Health Assessment - Assessing the Older Adult

The Older Adult in Australia

• As of 2020, 16% of the Australian population (around 4.2 million people) are aged 65 or over.
• By 2066, the proportion of people aged 65 and over is predicted to increase to between 21-23% of the total population.
• The proportion of people aged 85 and over has increased from 0.5% in 1970 to 2.1% in 2020 and is expected to continue to rise to between 3.6% and 4.4% in 2066.

Physiological Changes Associated with Ageing

• Ageing affects all body systems, including:
  • Neurological system
  • Cardiovascular system
  • Respiratory system
  • Genitourinary and renal systems
  • Gastrointestinal system
  • Reproductive systems (Male and Female)
  • Musculoskeletal system
  • Integumentary system
• Other physiological changes associated with ageing include:
  • Decreased myelin sheath of nerves
  • Decreased neurotransmitter production
  • Decline in mental flexibility, abstract thinking, and recall
  • Decreased cardiac output and increased blood pressure
  • Decreased respiratory endurance and increased airway resistance
  • Kidney shrinkage and decreased renal filtration rate
  • Decreased digestive enzyme production and gut motility
  • Decreased breast tissue and oestrogen production in females
  • Decreased testicular size and testosterone levels in males

Physiological Changes of the Older Adult: Neurological System

• Myelin sheath of nerves degenerates
• Decreased neurotransmitter production

Physiological Changes of the Older Adult: Cardiovascular System

• Decreased cardiac output
• Increased blood pressure
• Calcifications and fibrosis of cardiac valves
• Arterial system becomes increasingly rigid

Physiological Changes of the Older Adult: Respiratory System

• Decreased respiratory endurance
• Increased airway resistance
• Loss of alveolar capillaries and lung tissue and pulmonary wall thickening
• Cough reflex decreases (increased risk of aspiration)

Physiological Changes of the Older Adult: Genitourinary and Renal Systems

• Kidney shrinkage
• Decreased renal filtration rate
• Decreased renal efficiency
• Subsequent loss of protein from kidney

Physiological Changes of the Older Adult: Gastrointestinal System

• Decreased salivary secretions and swallowing difficulties
• Decreased number of taste buds
• Decreased peristalsis
• Decline in large bowel transit time
• Decreased production of digestive enzymes
• Abdominal musculature diminishes in mass and tone
• Increased fat deposition in abdominal area

Physiological Changes of the Older Adult: Female Reproductive System

• Adipose tissue of the breast atrophies
• Diminished breast tissue
• Pendulous and sagging breasts
• Decreased oestrogen production
• Decreased secretions
• Atrophy of epithelial lining of vagina
• Atrophy of internal and external reproductive organs
• Decreased uterine size
• Atrophy of pelvic muscles
• Decrease in perineal muscle tone

Physiological Changes of the Older Adult: Male Reproductive System

• Testicular degeneration resulting in decreased testicular size
• Decreased testosterone levels
• Decreased sperm count
• Prostate enlargement

Physiological Changes of the Older Adult: Musculoskeletal System

• Decreased bone density
• Muscle fibers deteriorate and are replaced by fibrous connective tissue
• Muscle atrophy
• Decreased muscle mass and strength
• Bone demineralisation
• Shortening of trunk as a result of intervertebral space narrowing
• Decreased joint mobility
• Decreased range of joint motion

Physiological Changes of the Older Adult: Integumentary System

• Skin: spotty pigmentation, pallor, dryness, and decreased elasticity
• Hair: thinning and greying on scalp; decreased amount on extremities and in pubic area
• Nails: decreased growth rate, thickening, and splitting

Pain Assessment in Dementia

• The Abbey Pain Scale is used to measure pain in people with dementia who cannot verbalize.
• The scale has 6 questions to assess pain:
  • Q1: Vocalization (e.g. whimpering, groaning, crying)
  • Q2: Facial expression (e.g. looking tense, frowning, grimacing)
  • Q3: Change in body language (e.g. fidgeting, rocking, guarding part of body)
  • Q4: Behavioural change (e.g. increased confusion, refusing to eat)
  • Q5: Physiological change (e.g. temperature, pulse or blood pressure outside normal limits)
  • Q6: Physical changes (e.g. skin tears, pressure areas, arthritis)

Scoring and Interpretation

• Add scores for questions 1-6 to obtain the Total Pain Score.
• The Total Pain Score is categorized into:
  • 0-2: No pain
  • 3-7: Mild pain
  • 8-13: Moderate pain
  • 14+: Severe pain

Assessment of Cognitive Status

• The Mini-Mental State Examination (MMSE) is used to assess cognitive status in older adults.
• The MMSE is a widely used tool to assess cognitive impairment.

Delirium Screening

• The Confusion Assessment Method (CAM) is used to screen for delirium in older adults.
• The CAM is a reliable and valid tool for diagnosing delirium.

Disability Assessment

• Disability is an umbrella term that includes impairments, activity limitations, and participation restrictions.
• The Assessment Tool is used to assess the person with a disability.

Skin Tear Grading and Pressure Injury

• The Waterlow Scale is used to assess the risk of pressure injury.
• The scale takes into account various factors, including skin tears, pressure areas, and medical conditions.
• The scale scores range from 10 to 24, with higher scores indicating a higher risk of pressure injury.

