates. Because of thinning of skin,
“tenting” cannot be used as a measure of hydration status.
Ears · Cerumen impactions are common. These must be removed before hearing
can be adequately assessed or tympanic membrane visualized.
Hearing · High-frequency hearing loss (presbycusis) is common. The person often
complains that he or she can hear but not understand because some, but
not all, sounds are lost. The person with severe but unrecognized hearing
loss may be incorrectly thought to have dementia.
Eyes · Lids sag and position of lids may change. Reduced pupillary responsiveness
(miosis) occurs (normal if equal bilaterally). Gray ring around the iris (arcus
senilis) may develop.
Vision · Person exhibits increased glare sensitivity, decreased contrast sensitivity,
and need for more light to see and read. Ensure that waiting rooms,
hallways, and exam rooms are adequately lit. Decreased color
discrimination may affect ability to self-administer medications safely.
Mouth · Excessive dryness is common and exacerbated by many medications.
Cannot use mouth moisture to estimate hydration status. Periodontal
disease is common. Decreased sense of taste occurs. Tooth surface may be
abraded.
Neck · Because of loss of subcutaneous fat it may appear that carotid arteries are
enlarged when they are not.
Chest · Any kyphosis will alter the location of the lobes, making careful
assessment more important.
· Risk for aspiration pneumonia is increased, increasing the importance of
, the lateral exam and the need for measurement of oxygen saturation.
· Evidence of pneumonia may not be evident if the person is dehydrated.
· Third heart sound indicative of pathology.
Heart · Listen carefully for third and fourth heart sounds. Faint fourth heart sounds may
be heard. Determine if this was present in the past or is new. Up to 50% of
persons have a heart murmur.
Extremities · Dorsalis pedis and posterior tibial pulses are very difficult or impossible to
palpate. Must look for other indications of vascular integrity.
Abdomen · Because of deposition of fat in the abdomen, auscultation of bowel sounds
may be difficult.
Musculoskeletal · Osteoarthritis is very common and pain is often undertreated. Ask about
pain and function in joints. Conduct very gentle passive range of motion if
active range of motion not possible. Do not push past comfort level.
Observe for gait disorders. Observe the person get in and out of chair in
order to assess independent function and fall risk.
Neurological · Although there is a gradual decrease in muscle strength, it still should
remain equal bilaterally. Greatly diminished or absent ankle jerk (Achilles)
tendon reflex is common and normal. Decreased or absent vibratory sense
of the lower extremities is common, making testing unnecessary.
Genitourinary: · Men have pendulous scrotum with less rugae. Have thin and graying pubic
Male hair
Genitourinary: · Women have nonpalpable ovaries; short, dryer vagina; decreased size of
Female labia and clitoris; sparse pubic hair. NOTE: Use utmost care with exam to
avoid trauma to the tissues.
Consider what nursing interventions to employ with these changes.
FANCAPES (pg. 96)
Ø Fluids: “State of hydration”. Oral hydration is the first TX approach for dehydration.
Water is best but depends on the severity the TX may include IV or hypodermoclysis (HDC) approach.
General rule = replace 50% of loss within the first 12 hours or 1L/day in a febrile elder.
Nurse should monitor: S/S of overhydration (Unexplained wt. gain, pedal edema, neck vein distention,
SOB)
PT taking SSRI = monitor their na+ and hydration status due to risk of hyponatremia
Ø Aeration: “Respiratory function”. Intervention is based on stabilizing the disease.
Educate on: smoking cessation, secretion clearance techniques, how to deal with supplemental O2 if
required, parental fluid, BX
It’s not unusual for COPD PT sat rate to be 90%-95%. It’s a concern when it’s below.
Sat rate of 88% is respiratory emergency, PT may be advancing to Respiratory failure.
Measure Sat rate, is O2 required and if so, is the PT able to obtain it.
Check PT respiratory rate and depth at: rest, during activity, talking, walking.
What sound were auscultated and what do they suggest?
Ø Nutrition: “Type and amount of food consumed”.
Intervention: What is PT oral health status, what is the impact of periodontal disease
Has recommended diet been followed and consistent with culture, and affordable.
Collab with interprofessional team (Dietitian, pharmacist, social worker, OT, Speech)
, Does the PT have the ability to bite, chew, swallow?
Ø Communication: “Adequate ability to communicate needs”
Is the PT depending on lip reading or is vision adequate?
Does PT have expressive or receptive aphasia if so is Speech therapist available?
What is PT literacy level?
Ø Activity: “Ability to meet basic needs of toileting, grooming, and meal preparation”
Assess for falling risk, assistive devices need, degree of aerobic exercise to participate.
Interprofessional team (Nurse, PT, personal trainers)
Ø Pain: “Physical, psychological, or spiritual pain”
Are there any cultural barriers that make assessment/expression of pain difficult?
What does PT us for pain relief?
Intervention: Careful listening, positive regard, use of pillow for support, seating mattress, frequent rest
period
Encourage PT to keep diary of highs and lows level of pain.
Ø Elimination: “Difficulty with bladder or bowel elimination are not normal part of aging”
Does the environment interfere with elimination and personal hygiene?
Is high-rise toilet seat, bedside commode available?
How is this affecting the PT social functioning and self-esteem.
Ø Socialization: “Ability to give and receive love and friendship"
The nurse will assess PT ability to deal with loss, interact with others in give-take situations.
Mini-mental State Exam (pg. 99) “MMSE”
Used to screen and monitor orientation, short term memory and attention, calculation ability, language, and
ability to correctly copy a figure.
Geriatric Depression Scale (pg. 102) “GDS”
This has been successful in determining depression because it de-emphasize physical complaints, sex drive,
appetite, and those things affected by medications.
Do not use in PT with Dementia, or cognitive impairment.
Functional assessment (pg.102)
A thorough functional assessment includes the following:
1. Identify areas in which PT need help.
2. Identify changes in PT abilities from one period to another.
