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ABDOMINAL PAIN, DISTENSION OR DISCOMFORT

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PHYSICAL DATA

. Vital signs
. Stomach assessment which includes tenderness, soreness,
protruding, distension upon palpation and bowel noises
upon auscultation
. Digital rectal evaluation including any tenderness,
mass or hard stool
. lf vomiting, identify contents, amount and presence of
blood, examine hemoccult
. Type of pain (dull, sharp, stabbing, burning, and to rate
their pain on a scale (including whether pain is consistent
or spotty)
. Observe alleviating elements or irritating factors

HEALTH CARE HISTORY

Patient’s age and sex
Starting point, length of time frequency and intensity of symptoms
Existing medications, including any recent changes
Recent food and fluid intake habits, including any
recent variations
Current diet (typical, constrained, etc. )
All current diagnoses
Any recent laboratory or diagnostic examination outcomes
Record of relevant gastrointestinal conditions (previous
surgery, record of peptic ulcers, diverticulitis, etc. )
Approximate rate of bowel movements last bowel
movement and any connected problems

ABDOMINAL ASSESSMENT

Listen: Auscultation of the abdomen needs to
be completed prior to palpation. you want to
listen before you touch, since oftentimes
pressing the stomach can stimulate “noises”.
Listen for bowel sounds to see if they are dynamic
and audible in all four quadrants. Position the bell
of the stethoscope gently over each of the 4
quadrants. Ask the individual not to talk. Listen until
you hear recurrent gurgling or bubbling noises
once in each quadrant. Express sounds as
typical, hyperactive, hypoactive, absent. It may
require about 5 minutes to hear bowel noises.

Look: Examination is the visible assessment of the
abdomen. Look for changes to the abdomen
such as distension, bruising, rashes, coloring, scars,
pulsations, symmetry. If you notice bruising, look
at patient’s history to see if she/he is receiv: ing
heparin or insulin injections. Scars reveal
evidence of previous surgery treatment or injury.

Feel: Palpation is pressing the area. Lightly
palpate over each one of the 4 abdominal
quadrants. Note if the abdomen is soft or firm.
Look for tenderness and/or ache, muscle rigidity,
heat, superficial masses and watch patient’s facial
expressions during palpation.

ABRASION

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PHYSICAL DATA

. Outline of abrasion (dimension, location, etc. )
. Whether or not significant bleeding or pain is present at
the abrasion site
. lf reporting a complication of an existing abrasion,
any signs of infection or significant bleeding
. Description of skin condition around the abrasion
(normal, reddened, enlarged, tender, etc. )

MEDICAL BACKGROUND

. Patient’s age and sex
. Date and circumstance of onset (exactly how abrasion
developed, if known)
. All current medications, including any recent
alterations, especially anticoagulants, prednisone,
and additional prescription medication associated with thin or
fragile skin
. Whether person has background of fragile skin or
frequent skin tears
. Outcomes of any interventions thus far

ABRASION ASSESSMENT
Include the following when describing an abrasion:

Precise location (temple, wrist, forearm, hand, etc. )
. Duration (how long has it been there? )
. Size (width, length, depth) in mm, cm
. Drainage (colouring, scent, volume)
. Does it feel tender?
. ls it warm to touch?
. Is there swelling?
. Is the location reddened?
. Grievances of soreness, tightness, itching, or additional symptoms

Investigate source of abrasion and document
nursing methods to lessen chances of this
happening again. Update the resident’s care plan in ‘Real Time”.

Check on status of previous tetanus shot. Alert practitioner of when last tetanus shot was given or if you can not find status of last tetanus shot.