Data Collection in Nursing Assessment

• Subjective data collection involves gathering information from the patient through interviews, questionnaires, and other methods
• Types of subjective data include:
  • Chief complaint: the patient's primary reason for seeking medical attention
  • History of present illness (HPI): detailed information about the patient's symptoms and condition
  • Past medical history: previous illnesses, allergies, and medical conditions
  • Family medical history: medical conditions and risk factors in the patient's family
  • Review of systems (ROS): a systematic review of the patient's body systems
  • Medications and allergies: current medications, dosages, and allergies
  • Social and cultural history: lifestyle, occupation, and cultural factors that may impact health

Objective Data Analysis

• Objective data collection involves gathering information through physical examination, diagnostic tests, and other objective measures
• Types of objective data include:
  • Vital signs: temperature, pulse, blood pressure, respiratory rate, and oxygen saturation
  • Physical examination findings: observations and measurements from the physical exam
  • Laboratory and diagnostic test results: blood work, imaging studies, and other test results
  • Anthropometric measurements: height, weight, body mass index (BMI), and other measurements

Body Systems Assessment

• Body systems assessment involves evaluating the patient's body systems to identify potential health problems
• Body systems to be assessed include:
  • Integumentary system: skin, hair, and nails
  • Musculoskeletal system: muscles, bones, and joints
  • Cardiovascular system: heart and blood vessels
  • Respiratory system: lungs and breathing
  • Neurological system: brain, spinal cord, and nerves
  • Gastrointestinal system: digestive system
  • Endocrine system: hormones and glands
  • Renal/urinary system: kidneys and urinary tract
  • Reproductive system: male and female reproductive systems

Abnormal Findings Identification

• Abnormal findings identification involves recognizing deviations from normal during the assessment
• Types of abnormal findings include:
  • Abnormal vital signs: deviations from normal ranges
  • Abnormal physical examination findings: unusual observations or measurements
  • Abnormal laboratory and diagnostic test results: deviations from normal ranges
  • Abnormal anthropometric measurements: deviations from normal ranges

Primary Survey Techniques

• Primary survey techniques involve a rapid and systematic assessment of the patient's airway, breathing, and circulation (ABCs)
• Primary survey techniques include:
  • Airway assessment: checking for patency and clearing the airway if necessary
  • Breathing assessment: evaluating respiratory rate, rhythm, and effort
  • Circulation assessment: evaluating pulse, blood pressure, and perfusion
  • Disability assessment: evaluating neurological status and level of consciousness
  • Exposure assessment: evaluating for potential injuries or conditions that may require further assessment

Cognitive Decline

• Age is a significant risk factor for cognitive decline, with decreased processing speed and reaction time
• Impaired memory, especially short-term and working memory, is a hallmark of cognitive decline
• Executive function, including planning, decision-making, and problem-solving, is also negatively impacted
• Cognitive decline increases the risk of dementia, Alzheimer's disease, and other neurodegenerative disorders

Factors Contributing to Cognitive Decline

• Genetics play a role in cognitive decline
• Lifestyle factors, such as physical inactivity, smoking, and social isolation, contribute to cognitive decline
• Certain medical conditions, including hypertension, diabetes, and sleep disorders, also contribute to cognitive decline
• Certain medications, such as anticholinergics and benzodiazepines, can exacerbate cognitive decline

Sensory Impairment

• Age-related changes in sensory systems lead to visual impairment, including presbyopia and increased risk of cataracts, glaucoma, and age-related macular degeneration
• Hearing impairment, including presbycusis, increases with age, leading to a higher risk of tinnitus and balance disorders
• Decreased sense of smell and taste, and impaired proprioception (sense of body position and movement), are also common with age
• Sensory impairment increases the risk of falls and injuries, decreases independence and social participation, and impairs communication and relationships

Mobility Assessment

• Mobility assessment is crucial in older adults to identify the risk of falls and injuries, evaluate functional ability and independence, and develop exercise and rehabilitation programs
• Mobility assessment components include gait speed and balance, muscle strength and endurance, range of motion and flexibility, and functional tasks such as walking, transfers, and stairs

Polypharmacy Management

• Polypharmacy, defined as taking five or more medications concurrently, increases the risk of adverse drug reactions and interactions, decreases medication adherence, and increases the risk of falls and hospitalization
• Polypharmacy management strategies include medication reconciliation and review, deprescription and optimization of medications, and patient education and support

Incontinence Management

• Urinary incontinence (UI), fecal incontinence (FI), and dual incontinence (UI and FI) are common in older adults
• Age-related changes in bladder and bowel function, medical conditions, and medications contribute to incontinence
• Management strategies include behavioral interventions, pharmacological interventions, absorbent products, catheters, surgery, and other invasive treatments

Respiratory Assessment

• Large tongue and obligate nose breathing increase risk of airway obstruction
• Cricoid cartilage is narrow, and trachea is short
• Smaller tubes are used for pediatric airways
• Respiratory rate varies with age and is a key indicator of distress
• Rate > 40 breaths/minute requires immediate assessment
• Look for signs of distress: sub-sternal recession, intercostal retractions, or tracheal tug

Circulatory Assessment

• Infants have decreased circulating blood volume (90 ml/kg) compared to children (80 ml/kg) and adults (70 ml/kg)
• Rapid heart rate and higher cardiac output increase oxygen demand
• Strong compensatory mechanisms help maintain cardiac output
• Children remain normotensive until 25% of blood volume is lost
• Compensatory mechanisms shunt blood from peripheries to vital organs
• Cardiac output is maintained by increasing heart rate

