Week 6

Week 6: Assessment of
Special Populations

Required reading: Wilson & Giddens, Ch. 26

Assessment of the Pregnant Woman
1. Signs of pregnancy
  1. Presumptive signs - woman is likely pregnant
    1. Absent menstrual periods
    2. Nausea & vomiting
    3. Frequent need to urinate
    4. Breast tenderness
    5. Fatigue
    6. Skin changes
    7. Sensation of movement in abdomen
  2. Probable signs
    1. Softening of cervix at 6-8 weeks
    2. Bluish coloration of cervix, vagina and vulva at 6-8 weeks
    3. Abdominal enlargement
    4. Passive movement of fetus during exam
    5. Braxton-Hicks contractions
    6. Positive pregnancy test
  3. Positive signs
    1. Fetal heart sounds
    2. Fetal movements felt by examiner
    3. Outline of fetus on x-ray
    4. Sonogram
2. Physical and psychological changes during pregnancy
  1. Pregnancy affects almost every system of the body.
  2. Body changes - gives a month by month description of the physiological changes http://www.health-center.com/family/pregnancy/changes_in_mom/default.htm
    1. Hormones - All of the physiological changes are related to hormones produced by the placenta or fetal chorionic tissues.
    2. Human chorionic gonadatropic hormone (HCG) is present in detectable amounts by day 8 or 10. This is the basis of pregnancy testing.
    3. Estriol is produced in large amounts during the middle and late pregnancy. It is responsible for the placental and fetal well-being.
    4. The thyroid gland hypertrophies and increased thyroid hormone production results in increased basal metabolic rate.
  3. Uterine
    1. The uterine size increases 5-6 times
    2. The uterine weight increases about 20 times
    3. The uterine cervix softens and becomes bluish in color at 6-8 weeks.
  4. Breast
    1. The breasts begin enlarging around the 8th week. The enlarged breasts may become tender.
    2. The nipple become larger and more erectile.
    3. The areola darkens and the sebaceous glands hypertrophy.
    4. Colostrum can be expressed about the 24th week.
    5. Stretching of the skin may produce striae gravidarum (stretch marks) and the blood vessels may become more prominent.
  5. Abdomen
    1. The muscles stretch and striae gravidarum (stretch marks) may appear.
    2. The umbilicus flattens or protrudes.
    3. Smooth muscles relax
    4. Peristalsis decreases resulting in decreased bowel sounds
    5. Increased incidence of nausea and vomiting, heartburn, constipation
    6. Increased pressure on pelvic blood flow results in hemorrhoids
    7. Ptyalism (excessive salivation) may occur
    8. Pica (a craving for substances with little food value) is common and is considered normal in some cultures
  6. Skin and hair
    1. Melanocyte activity increases with darkening of all skin
    2. Linea nigra - darkened streak midline in abdomen
    3. Chloasma - mask of pregnancy
    4. Scars and moles darken
    5. Palmar erythema - palms redden
    6. Spider nevi - reddened capillaries (look like red spiders on the skin)
    7. Hypertrophy of gums
    8. Hair may straighten and become oily, some women have increased hair loss
    9. Facial and abdominal hair may increase
  7. Cardiovascular
    1. Blood volume increased up to 45%
    2. Cardiac output increased up to 30%
    3. Splitting of S1 and S2
    4. 3 may be heard
    5. Heart sounds louder and a grade II/VI systolic murmur may appear
    6. Venous pressure in lower extremities increases when woman standing, sitting or lying supine because of pressure of uterus.
    7. Varicosities of legs and vulva
    8. Edema
  8. Respiratory
    1. Increased tidal volume, rate and alveolar ventilation
    2. Oxygen consumption increases by about 20%, carbon dioxide content decreases
    3. Dyspnea common complaint in last trimester due to pressure on diaphragm
    4. Hyperemia and edema of nasal, sinus, nasopharyngeal and lower respiratory tract.
    5. Nosebleeds common
    6. Increased nasal stuffiness
    7. Vocal cord edema results in voice changes
    8. Blockage of eustachian tubes and increased blood flow to tympanic membranes may result in ears feeling stuffy or decreased hearing
  9. Musculoskeletal
    1. About the 24th week, the enlarged uterus causes lordosis
    2. Low backache
    3. Gait changes
    4. Fatigue
    5. Unstable balance
    6. After the 7th month, the joints of the pelvis relax
    7. Waddling gait
  10. Urinary
    1. Increased blood volume results in 50% increase in urinary blood flow
    2. Decreased glucose reabsorption — glycosuria
    3. Growing uterus causes pressure on bladder resulting in increased frequency
  11. Neurological
    1. Numbness and tingling of hands