AGITATION OR BEHAVIOR DYSFUNCTION

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PHYSICAL DATA

. Vital signs
. Lung and stomach evaluation
. Details of the behavior problem (onset, frequency,
duration, characteristics, etc. )
. Neurological assessment, including specifics of mood,
orientation, and level of consciousness
. Any signals indicating possible infection
‘ Any significant changes in bowel and bladder function
. Any evidence of head trauma or some other recent injury
. Assessment of any pain (location, character, severeness, etc. )

MEDICAL BACKGROUND

. Patient’s age and sex
. Onset, timeframe, frequency, and severeness
. Food and fluid intake patterns over preceding week
. Complete account of behavior in comparison to usual behavior
. Any recent record of injury or fall
‘ All current prescription drugs, including any recent changes
. Record of any psychiatric disorders
. All current medical diagnoses
. Any recent lab or diagnostic test results, especially BMP
(Basic Metabolic Profile )
. Recent blood sugar trends, if affected person is diabetic

The term “agitation” is normally used to
express symptoms. Instead of using the word
“agitation” by itself, express the behavior using
terms to show what the behavior is demonstrating
such as frustration, uneasyness, aggression,
shouting, rummaging, opposition to care,
disinhibition, and roaming. Be extremely precise
when reporting the conduct to the practitioner.
Try to remember the circumstance preceding the behavior.

You will need to play detective and discover the
origin of the “agitated” behavior. Agitation can
result from frustration of having an impairment,
or the difficulty of making progress in recuperating
from sickness or injury.
Particular drugs may lead to behavior modifications
such as antiarrhythmic agents, anticholinergic
agents (and medications with anticholinergic
effects or side effects), anticonvulsants,
antidepressant, antiemetics, antihistamines/
decongestants, antihypertensive agents,
antineoplastic agents, antimanic agents, anti-
Parkinson’s agents, antipsychotics, anxiolytics,
corticosteroids, muscle relaxants, opioids,
sedatives/sleeping medicines.

A patient’s agitated behavior is better described with action words such as: irritability, restlessness, resistance to care, disinhibition, wandering, etc. Avoid using only the term “agitated” to describe the patient’s behavior. When reporting to the practitioner, facts associated with the behavior are important. Inquire about the patient’s situation preceding the agitated behavior. Remember that frustration (having a physical/mental impairment or recovering from an illness/injury) leads to agitation.

Behavior changes can occur when using certain medications such as antiarrhythmic agents, anticholinergic agents (and medications with anticholinergic effects or side effects),  anticonvulsants, antidepressants, antiemetics, antihistamines/decongestants, antihypertensive agents, antineoplastic agents, antimanic agents, anti-Parkinson’s agents, antipsychotics, anxiolytics, corticosteroids, muscle relaxants, opioids, sedatives/sleep medication.

AMBULATION, MODIFIED

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PHYSICAL DATA

. Vital signs
. Details of existing ambulatory capability, gait, and
balance
. Extremities and musculoskeletal evaluation,
including evidence of deformity, pain, modified
range of motion, etc. of lower extremities
. Any alterations in psychological status and level of
awareness
‘ Evidence of recent injury to lower extremities
. Ability to ambulate with assistive products

HEALTH CARE BACKGROUND

. Patient’s age and sex
. Onset, time-span, frequency, and severeness of
symptoms
. Usual (standard) ambulatory functions
. All current medical diagnoses
‘ All current medications, including any recent
adjustments
. History of any episodes of falling, injury or other
occurrences affecting ambulation

AMBULATION EVALUATION
During the assessment of the Musculoskeletal System, the health professional needs to employ his/her knowledge of examination and observation such as: Recognition of problems with gait and Range of Motion (ROM), reporting any problems noted in ROM or muscular strength, and using precautions during ROM routines to prevent forcing a joint past the patient’s current ROM.

Joints: Pain, stiffness, swelling, warmth, redness, limitation
of activity
Muscles: Soreness, cramping, weakness
Bones: Deformity, discomfort, trauma (fractures, sprains, dislocation.

This assessment is essential when a person reports pain, loss of sensation, or impairment of joint and/or muscular function.

Examples of a Functional Examination, How to start:

Place the person’s leg flat on the bed. Put one hand beneath the ankle and your other hand under the knee. Straighten the leg and return
it to a flat position on the bed atter every motion.