Neurological Assessment

• Use AVPU scale initially: ALERT, Response to VOICE, Responses to PAIN, UNRESPONSIVE
• Consider modifications for young, distressed, or non-verbal children
• Assess pupillary size and reaction, abnormal movements, and Glasgow Coma Scale/Grimace score
• Document observed data and note any changes

Vital Signs

• Pulse: apex beat, use stethoscope, and palpation (difficult in young children)
• Pulse rate varies with age: infant (100-160b/min), toddler (70-150b/min)
• Blood pressure measurement is age-dependent and late sign of cardiopulmonary compromise
• Capillary refill reflects cardiac perfusion: < 2 seconds in children, 1-2 or 3 seconds in adults
• Temperature: normal range 36.6-37.5°C, fever is immune response, and axillary site is used

Paediatric Assessment Triangle

• Rapid assessment of children determines need for further immediate assessment and emergency action
• Airway, Breathing, Circulation, Disability, and Exposure are key components of the Paediatric Triangle

Developmental Milestones

• Physical Development entails:
  • Gross motor skills: sitting, standing, walking, running, jumping
  • Fine motor skills: grasping, manipulating objects, using utensils
• Cognitive Development involves:
  • Problem-solving, memory, language, and thinking skills
• Language and Communication encompasses:
  • Verbal and non-verbal communication, reading, and writing skills
• Social-Emotional Development involves:
  • Emotional regulation, empathy, and relationships

Disability Care

• Types of Disabilities include:
  • Developmental disabilities (e.g., autism, cerebral palsy)
  • Physical disabilities (e.g., muscular dystrophy, spinal cord injuries)
  • Sensory disabilities (e.g., visual, hearing impairments)
• Care Considerations involve:
  • Individualized support and accommodations
  • Collaboration with interdisciplinary teams
  • Family-centered care and support

Pain Management

• Assessment of Pain involves:
  • Behavioral and physiological indicators
  • Self-reporting and observational tools
• Pharmacological Interventions include:
  • Analgesics, anesthetics, and adjuvant medications
• Non-Pharmacological Interventions include:
  • Distraction, relaxation, and cognitive-behavioral techniques
  • Alternative therapies (e.g., acupuncture, massage)

Family-centered Care

• Key Principles include:
  • Family as the unit of care
  • Respect for diversity and individuality
  • Empowerment and participation in decision-making
• Care Strategies involve:
  • Education and support for families
  • Collaboration with healthcare providers
  • Enabling family involvement in care planning

Assessment Techniques

• Physical Assessment involves:
  • Observation, inspection, palpation, percussion, and auscultation
• Developmental Screening includes:
  • Denver Developmental Screening Test (DDST)
  • Battelle Developmental Inventory (BDI)
• Behavioral and Emotional Assessment involves:
  • Behavioral rating scales (e.g., Child Behavior Checklist)
  • Emotional and behavioral questionnaires (e.g., Pediatric Symptom Checklist)

Stool Characteristics

• Newborns: meconium (black, tarry)
• Adults: brown to green color

Bowel Movements

• Constipation: decreased frequency, hard, dry, pebbly stool
• Diarrhea: frequent bowel movements, loose to fluid motions

Bristol Stool Chart

• A tool used to assess stool characteristics

Upper GI System

• Mucositis (mouth ulcers)
• Esophageal varices
• Indigestion and gastroesophageal reflux disease (GORD)
• Gastritis and gastroenteritis
• Dysphagia
• Peptic ulcers
• Pyloric stenosis
• Hiatus hernia
• Nausea and vomiting (symptoms of other causes)

Lower GI System

• Constipation
• Diarrhea
• Faecal incontinence
• Prolapse of the bowel
• Bowel cancer
• Celiac disease
• Crohn's disease
• Ulcerative colitis
• Diverticular disease
• Irritable bowel syndrome
• Haemorrhoids
• Dehydration/Malnutrition

Abdominal Muscles

• Function: protect internal organs and allow normal functional compression activities (e.g. coughing, sneezing, urination, defecation, and childbirth)
• In pregnancy: rectus abdominis separates, impacting the pregnant woman's ability to set her core muscles

Focused Gastrointestinal System Assessment

• Review baseline assessment data
• Perform hand hygiene
• Comfort/Privacy/Explain procedure
• Inspect abdomen
• Auscultate for bowel sounds
• Gently percuss over abdomen
• Lightly palpate each quadrant
• Assess recent and frequency of bowel movements
• Determine frequency of gastrointestinal assessment based on patient's condition

Objective Assessment of the Abdomen

• Inspection
• Auscultation
• Percussion
• Palpation

Abdominal Regions and Quadrants

• Nine regions: right upper, right lower, left upper, left lower, epigastric, umbilical, hypogastric, and two iliac fossae

Assessment: Inspection

• Inspect contour, symmetry, skin color, moisture, scarring, pulsation, and movement
• Umbilicus: midline, inverted, everted, swelling

Assessment: Auscultation

• Listen for bowel sounds in all quadrants for 1-3 minutes
• Normal: low-pitched continuous gurgles