    2. Headaches
3. Possible problems/complaints
  1. First trimester
    1. Nausea and vomiting http://www.mayohealth.org/mayo/baby/htm/baby1.htm#nausea
    2. Fatigue http://www.mayohealth.org/mayo/baby/htm/baby1.htm#fatigue
    3. Urinary frequency http://www.mayohealth.org/mayo/baby/htm/baby1.htm#urinary
    4. Breast tenderness http://www.mayohealth.org/mayo/baby/htm/baby1.htm#breast
    5. Headaches & dizziness http://www.mayohealth.org/mayo/baby/htm/baby1.htm#headache
    6. Weight gain http://www.mayohealth.org/mayo/baby/htm/baby1.htm#weight
    7. Spotting or bleeding http://www.mayohealth.org/mayo/baby/htm/baby3.htm#spotting
    8. Pelvic pains http://www.mayohealth.org/mayo/baby/htm/baby3.htm#spotting
  2. Second trimester
    1. Aches and pains http://www.mayohealth.org/mayo/baby/htm/bab_2_1.htm#Aches
    2. Skin changes http://www.mayohealth.org/mayo/baby/htm/bab_2_1.htm#Skin
    3. Constipation http://www.mayohealth.org/mayo/baby/htm/bab_2_1.htm#Constipation
    4. Weight gain http://www.mayohealth.org/mayo/baby/htm/bab_2_1.htm#Weight
    5. Vaginal discharge and infections http://www.mayohealth.org/mayo/baby/htm/bab_2_3.htm#Discharge
    6. Cravings http://www.mayohealth.org/mayo/baby/htm/bab_2_3.htm#Cravings
  3. Third trimester
    1. Shortness of breath http://www.mayohealth.org/mayo/baby/htm/bab_3_1.htm#Breath
    2. Sleeping problems http://www.mayohealth.org/mayo/baby/htm/bab_3_1.htm#Sleeping
    3. Skin changes http://www.mayohealth.org/mayo/baby/htm/bab_3_1.htm#Skin
    4. Hemorrhoids http://www.mayohealth.org/mayo/baby/htm/bab_3_1.htm#Hemorrhoids
    5. Urinary incontinence http://www.mayohealth.org/mayo/baby/htm/bab_3_1.htm#Urine
    6. Weight gain http://www.mayohealth.org/mayo/baby/htm/bab_3_1.htm#Weight
    7. Fetal movements http://www.mayohealth.org/mayo/baby/htm/bab_3_2.htm#Movements
4. Measuring fundal height
  1. At 12 weeks the fundus is at the symphysis pubis.
  2. At 20 weeks the fundus is at the umbilicus.
  3. After 20 weeks fundal height above the symphsis pubis is equal to the number of weeks of gestation. For example, at 25 weeks gestation, the fundus should be 25 cm above the symphysis pubis.
5. Leopold maneuvers
  1. A systematic method of palpating the abdomen to discover fetal position. After weeks 32-34 the position, presentation and attitude of the fetus can be assessed. The woman's leg should be bent and the bladder emptied.
  2. First maneuver - Palpate the upper abdomen with both hands to determine if the head or buttocks is present. The head will feel firm, hard, and round and will move independently of the trunk. The buttocks will feel irregular, soft and are difficult to move.
  3. Third maneuver - determine what part is lying just above the symphysis pubis. Cup the abdomen just above the symphysis pubis with the thumb and fingers of one hand. The head will feel hard, round and smooth. The buttocks will be softer and irregular.
  4. Fourth maneuver - In late stages of pregnancy, determine the degree of engagement and cephalic flexion. Palpate the lower abdomen with both hands in an attempt to feel the cephalic prominence (brow). Move the hands down the sides of the uterus towards the pubis. The cephalic prominence will present greatest resistance to the descent of the fingers to the uterus.
6. Psychological assessment - Perform a psychological assessment during each visit to determine the client's emotional response to pregnancy. To help the woman cope with changes provide information about body changes, anticipated problems and methods to handle the expected problems.
Postpartum assessment - 6 week period after delivery when reproductive organs return to prepregnancy state
1. Physical and psychological changes
  1. Hormones related to postpartum physiologic changes
    1. Human chorionic gonadatropic hormone (HCG) is present in detectable amounts by day 8 or 10. This is the basis of pregnancy testing.
    2. Estriol is produced in large amounts during the middle and late pregnancy. It is responsible for the placental and fetal well-being.
    3. The thyroid gland hypertrophies and increased thyroid hormone production results in increased basal metabolic rate
2. Body changes
  1. Uterus
    1. Uterus at level of umbilicus immediately after delivery.
    2. Uterus decreases in sized about 1 finger breadth per day until day 9-10 when it can no longer be palpated above the pelvis.
    3. Placental site heals in 6 weeks
    4. Os closes to 1 cm by 1 week, edema continues for 3-4 weeks
    5. Vaginal rugae reappear by week 3, lubrication returns by week 6 when estrogen levels return to normal
    6. Lochia
      1. Lochia rubra
        