. Hip and knee bends. Slowly flex the hip and knee up
toward the chest as much as possible (flexion). Slide your
hand out from under the knee and toward the upper thigh.
Do this to help the knee flex fully.
. Leg motion, side to side. Move the leg out to the outer
side as far as feasible. (abduction) Then return the leg to
the middle and cross it above the other leg (adduction).
. Leg rotation, in and out. With the leg flat on the bed. roll
the leg toward the middle so the big toe touches the bed (internal rotation). Roll the leg outward so the little toe
touches the bed (external rotation).
. Knee rotation, In and out. Bend the person’s knee so the
bottom part of the foot is flat on the bed. Roll the leg inward as
much as possible. Try to contact the bed with the big toe. Roll
the leg outward as far as possible. Try to touch the bed
with the little toe.

DESIRE FOR FOOD, DECREASED.

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PHYSICAL INFORMATION

* Vital signs
* Signs of change in psychological status, mood, conduct, orientation,
or alertness
* Symptoms of dehydration or fluid and electrolyte imbalance
*Abdominal evaluation, particularly for bowel noises, tenderness, pain, or distension
*Any indicators of infection
* Any queasieness and vomiting
” Mouth/throat, teeth/gums evalution, specifically condition
of the teeth and gums, mouth pain, throat or tongue inflammation, or
pain

MEDICAL HISTORY

* Patient’s age and sex
* Particulars of individual’s wishes for food and food and fluid intake
patterns over preceding couple of days, in comparison to typical (baseline)
* All present prescription medicines, including any recent alterations,
particularly medications known to bring about anorexia
* Present diet regime (typical, mechanical, soft, etc. ) including any
constraints and any recent adjustments
* Any recent track record of mouth or throat soreness, queasieness or vomiting,
stomach pain, heartburn, or indigestion
*Any recent changes in abdominal pattern (constipation, diarrhea,
etc. )
* Recent background of alterations in mood, conduct
* Any current nutritional dietary supplements
*All current diagnoses
* Any recent lab or diagnostic assessment results

INSUFFICIENT APPETITE EVALUATION

Oral Assessment
. Look for quantity and condition of teeth, particularly pairs of
teeth, in eating position
‘ Tenderness and pain due to partial plates or dentures that
do not fit properly
‘ Dried out, sticky, reddish tissue, or blisters on the tongue or floor of
oral cavity
. Dry, chapped, or blisters on or around lip region
‘ Swollen or hemorrhaging gums
. White or red sections, bleeding, or ulcers on material inside
cheeks of mouth
. Potent odor (probably due to tooth decay)
Mini-Nutritional Assessment (MNA) is a straightforward, reliable tool
for evaluating nutritionary levels in elderly people. It consists of
18 items in 4 parts. The MNA was confirmed to be 98%
accurate when compared with a comprehensive dietary
evaluation that included food records and laboratory tests.
The MNA can be acquired at http: //www. nursingcenter. com/
pdf. asp? AlD=770859 (or tool indicated by facility).

Abdominal Assessment
Listen carefully for bowel noises to see if they
are active and clear in all four quadrants. Delicately palpate
over each of the 4 abdominal quadrants. Notice if the abdomen is soft or firm. Look for tenderness, muscular rigidity,
warmth, superficial masses and watch patient’s facial expressions
in the course of palpation. Check for hard stool in the rectum
if the resident has not had a bowel movement in respect to
facility policy.