Assessment: Percussion

• Determine the size of solid organs and presence of masses, fluid, and gas
• Undertaken by medical staff and expert nursing staff

Assessment: Palpation

• Assess shape and size of organs
• Tenderness or pain
• Rebound tenderness
• Light or deep palpation
• Liver and spleen palpation
• Muscle rigidity

Focused Gastrointestinal History - Subjective Data

• Change in appetite
• Weight gain or loss
• Presence of dysphagia
• Intolerance to certain foods
• Nausea and/or vomiting
• Change in bowel habits
• Abdominal pain

Other Subjective Data Related to GI Assessment

• Medications (laxatives, stool softeners, iron supplements, opioids)
• Nutritional assessment
• Difficulty chewing
• Pain in relation to eating and digestion
• Meal preferences
• Social history and lifestyle risk factors
• Meal preparation difficulties
• Financial constraints
• Ability to access shops

Inspection and Examination

• Ensure privacy and confidentiality before examination
• Inform the patient about the purpose of the examination

Male Reproductive System Examination

• Inspect for symmetry, swelling, inflammation, rashes, and surgical procedures
• Palpate for texture of skin and tissues, looking for tumours, cysts, and scar tissue
• Check for ambiguous genitalia, micropenis, bifid scrotum, and bilateral undescended testes in males

Female Adolescent Reproductive Examination

• Ensure parental presence if necessary
• Assess menstrual history and sexual maturity development (Tanner stages)
• Conduct pelvic examination if requiring contraception or having genital or vaginal irritation/infection
• Perform Pap smears if sexually active

Adult Female Reproductive System Assessment

• Take a history of reproductive cancers, sexual history, obstetric history, and menstrual cycle irregularities
• Assess knowledge deficit and concerns
• Conduct physical examination, ensuring privacy and confidentiality
• Perform inspection, palpation, and bimanual examination

Pregnancy Assessment

• Assess knowledge of changes in pregnancy (physiological and psychological)
• Conduct breast changes assessment, abdominal palpation, and vaginal examination
• Take observations, blood pressure, pulse, and urinalysis
• Document findings and identify knowledge deficits and concerns

Primary Assessment and Abdominal Examination

• Obtain social, medical, surgical, general, and obstetric history
• Conduct physical assessment, including abdominal exam, height, weight, and BMI
• Perform abdominal examination, inspecting for skin changes and abdominal shape
• Palpate gently and firmly, checking fundal, lateral, and pelvic areas

Fetal Assessment

• Check fetal position and lie
• Assess fetal heart rate (120-160bpm) using Pinards, stethoscope, doppler, or CTG
• Take maternal pulse before measuring fetal heart rate

Urinary System Assessment

• Urge to urinate occurs at around 200 mls
• Assessment of urination includes:
  • Frequency
  • Volume
  • Color (concentration)
  • Odour
  • Consistency
  • Pain
  • Continence

Urinary System Problems

• Mechanical injury to the kidney can cause:
  • Loin pain
• Infection and inflammation can occur due to:
  • Blockage caused by:
    • Strictures
    • Tumours
    • Renal calculi
  • Iatrogenic injury in error

Normal Ranges

• SpecificGravity: normal ranges can be found in the provided reference

Genito Urinary System

• The genito urinary system includes:
  • Renal/urinary system
  • Reproductive systems
  • Organs involved:
    • Kidneys
    • Ureters
    • Urinary bladder
    • Urethra
    • Reproductive organs

Female Genito Urinary Anatomy

• Includes:
  • Female external genitalia

Male Genito Urinary Anatomy

• Includes:
  • Penis
  • Scrotum
  • Testes
  • Spermatic cord
  • Urethra
  • Prostate gland (normal enlargement)
  • Urinary bladder
  • Ureters
  • Kidney

Renal System Functions

• The renal system is responsible for:
  • Fluid and volume regulation
  • Electrolyte balance
  • Acid base regulation
  • Removal of toxins
  • Calcium and phosphate homeostasis
  • Red blood cell maturation via erythropoietin (EPO)

Urinary Elimination

• Urinary bladder capacity:
  • 15-50 ml at birth
  • 500-800 ml in adults

Reproductive Health Assessment

• Inspect external genitalia for abnormalities, lesions, or discharge in females
• Perform pelvic exam to assess uterus, cervix, and adnexa in females
• Evaluate menstrual history, including frequency, duration, and pain in females
• Inspect external genitalia for abnormalities, lesions, or discharge in males
• Evaluate testicular size, shape, and consistency in males
• Assess penis for lesions, curvature, or abnormality in males
• Ask about sexual history, including number of partners and safer sex practices
• Evaluate contraception methods and effectiveness
• Assess history of sexually transmitted infections (STIs)

Genitourinary Health Assessment

• Inspect urethral meatus for abnormalities, lesions, or discharge
• Evaluate urinary frequency, urgency, and incontinence
• Assess for pain or burning during urination
• Ask about history of urinary tract infections (UTIs) or kidney stones
• Evaluate urinary habits, including fluid intake and voiding patterns
• Ask about history of prostate issues or benign prostatic hyperplasia (BPH)

Renal System Assessment

• Inspect urine for color, clarity, and specific gravity
• Evaluate blood pressure and edema
• Palpate kidneys for tenderness or pain
• Ask about history of kidney disease, kidney stones, or dialysis
• Evaluate fluid intake and output patterns
• Ask about medication use, including diuretics and nephrotoxic drugs