        bright red discharge
        
        lasts about 3 days
        
        contains blood, mucus, cellular debris
      2. Lochia serosa
        
        pink, watery discharge from day3-10
        
        consists of old blood, serum, leukocytes, and tissue debris
      3. Lochia alba
        
        thin, scanty whitish-tan discharge from day 10 to end of week 3, may continue to week 6
        
        contains leukocytes, mucus, serum, epithelial cells, tissue debris
    7. Return of ovulation depends upon lactation
      - Lactating women - ovulation usually returns 12-36 weeks
      - Nonlactating women - ovulation usually returns 10-12 weeks
  2. Breasts
    1. Lactating woman
      1. Remain enlarged
      2. Colustrum secreted after delivery
      3. Milk produced in 3-4 days
      4. May be engorged for 3 days
      5. Milk production continues as long as the infant nurses approximately 6 times per day
    2. Nonlactating woman
      1. Breasts may be engorged, tender, inflamed briefly (3 days)
      2. Lactation can be suppressed by wearing a tight brassiere and avoiding stimulation of the nipples and breasts in about 70% of women
      3. Lactation ceases in 1 week and breasts return to non-pregnant state gradually
      4. Lactation may be suppressed by synthetic ergots that inhibit prolactin
  3. Cardiovascular
    1. Blood volume
      1. transient 10-30% increase in circulating blood volume 12-48 hours afte delivery
      2. By day 3 the blood volume has decreased 16% from pregnancy
      3. By week 4, the blood volume returns to prepregnancy level of 4 liters
      4. Loss of prolactin reduces vasodilation
      5. Renin/angiotensin levels return to normal in 2 hours
    2. Cardiac output
      1. Increased stroke volume and cardiac produced by pregnancy lasts ~ 48 hours after delivery
      2. Cardiac output returns to prepregnancy levels after 3 weeks
    3. Vital signs
      1. Temperature rises during first 34 hours to as high as 38� C due to dehydration. After 24 hours mother should be afebrile.
      2. Bradycardia is common for 6-8 days.
      3. Blood pressure is altered sightly if at all. Orthostatic hypotension may occur for 48 hours.
      4. Respiratory function returns to nonpregnant levels by 6 months after delivery.
    4. Varicosities
      1. Hemorrhoids - Regression is expected following pregnancy http://www.babycenter.com/refcap/244.html#4
      2. Leg - varicose veins - should also regress after pregnancy http://members.aol.com/gvg97/vvinfo.htm#causes
  4. Renal and urinary bladder
    1. Marked diuresis occurs within 12 hours after birth
    2. Diaphoresis, especially at night, may occur for 2-3 days.
    3. Bladder tone usually returns within one week.
    4. Renal function returns to normal within the first month.
    5. Hypotonia and dilation of ureters and renal pelvis returns to normal in about 6 weeks.
    6. Glycosuria induced by pregnancy disappears.
    7. Lactosuria may develop in lactating women, this will not be detected by usual glucose testing methods.
    8. Hematuria is not unusual immediately after delivery due to trauma to the urethra and bladder. Hematuria after week 2 is probably due to urinary tract infection.
  5. Gastrointestinal