ASTHMA

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PHYSICAL DATA

*Vital signs, including comprehensive description of respiratory rate and tempo
*Lung evaluation, listen particularly for wheezing
rates, rhonchi, look for the use of accessory
muscular tissues to breathe, and extented expiraiion
*Any sputum production (including consistency and coloring)
*Level of awareness

HEALTH CARE BACKGROUND

Onset, duration, rate of recurrence, and severity of
symptoms
What has been carried out so far to deal with the
problem
All current medications, including any recent
variations
Precipitating and relieving elements
Whether or not patient is utilizing oxygen (O2), and what
are O2 configurations
Pulse oximetry results (current and previous)
All current diagnoses
Any recent lab or diagnostic exams

When listening to sounds of the lungs you want to
place your stethoscope over the following places:
Right Upper Lobe ……. Left Upper Lobe
Right Middle Lobe
Right Lower Lobe…….. Left Lower Lobe

Listen
. Crackles: These are high pitched,
discontinuous sounds similar to the sound
made by rubbing your hair between your
flngers (atso known as Rales).
. Wheezes: These are usually high pitched and
“musical” in quality.
Stridor is an inspiratory
wheeze affiliated with upper airway
blockage (croup).
Rhonchi: These typically have a snoring, or
“gurgling” quality. Any excess sound that is not
a crackle or a wheeze is probably a rhonchi.

Look
. Resident is unable to speak at all or cannot
converse in sentences because of shortness of
breath.
. Inhalation patterns such as Cheyne-stokes,
hyperventilation.
. Observe the resident for signs of cyanosis,
molting, etc.

BACK (lNJURlES AND PAlN)

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PHYSICAL INFORMATION

Vital signs
Indicators of inflammation, bruising, fracture or deformity of
back, spine, hips, or pelvis
Discomfort assessment (location, nature, severity, etc.
Does it change with activities)
Movement of, and sensation in, lower extremities
Range of movements of hips and knees, as opposed to
normal baseline

MEDICAL HISTORY

Patient’s age and sex
Any history of back surgery, spinal cord damage,
urinary tract infections, pneumonia and other
respiratory infections, cardiac ailment, or
diabetes
Attempted symptom management to date
All current diagnoses
History of any recent falls, injuries, or recent back
surgical procedures
Grade of mobility (ambulatory, bed-bound or chair-bound,
etc. )
All current medications, including any recent
changes

BACK INJURY/DISCOMFORT EVALUATION
Listen for words from the elderly patient such as
discomfort, hurting, or aching rather than use the
specific word pain. Not everyone uses the word ‘pain’ to describe discomfort.
Look: Crucial info is attained easily
from observing the patient’s routine of movement.
. Observe level of mobility
. Observe patient for significant changes
. Observe gait and standing up/sitting balance
. Observe lower extremity joint function
. Observe ability to use ambulatory assistive
equipment (cane, walker, etc. ) and modify as
indicated
. Observe activity tolerance
. Observe for significant alterations in activity
Present employees with a clear, written procedure that
describes what to do when a patient falls.

BLISTERS

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PHYSICAL DATA
Vital signs
‘Skin examination, including location (localized or
diffuse), dimension, appearance (vesicles, pustules,
bullae, etc. ), number (individual or numerous), and any
underlying inflammation or exudate
Discomfort evaluation (place, characteristics, severity, etc. )
Any signs of secondary bacterial infection
HEALTH CARE HISTORY
Patient’s age and sex
‘Onset, duration, rate of appearance of new
blisters etc.
Health care history, including record of autoimmune
diseases or skin rashes
All present diagnoses
Any allergies to food, medications, detergents, etc.
All current medications, including any recent
alterations
Current treatments

BLISTER EVALUATION

A blister is a local swelling of the skin that is made up of
watery liquid. There are many circumstances that may result
in blisters, such as: cold sores, impetigo, shingles, eczema,
chicken pox, bullous pemphigoid (which is more
common in the aging population), sunburn.

It is important to describe the f ollowing:
. Are they found over the whole body?
. Are they cropped together in one location of the body?
. Are they located in an area inclined to rubbing or
shearing?
. Are they painful?
. Does the affected person have an elevated temperature?
. Does the patient have a history/diagnosis of a
blister forming condition in the past?
. Has the patient had past history of chicken pox/
shingles?
. Is there drainage (color & consistency)?
Vesicle: A vesicle of the skin, comprising watery matter
or serum.
Pustules: Inflammation of the skin filled with pus.
Bulla: Blister more than five mm (about 3 /16 inch) in
diameter with thin surfaces that is full of fluid.
lf one of the herpes viruses are suspected (such as varicella)
assess all areas of the body, including armpit,
groin, joints, stomach, mouth, neck
A healthcare diagnosis must be made promptly in case
isolation is necessary and employee health options
need to be put in place.