Gastrointestinal Health Assessment

• Inspect abdomen for distension, tenderness, or masses
• Evaluate bowel sounds and abdominal reflexes
• Palpate liver and spleen for enlargement or tenderness
• Ask about dietary habits, including fiber and fluid intake
• Evaluate history of gastrointestinal diseases, such as irritable bowel syndrome (IBS) or gastroesophageal reflux disease (GERD)
• Ask about abdominal pain or discomfort, including location and duration

Fluid Balance Management

• Evaluate fluid intake and output patterns
• Monitor urine specific gravity and osmolality
• Assess for signs of dehydration or overhydration, such as dry mucous membranes or edema
• Encourage adequate fluid intake, especially in elderly or debilitated patients
• Monitor and adjust diuretic therapy as needed
• Provide education on proper hydration and fluid management

Ageing in Australia

• As of June 2020, approximately 4.2 million people (16% of the population) were aged 65 or over in Australia.
• By 2066, it is predicted that 21-23% of the total population will be aged 65 and over.
• The proportion of people aged 85 and over has increased from 0.5% (63,200) in 1970 to 2.1% (528,000) in 2020.
• The proportion of people aged 85 and over is expected to rise to between 3.6% and 4.4% in 2066.

Physiological Changes of Ageing

• Ageing affects all body systems.
• Physiological changes associated with ageing include:
  • Neurological system: myelin sheath degeneration, decreased neurotransmitter production.
  • Cardiovascular system: decreased heart size, decreased cardiac output, calcification and fibrosis of cardiac valves.
  • Respiratory system: decreased chest wall expansion, flattening of the diaphragm, increased respiratory rate, and decreased lung expansion.
  • Genitourinary and renal systems: kidney shrinkage, decreased glomerular filtration rate, and decreased renal filtration.
  • Gastrointestinal system: decreased salivary secretions, swallowing difficulties, decreased taste buds, and decreased peristalsis.
  • Musculoskeletal system: decreased bone density, muscle atrophy, and decreased joint mobility.
  • Integumentary system: skin colour changes, dry skin, decreased perspiration, and decreased elasticity.
  • Reproductive systems: decreased oestrogen production, decreased testicular size, decreased sperm count, and prostate enlargement.

Physiological Changes of the Older Adult

• Neurological system:
  • Decreased mental flexibility, abstract thinking, and recall.
• Cardiovascular system:
  • Decreased heart size, decreased cardiac output, calcification and fibrosis of cardiac valves.
• Respiratory system:
  • Decreased chest wall expansion, flattening of the diaphragm, increased respiratory rate, and decreased lung expansion.
• Genitourinary and renal systems:
  • Kidney shrinkage, decreased glomerular filtration rate, and decreased renal filtration.
• Gastrointestinal system:
  • Decreased salivary secretions, swallowing difficulties, decreased taste buds, and decreased peristalsis.
• Musculoskeletal system:
  • Decreased bone density, muscle atrophy, and decreased joint mobility.
• Integumentary system:
  • Skin colour changes, dry skin, decreased perspiration, and decreased elasticity.
• Reproductive systems:
  • Decreased oestrogen production, decreased testicular size, decreased sperm count, and prostate enlargement.

Assessment of the Older Adult

• Assessment of the older adult should consider physiological changes associated with ageing.
• Assessment of the person with dementia and disability should also be considered.
• Aged care standards should be met in the assessment of the older adult.

Ageing in Australia

• As of June 2020, approximately 4.2 million people (16% of the population) were aged 65 or over in Australia.
• By 2066, it is predicted that 21-23% of the total population will be aged 65 and over.
• The proportion of people aged 85 and over has increased from 0.5% (63,200) in 1970 to 2.1% (528,000) in 2020.
• The proportion of people aged 85 and over is expected to rise to between 3.6% and 4.4% in 2066.

Physiological Changes of Ageing

• Ageing affects all body systems.
• Physiological changes associated with ageing include:
  • Neurological system: myelin sheath degeneration, decreased neurotransmitter production.
  • Cardiovascular system: decreased heart size, decreased cardiac output, calcification and fibrosis of cardiac valves.
  • Respiratory system: decreased chest wall expansion, flattening of the diaphragm, increased respiratory rate, and decreased lung expansion.
  • Genitourinary and renal systems: kidney shrinkage, decreased glomerular filtration rate, and decreased renal filtration.
  • Gastrointestinal system: decreased salivary secretions, swallowing difficulties, decreased taste buds, and decreased peristalsis.
  • Musculoskeletal system: decreased bone density, muscle atrophy, and decreased joint mobility.
  • Integumentary system: skin colour changes, dry skin, decreased perspiration, and decreased elasticity.
  • Reproductive systems: decreased oestrogen production, decreased testicular size, decreased sperm count, and prostate enlargement.

