Week Three Flashcards
Physical Assessments
- Weight, vital signs
- Vision
- Ear and oral assessments
System Assessment
- Neurological assessment (Cranial - - - Nerves, Cerebellar Dysfunction)
- Cardiovascular assessment
- Respiratory Assessment
- Nutrition/ Elimination/ Pain: Abdominal assessment
- Falls/ Mobility: Reflex, gait and strength assessments
What Assessment Tools should we Use?
Screening Tools: MoCA, Fraility Scale, Geriatric Depression Scale
Comprehensive Assessments: FANCAPES, FULMER SPICES, Comprehensive Geriatric
Assessment
Ear Examination
- cerumen impaction
- whisper test
weber and rinne test
oral assessment
Ulcers – may be caused by nutritional deficiencies
* Dental Carries – can be painful, may result from
poor oral hygiene
* Oral Thrush – an overgrowth of yeast, may be
caused by steroid inhalers
* Xerostomia – a fancy word for dry mouth, often
caused by medication
Neurological Assessments: Cranial Nerves
Numerous disorders in the elderly can cause dysfunction of cranial nerves
* Examples: stroke, Parkinson’s, peripheral neuropathy, herniated disc, arthritis, MS
* Cranial nerve dysfunction can cause motor and/or sensory issues depending on what nerves are impacted
* Examples: balance issues, hearing loss, visual disturbance, speech, swallowing, pain perception
* Cranial Nerve 9, 10 – glossopharyngeal and Vagus
* Phonation “ah”
* Swallowing
* Gag reflex
* Cranial Nerve 7 (Facial)
* Facial symmetry
* Ability to raise eyebrows, frown, smile, close eyes tightly, puff out cheeks
* Cranial Nerve 3, 4, 6 – Oculomotor, trochlear, abducens
* Light pupillary response
* Extra-ocular movement (six cardinal positions of gaze)
Cerebellar Dysfunction
The Cerebellum is the part of the brain responsible for
coordination
Disorders such as alcohol misuse, stroke, tumor, brain
degeneration, MS, and certain medications (i.e.,
benzodiazepines, antiepileptics) can cause cerebellar
dysfunction
Assessment findings in cerebellar dysfunction may include:
* Nystagmus
* Action tremor
* Dysmetria in upper or lower extremities – i.e., rapid
alternating movements, finger-finger, finger-nose, heelshin
* Gait ataxia
Visual Acuity
- snellen chart
- assess from 20 meters
- assess right and left eye
Gait Assessment
Assess normal gait, tandem gait, heel walking, and toe walking
Step: The distance from one heel strike to the next contralateral heel strike
* Normal: About 72 cm
* Stride: The distance covered from one heel strike to the next ipsilateral heel strike (2 steps)
* Normal: About 144 cm
* Cadence (step rate): Number of steps per unit of time
* Normal: 90-120 steps/minute
* Gait speed: Distance covered in a given amount of time
* TUG Test
* Step or base width: The lateral distance between the heel centers of two consecutive foot
contacts
* Normal: 5-10 cm
Strength Assessment
0/5: no contraction
1/5: muscle flicker, but no
movement
2/5: movement possible, but not
against gravity
3/5: movement possible against
gravity, but not against
resistance by the examiner
4/5: movement possible against
some resistance by the
examiner
5/5: normal strength
Reflex Assessment
0 = no response
* 1+ = a slight but definitely
present response
* 2+ = a brisk response;
normal.
* 3+ = a very brisk
response
* 4+ = clonus
Cardiovascular Assessment
- Edema
- Peripheral Vascular Disease
- Murmurs
- Jugular Venous Pulse
Respiratory Assessment
Respiratory rate
* Auscultate lungs
* Cap refill, digital clubbing,
peripheral cyanosis
* Posture
* Stigmata of COPD
Abdominal Assessment
Pain
* Distention
* Masses
* Palpable bladder
* Rectal exam if constipated