BLOOD PRESSURE, HIGH OR LOW

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PHYSICAL INFORMATION
Vital signs, including orthostatic BP obtained white lying down, sitting
and standing, if possible
Any associated indicators of related neurological or cardiac decline
which include modified level of consciousness, significant new
neurological abnormalities cardiac rate or rhythm disturbances
Any related signs of hemorrhage, including bleeding,
bruising, and tenderness
Pain evaluation
Headaches, facial flushing, nosebleed, and fatigue
(hypertension)
Tachycardia, weak or thready pulse, weakness, dizziness,
confusion, or cool, pale, dusky or cyanotic skin (hypotension)

HEALTH CARE BACKGROUND
Patient’s age and sex
Abnormal BP patterns over time, including any relationship with
prescription medication adjustments
Any_associated symptoms of relevant neurological or cardiac
decline including chest pain, dizziness, lightheadedness,
blurred vision, headache, weakness or weakness, problems
inhaling and exhaling, palpitations, nausea, vomiting, or dark or bloody
stools
Any alterations in coloring or output of urine
All current prescription drugs, including any recent changes;
especially any hypertensive or heart drugs
Recent or current background of chest pain, head trauma, persistent
headache, change in degree of consciousness, dizziness, and
diaphoresis
All existing diagnoses

BLOOD PRESSURE EVALUATION
Special focus must be made to selection of size of BP cuff
in elderly adults, especially frail older adults, because they have
decreased or lost upper body mass.
Classification of Blood Pressure
High Blood Pressure
Stage1
Stage2
Illustrations of Typical Errors in
Blood Pressure Measurement
Error Effect
Bladder or cuff too wide False low reading
Bladder or cuff too narrow/too short False high reading
Cuff wrapped too loosely/unevenly False high reading
Deflating cuff too slowly False high diastolic
reading
Deflating cuff too quickly False low systolic/false
high diastolic reading
Arm underneath heart level False high reading
Arm above heart level False low reading
Arm not reinforced False high reading
Stethoscope that fits inadequately False low systolic/false
high diastolic reading
Stethoscope applied too tightly False low diastolic reading
Inflating too slowly False high diastolic
reading
Repeating assessments too quickly False low systolic reading
Imprecise inflation level False low systolic reading.

BRUISE

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PHYSICAL DATA
Vital signs
Description Of bruise
Pain evaluation (location, nature, severity, etc.)
Injury evaluation (any associated bleeding,
deformity, swelling, etc.)
Evidence of a recent fall

MEDICAL HISTORY
Patients age and sex
All current medications, including any recent
changes, especially anticoagulants, NSAIDs,
salicylates and other platelet inhibitors
Behavior over last 48 hours (especially whether
patient has movement disorder or aggressive
behavior)
Any history of tendency to easy bruising
All current diagnoses
Any recent lab or diagnostic test results

BRUISE DESCRIPTORS
Stage1: Pinkish red color that can be very tender
to touch
Stage2 : Blue or purplish color
Stage3 : Greenish color
Stage4 : Brown or yellowish color
Bruises change colors over time in a fairly
predictable pattern. This makes it possible to
estimate when an injury occurred by the color of
the bruise. Initially, a bruise will be reddish, the
color of the blood under the skin. After one to two
days, the red blood cells begin to break down,
and the bruise will darken to a blue or purplish
color. This fades to green at about day six. Around
the eighth or ninth day, the skin over the bruised
area will have a brown or yellowish appearance.
It is important to note the color of a bruise so
you can look back and try to figure out when it
occurred and perhaps try and figure out what
may have happened.
Signs of infection around the bruised area include
streaks of redness, pus or other drainage, or
fever.