Physiological Changes of the Older Adult

• Neurological system:
  • Decreased mental flexibility, abstract thinking, and recall.
• Cardiovascular system:
  • Decreased heart size, decreased cardiac output, calcification and fibrosis of cardiac valves.
• Respiratory system:
  • Decreased chest wall expansion, flattening of the diaphragm, increased respiratory rate, and decreased lung expansion.
• Genitourinary and renal systems:
  • Kidney shrinkage, decreased glomerular filtration rate, and decreased renal filtration.
• Gastrointestinal system:
  • Decreased salivary secretions, swallowing difficulties, decreased taste buds, and decreased peristalsis.
• Musculoskeletal system:
  • Decreased bone density, muscle atrophy, and decreased joint mobility.
• Integumentary system:
  • Skin colour changes, dry skin, decreased perspiration, and decreased elasticity.
• Reproductive systems:
  • Decreased oestrogen production, decreased testicular size, decreased sperm count, and prostate enlargement.

Assessment of the Older Adult

• Assessment of the older adult should consider physiological changes associated with ageing.
• Assessment of the person with dementia and disability should also be considered.
• Aged care standards should be met in the assessment of the older adult.

Pain Management

• Goals of pain management include alleviating pain and discomfort, improving patient satisfaction and quality of life, and reducing the risk of chronic pain and associated complications
• A standardized pain assessment tool, such as a numerical rating scale or visual analog scale, should be used to evaluate pain intensity, location, duration, and quality
• Patient's medical history, current medications, and allergies should be considered during pain assessment

Infection Prevention

• Preventing healthcare-associated infections (HAIs) is crucial for patient safety, as HAIs can lead to increased morbidity, mortality, and healthcare costs
• Hand hygiene is essential for preventing HAIs, and should be performed before and after patient contact, before and after invasive procedures, and after contact with bodily fluids
• Other strategies for preventing HAIs include using personal protective equipment, environmental cleaning and disinfection, surveillance and monitoring of infection rates, and staff education and training
• Key infection prevention measures include prevention of central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), surgical site infections (SSIs), and Clostridioides difficile infections (CDIs)

Hand Hygiene Protocols

• Hand hygiene is the single most effective way to prevent HAIs
• Hand hygiene should be performed using soap and water or an alcohol-based hand rub, and should include rubbing hands together for at least 15-30 seconds
• Hand hygiene compliance should be monitored and feedback provided to healthcare workers

Electronic Health Records (EHRs)

• An EHR is a digital version of a patient's medical chart
• EHRs improve patient safety by reducing medication errors and improving continuity of care
• EHRs enhance patient engagement and empowerment, increase efficiency and productivity for healthcare providers, and provide better data analytics and research capabilities
• Key components of EHRs include demographic and medical history information, medication lists and allergy information, laboratory and radiology results, and clinical notes and documentation

Vital Sign Analysis

• Vital signs are essential for monitoring patient health and detecting potential complications
• Key vital signs include temperature, pulse, blood pressure, respiratory rate, and oxygen saturation
• Vital signs should be evaluated in context of patient's medical history and current condition, and should be used to guide clinical decision-making and interventions

Structure of the Cardiovascular System

• The heart has 4 chambers: right atrium, right ventricle, left atrium, and left ventricle
• Right side of the heart: receives deoxygenated blood from the body via the vena cava and pumps it to the lungs via the pulmonary artery
• Left side of the heart: receives oxygenated blood from the lungs via the pulmonary vein and pumps it to the body via the aorta

Conduction System

• SA node: pacemaker in the right atrium
• AV node: impulses travel through the internodal tract with a slight delay, allowing for ventricular filling
• Bundle of HIS: impulses travel through the interventricular septum
• Purkinje fibers: impulses travel to myocardial cells, causing the apex to contract first

Circulatory System Pathophysiology

• Blood vessels: a closed system of tubes
• Blood volume: 64% in veins and venules, 13% in arterioles, 7% in capillaries, 9% in pulmonary vessels, and 7% in the heart

Cardiovascular Health Problems

• Symptoms: chest discomfort, palpitations, shortness of breath, pain and/or numbness/tingling in the extremities, fatigue, and feeling of doom
• Signs: color changes to lips, face, and nail bed, and peripheral skin color changes

Preparing for a Physical Assessment

• Introduce yourself and explain the assessment process
• Invite and answer patient questions
• Warm equipment and use a systematic approach

Focused Cardiovascular Assessment

• Primary survey: inspect and palpate calves for redness, warmth, and tenderness, and check peripheral capillary refill time
• Auscultation: listen to heart sounds, including the 1st heart sound (S1) and 2nd heart sound (S2)
• Assess apical heart beat and document findings

Auscultation - Breath Sounds

• Crackles: scratchy sounds indicating fluid in alveoli and airways, commonly seen in pneumonia, pulmonary oedema, and fibrosis
• Rhonchi: gurgling sounds indicating fluid in large and medium-sized airways, commonly seen in bronchitis, pneumonia, and asthma
• Wheezing: whistling sounds indicating air forced through narrow airways, commonly seen in asthma
• Stridor: inspiratory whistling indicating tracheal narrowing

Spirometry - Lung Function Test

• Determines the level of respiratory function
• Measures lung volume (forced expiratory volume) and lung capacity (forced vital capacity)
• Used to monitor progression of respiratory disease and response to therapy

Respiratory Assessment

• Focused health assessment of the respiratory system includes:
  • General survey (appearance)
  • Subjective data (health history)
  • Assessment of airway entry (rapid primary survey: A, B)
  • Objective data (vital signs, oxygen saturation)
  • 4 assessment techniques (inspection, palpation, auscultation, percussion)

Primary Survey

• Rapid assessment of airway, breathing, and circulation
• Checks for patent airway, blockages, and decreased air entry

Documenting Findings

• Importance of thoroughly documenting findings, including:
  • Respiratory assessment
  • Vital signs (respirations, oxygen saturation, etc.)
  • Spirometry/Peak flow
  • Clinical history
  • Physical assessment (IPPA)

Importance of Documentation

• "If you didn't document it, then it didn't happen!"