    1. Decreased muscle tone and peristalsis persist for only a short time after delivery.
    2. Mothers are usually hungry immediately after delivery. After recovery from analgesics, anesthetics and fatigue, mothers often consume double portions and ask for snacks.
    3. The first bowel movement may not occur for 2-3 days following delivery.
  6. Neuromuscular
    1. Diuresis after delivery reduces carpal tunnel syndrome.
    2. Postpartum headaches may be caused by
      1. hypertension
      2. stress
      3. leakage of cerebral spinal fluid after spinal anesthesia
    3. Stabilization of joints is complete by 6-8 weeks
    4. Joints in the feet may never return to prepregancy status - the mother often has a permanent increase in shoe size
  7. Skin
    1. Chloasma usually disappears after delivery.
    2. Hyperpigmentation of areolae and linea nigra may not completely regress.
    3. Vascular abnormalities (spider angiomas, palmar erythema, epulis) generally regress with the decline in estrogen. Some women retain spider angiomas.
    4. Fine hair associated with pregnancy disappears. Coarse hair remains.
    5. Fingernails return to nonpregnant state.
    6. Diaphoresis for 2-3 days is common.
  8. Immune system - the mother may need Rh isoimmunization. http://rainforest.parentsplace.com/dialog/get/f9pregloss/26/2.html
12 point assessment
1. Vital signs
  1. checked every 15 minutes during first hour after birth, every 30 minutes for the next hour, hourly for next 2-6 hours, every 4 hours for remainder of 24 hours, then every shift.
  2. Oral temperature may be up to 100.4� F for first 24 hours due to dehydration. Temperature over 100.4� F suggests infection (sepsis, UTI, endometritis, or mastitis).
  3. Pulse rate may decrease to 50-70 due to increased stroke volume.
  4. Orthostatic hypotension may occur for first 8 hours after birth. Otherwise BP should be similar to pressure during labor.
2. Fundus of uterus - palpate for firmness and location. Uterus should be at umbilicus after birth and should be firm.
3. Lochia - check for amount, color, presence of clots and odor.
4. Perineum - Observe for redness, edema, ecchymosis, discharge and approximation (REEDA)
5. Breasts - examine every 8 hours. Encourage mother to wear a bra for support. Inspect and palpate for nipple soreness, breast tenderness, lumps, ingorgement, mmastitis, and presence of colostrum or milk.
6. GI system - auscultate for bowel sounds every 8 hours. Normal elimination should return in 2-3 days.
7. GU system - Assess mother's ability to void. Palpate bladder for position and fullness. Measure first 2-3 voidings to make sure bladder is completely emptying.
8. Cardiovascular system - Assess for Homan's sign every 8 hours.
9. Respiratory system - Assess lung sounds every 4-8 hours. For women who have received epidural anesthesia, assess respiratory rate every hour.
10. Nutritional assessment - breastfeeding women need an additional 500 calories per day. Recommend food groups that promote healing.
11. Psychosocial assessment
  1. Taking-in phase - occurs during first 2-3 days. Maternal needs for rest and nutrition must be met first. Woman accepts role of mother.
  2. Taking-hold phase - New mother becomes more independent and ready to make decisions. Normally from day 3-7.
12. Rest & sleep