Cardiovascular Assessment

ECG Lead Placement

• 12-lead ECG consists of 6 limb leads (I, II, III, aVR, aVL, aVF) and 6 chest leads (V1-V6)
• Limb leads are placed on 4 extremities (right arm, left arm, right leg, left leg)
• Chest leads are placed on:
  • V1: 4th intercostal space (ICS) right sternal border
  • V2: 4th ICS left sternal border
  • V3: Midway between V2 and V4
  • V4: 5th ICS midclavicular line
  • V5: 5th ICS anterior axillary line
  • V6: 5th ICS midaxillary line

Pulse Location

• Radial pulse is located on the thumb side of the wrist, medial to the radial artery
• Brachial pulse is located on the medial aspect of the antecubital fossa (bend of the elbow)
• Femoral pulse is located at the mid-inguinal point (midpoint between the pubic symphysis and anterior superior iliac spine)
• Popliteal pulse is located on the posterior aspect of the knee, behind the popliteal fossa
• Posterior tibial pulse is located posterior to the medial malleolus (ankle)
• Dorsalis pedis pulse is located on the dorsal surface of the foot, lateral to the extensor hallucis longus tendon

Heart Sound Differentiation

• S1 (first heart sound) is produced by the closure of atrioventricular valves (mitral and tricuspid) and is loudest at the apex of the heart
• S2 (second heart sound) is produced by the closure of semilunar valves (aortic and pulmonary) and is loudest at the base of the heart
• S3 (third heart sound) is produced by rapid ventricular filling and is normal in children and young adults, but abnormal in older adults
• S4 (fourth heart sound) is produced by atrial contraction and is abnormal in all ages

Manual Vital Signs

• Heart rate is measured in beats per minute (bpm)
• Blood pressure is measured in millimeters of mercury (mmHg)
• Respiratory rate is measured in breaths per minute

Respiratory Assessment Techniques

• Inspection involves observing chest movement and breathing pattern, and noting the use of accessory muscles
• Palpation involves feeling for vibrations (tactile fremitus) over lung fields and assessing chest expansion
• Percussion involves tapping on the chest to assess lung density and resonance, and identifying areas of dullness or hyperresonance
• Auscultation involves listening to breath sounds with a stethoscope, and identifying normal and abnormal breath sounds (e.g., wheezes, rhonchi, crackles)

Identifying Health Issues and Setting Goals

• Identify potential health issues/problems and relate them to relevant data to set goals in collaboration with the person and their family.
• Each goal is aligned with each potential health issue or problem.

Risk Factors for In-Hospital Falls

• Intrinsic risk factors:
  • Age
  • Fatigue
  • Mental status
  • Urinary issues
  • Mobility issues
• Comorbidities:
  • Hypertension
  • Anaemia
• Medications:
  • Digoxin
  • Antidepressants
  • Polypharmacy
• Extrinsic risk factors:
  • Environmental factors (flooring, cords)
  • Organisation and people factors (staffing, footwear)
  • Socioeconomic factors (literacy, dependency)

Risk Factors for Falls in Residential Aged Care

• Number of medications
• Sedatives
• Antidepressants
• Walking aids
• Disability
• History of falls
• Vision impairment
• Incontinence
• Parkinson's disease

Diagnostic Tests for Musculoskeletal Disorders

• Laboratory tests:
  • Erythrocyte sedimentation rate (ESR) to measure inflammation

Impaired Physical Mobility and Chronic Pain

• Impaired physical mobility related to:
  • Ineffective use of walking aids
  • Decreased muscle strength due to pain, stiffness, or osteoarthritis
• Chronic pain related to:
  • Joint inflammation
  • Overuse of joints
  • Ineffective pain and/or comfort measures

Documentation

• Regularly assess and document patient information
• Note any new abnormal findings or investigations
• Communicate abnormal findings

Case Study: Mr Brown

• Mr Brown is a 78-year-old widower who lives at home and uses a wheelie walker due to unsteadiness
• He fell and sustained a skin tear on his left arm
• Musculoskeletal assessment should consider:
  • The person and their context
  • Past medical history
  • Family history
  • Collecting subjective and objective data
  • Processing the information by comparing it to normal parameters and analysing it

Glasgow Coma Scale (GCS)

• GCS is a scoring system used to assess the level of consciousness (LOC) in patients, developed by Teasdale and Jennett in 1974.
• It consists of three parts: Eyes Opening, Best Verbal Response, and Best Motor Response.
• The total score ranges from 3 (worst) to 15 (best).

Eyes Opening (GCS Score: 1-4)

• Observe patient's alertness when entering the room.
• Spontaneous eye opening: 4 points.
• Eye opening to speech: 3 points.
• Eye opening to pain: 2 points.
• No eye opening: 1 point.

Best Verbal Response (GCS Score: 1-5)

• Assess orientation to person, place, and time.
• Ask questions like "Can you tell me your name and date of birth?" or "Do you know what day it is?"
• Response to verbal stimuli indicates higher consciousness.

Best Motor Response (GCS Score: 1-6)

• Assess the patient's ability to follow commands.
• Test symmetry of strength by asking the patient to squeeze fingers.
• Obeys commands: 6 points.
• Localizes to pain: 5 points.
• Withdrawal: 4 points.
• Flexion: 3 points.
• Extension: 2 points.
• No response: 1 point.

Interpreting GCS Scores

• Score 15: Alert, oriented, and follows commands.
• Score 14: Confused, possibly due to intoxication or organic causes.
• Score 13-14: Lethargy, possibly due to organic causes, medications, or increased ICP.
• Score 12-13: Stupor, possibly due to organic causes, medications, or increased ICP.
• Score 8-10: Permanent vegetative state, possibly due to anoxic brain injury.
• Score 6: Locked-in syndrome, possibly due to spinal cord injury.
• Score 3-6: Coma, possibly due to anoxia, trauma, or space-occupying lesion.
• Score 3: Brain death, possibly due to anoxia or structural damage.

Assessing Neurological Status in Children

• Changes to the neurological system, trauma, and oxygenation can impact neurological status.
• Manifestations include listlessness, decreased level of consciousness, and altered muscle and limb tone.
• Delirium, infection, and oxygenation can also affect neurological status.

Limitations of GCS

• Not suitable for paediatrics, where Best Verbal Response is modified to include developmental milestones.
• May not be useful for evaluating patients in longstanding unconscious states.

Focused Skin or Integumentary System Assessment

• Gather relevant information:
  • Past medical history
  • Medications (topical, systemic, over-the-counter)
  • Exposure to environmental or occupation hazards
  • Substance abuse
  • Recent physiological or psychological stress
  • Hair, nail, and skin care habits
  • Skin self-examination
  • Problems with the skin
• Inspect and palpate skin, hair, and nails noting:
  • General odor
  • Temperature
  • Moisture and turgor
  • Capillary refill time
  • Inspect and palpate for signs of pressure injury or skin lesions
  • Non-blanchable redness
  • Localized heat
  • Edema and induration

Skin Integrity Assessment

• Why assess?:
  • Often gives indications of other conditions
  • Risk assessment for wound types
  • Lack of mobility
  • Hospitalized and residential aged care facilities
• When to assess?:
  • All patients should have skin integrity assessed on admission and at regular intervals

Preparing the Environment

• Ensure the room is:
  • Quiet
  • Private
  • Has a stable temperature
• Ensure:
  • Adequate lighting
  • Adequate exposure of the skin, especially areas not usually inspected

Skin Integrity Assessment: Inspection

• Inspect skin for:
  • Skin color
  • Bleeding
  • Lesions
• Inspect hair for:
  • Hair distribution
  • Color
  • Quantity (thick, thin, balding)
• Inspect nails for:
  • Nail length
  • Color
  • Configuration
  • Symmetry and cleanliness

Skin Integrity Assessment: Palpation

• Palpation of the skin:
  • Skin temperature
  • Texture
  • Skin moisture
  • Skin turgor (resilience and elasticity of tissue)
• Palpation of the nails:
  • Texture
  • Configuration

Skin Integrity and Wounds

• Observe any wounds, dressings, drains, or invasive lines for:
  • Warmth
  • Redness
  • Swelling
  • Exudate or odor

Skin Tears and Pressure Injuries

• 70% of older people have skin problems, including wounds
• Risk factors for skin tears:
  • Limited mobility
  • Use of wheelchairs or other mobility aids
  • Cognitive impairment
  • Poor nutrition
  • Polypharmacy
  • Sensory loss
• Classification systems for skin tears:
  • STAR Classification System
  • ISTAP tool
• Pressure injury:
  • Localized injury to the skin and/or underlying tissue usually over a bony prominence
• Risk factors for pressure injuries:
  • Immobility or reduced physical mobility
  • Loss of sensation
  • Impaired cognitive state or level of consciousness
  • Urinary or faecal incontinence
  • Poor nutrition or recent weight loss
  • Dry skin
  • Acute or severe illness
• Classification systems for pressure injuries:
  • Pressure Injury Staging System

Pressure Injury Risk Assessment Tools

• Braden
• Waterlow
• Glamorgan Paediatric Scale

Clinical Reasoning Cycle

• Subjective
• Objective data
• Compare data against normal parameters
• Identify health problems
• Realistic goals (collaborative)
• Goal

Integumentary Assessment

• Inspect skin for lesions, rashes, ulcers, or areas of skin breakdown
• Assess skin temperature, turgor, and hydration
• Note any abnormal skin odors or lesions
• Inspect hair for texture, distribution, and any abnormalities
• Examine nails for shape, color, and any signs of clubbing or koilonychia
• Inspect scalp for lesions, rashes, or signs of scalp trauma

Musculoskeletal Assessment

• Observe posture, gait, and range of motion
• Inspect for muscle atrophy or hypertrophy
• Assess for tenderness, warmth, or swelling in joints and muscles
• Evaluate muscle tone and strength
• Assess active and passive range of motion in all joints
• Note any pain, stiffness, or limitations

Vital Signs

• Normal temperature range: 36.5°C - 37.5°C (97.7°F - 99.5°F)
• Abnormalities: hyperthermia (>37.5°C), hypothermia (<36.5°C)