Review questions - see on-line
Take the Pregnancy quiz on-line

Newborn
Required reading: Wilson & Giddens, pp. 56-57, 88-90, 123, 131, 153, 430, 770-771. Other information about assessment of newborns is scattered throughout your previous readings.
1. Apgar Scoring http://www.childbirth.org/articles/apgar.html
2. Gestational age http://www.merck.com/pubs/mmanual/section19/chapter260/260a.htm
3. Head
  1. Head: shape, symmetry -May be asymmetrical due to molding, this should disappear in 5-7 days. May have edema formation (caput succedaneum -not bound by suture lines) or bleeding into subperiosteum (cephalhematoma - not crossing suture lines).
  2. Fontanels
    1. "Soft spots" in skull. Should be flat, soft and firm. May buldge when infant is crying or coughing. Depressed fontanels indicates dehydration.
    2. Anterior - diamond-shaped, at front and top of head; may notice it pulsate; closes between 12 and 18 months.
    3. Posterior - is triangle-shaped, at top and to the back of the head; closes at birth or within 2 months.
  3. Face: shape, symmetry - Face may be asymmetrical due to soft tissue damage and swelling during birth process.
    1. Milia - pin-head sized white spots (clogged oil glands) over the nose, chin, or cheeks. These are normal and disappear within a few weeks without treatment. Should not be picked or squeezed.
  4. Nose: shape, placement, patentcy - Nose should be midline, symmetrical. Check for nasal flaring. Nose may need to be suctioned with bulb syringe to maintain patentcy. Infants are obligate nose breathers - they cannot breathe through their mouths at birth. It is common for neonates to sneeze frequently. Thin white mucus is common.
  5. Ears: size, placement, hearing, symmetry, amount of cartilage
    1. Top of ears should be level with outer canthus of eye. Ear cartilage should be formed so that ear holds shape.
    2. Audiology screening http://neonatal.peds.washington.edu/NICU-WEB/hearscrn.stm
  6. Eyes: color, pupil reaction, discharge
    1. Eyes may be swollen and red from trauma of birth or from reaction to medication routinely used in infant's eyes upon admission. Tears my not be present for several weeks or even 3-4 months. Eyes will be dark blue at birth, and will become their permanent color at 3 months of age. Color changes may not be complete for one year.
    2. Check for red reflex; blink, corneal and pupil reflexes.
    3. Nystagmus is a common finding.
  7. Mouth
    1. Mouth should be round, symmetrical. Hard palate should be intact with high arch.
    2. Epstein's pearls are common (small, white, epithelial cysts along sides of midline of hard palate) and will disappear in a few weeks.
    3. Look at the uvula and pharynx when the infant is crying. Tonsils are not visible in the newborn.
    4. Check for extrusion, sucking and rooting reflexes. See section on normal reflexes.
4. Reflexes
  1. Rooting/ Sucking - When cheek stroked child turns head toward side touched. Strongest during first 2 months. Disappears at 3-4 months.
  2. Moro's (Startle) - Sudden loud noise causes abduction of arms with elbow flexion, hands clenched. Should disappear by 4 months.
  3. Grasp - Infant will grasp anything placed in hand. Touching sole of foot will cause grasping motion of toes. Should disappear by 3 months. Palmar grasp reflex will gradually become voluntary.
  4. Tonic Neck - When head is quickly turned to one side, arm and leg will extend on that side. Opposite arm and leg will flex. Should disappear by 3-4 months.
  5. Pull-to-Sit - Head lag common until 3-4 months.
  6. Babinski - Great toe flares and other toes spread when outer edge of sole is stroked. Should disappear about 12 months. http://seniornet.drkoop.com/conditions/ency/article/003294.htm
  7. Trunk Incurvature - When back is stroked beside spinal column, the infant will move hips toward side stimulated.
  8. Stepping - Infant held so sole touches surface, flexion and extension of leg resembling walking. Should disappear by 3-4 weeks.
  9. Extrusion - When object is placed in mouth, the infant will push it out with tongue.
5. Vital Signs
  1. Temperature (axillary) - 97.5 to 99�F
  2. Heart
    1. Heart rate 120 - 160, may be irregular
    2. Listen for murmurs
  3. Blood Pressure - only taken with signs of illness.
  4. Pulses - Radial and femoral pulses should be strong and equal bilaterally
  5. Perfusion, Capillary Refill - refill less than 3 seconds
  6. Lungs
    1. Normal rate is 30-60 breaths per minute. Periods of apnea less than 15 seconds is normal.
    2. Breath sounds (http://www.med.ucla.edu/wilkes/html/normal.html0
6. Integument
  1. Color, consistency, hydration (http://www.babycentre.co.uk/refcap/178.html#1)
    1. Newborn is usually birght red with puffy skin. By the second to third day the skin should be pink, dry and flaky.
    2. Normal color changes:
      1. Acrocyanosis - blueness of hands and feet
      2. Mottling - transient when infant exposed to cold
      3. Mongolian spots (http://www.fwcc.org/mongolianspot.htm)
      4. Birthmarks (http://www.mylifepath.com/article/bcrefcap/183840
      5. Stork bites - telangiectatic nevi - flat, deep pink areas seen on the upper eyelids, between the eyebrows, on the upper lip, or at the nape of the neck. These eventually fade and disappear between 1 and 2 years of age.
      6. Jaundice - yellow skin due to increased breakdown of red blood cells (http://www.crha-health.ab.ca/hlthconn/items/jaundice.htm)
    3. Lesions
      1. "Newborn rash" - eruptions that appear 'hive-like' and may appear and disappear at intervals during the first few days of life. (http://www.drpaula.com/topics/newrashes.html)
      2. Milia (http://babyzone.com/drnathan/M/Milia.htm)
      3. Vernix (http://babyzone.com/drnathan/V/Vernix.htm)
      4. Lanugo (http://babyzone.com/drnathan/L/Lanugo.htm)
7. Chest
  1. Circumference - 12.5-13.5", 30-35 cm. Chest is almost circular. Slight intercostal retractions are normal.
  2. Clavicles - Check for bumps, clavicle may have been broken during birth.
  3. Breast Tissue - Breast of the newborn of both sexes may be swollen the first few days due to high level of maternal hormones. They may also excrete a whitish fluid that looks like milk (witch's milk). These are both normal and will disappear without treatment by 4-6 weeks of age. Breasts of infants should never be squeezed.
8. Elimination
  1. Urine: Usually 3-4 voidings per 8 hours. Color should be light yellow. Dark yellow urine indicates dehydration.
  2. Stools: Color, Type
    1. Initial stools are meconium (sticky greenish black) and should occur within the first 36 hours. After the infant begins eating transitional stools are passes - less sticky and brownish yellow. (http://drhull.com/EncyMaster/M/meconium.html)
    2. By the fourth day a milk stool should be passed - breast fed infants have pasty yellow to golden stools with an odor similar to sour milk. Bottle fed infants have pale yellow to light brown stools, firmer consistency and stronger odor.
  3. Patency of Anus - Patent anal opening. Passing of meconium stool indicates patent anus.
9. Abdomen
  1. Bowel sounds - 2-4 per minute should be present a few hours after birth.
  2. Abdomen
    1. Usually rounded with prominent veins.
    2. If scaphoid, suspect a diaphragmatic hernia. http://sandiegoinsider.adam.com/ency/article/001135.htm
    3. Liver is usually palpable 2-3 cm below costal margin.
  3. Condition of cord (number of vessels)
    1. Will fall off in approximately 7-14 days.
    2. There may be brownish-colored drainage after the cord falls off.
    3. There should be 3 vessels present in the cord.
10. Back / Spine
  1. Spine intact, no openings, masses or prominent curves. Spine usually rounded with none of curves seen later in life.
  2. Trunk incurvation reflex present - stroke back along one side of the vertebral column will cause the infant to move hips toward the stimulated side.
11. Extremities
  1. Arms/Hands
    1. Should have 10 fingers. Look for polydactyly and syndactyly. Nail beds should be pink. Slight blueness is common when extremities are cold.
    2. Negative scarf sign - elbow does not reach midline. Scarf sign- with the infant supine, take the infant's hand and draw it across the neck and as far across the opposite shoulder as possible. Assistance to the elbow is permissible by lifting it across the body.
  2. Legs/Feet
    1. Should have 10 toes. Sole usually flat with creases on anterior 2/3 of foot. Symmetry of legs with equal muscle tone and resistance to opposing flexion. Extremities usually have flexion.
    2. Ortolani's sign for hip dislocation. (http://www.medmedia.com/oa3/29.htm)
12. Genitals
  1. Male: testes,scrotum, penis
    1. Scrotum may appear swollen at birth due to maternal hormones. Check that both testes are descended.
  2. Female: labia, clitoris, vagina, discharge
    1. Smegma - white, mucous discharge secreted for about 6 weeks that protects the area.
    2. Pseudo-menstruation - pinkish-red discharge from the vagina, caused by the withdrawal of maternal hormones.
    3. Labia - may be swollen and red due to high level of maternal hormones.
13. Review questions are on-line
14. Newborn assessment quiz is on-line
Children

Required Reading: Wislon & Giddens: 10-22, 21, 58-60, 90-91, 123-125, 141, 153-155, 186, 227, 249-250, 275-277, 306-307, 338-339, 343, 375, 382-383, 430-431, 465-467, 504-505, 552-553, 585-586, 611-612, 685-687, 733, 788-793 Information about assessment of children has been included in each of the previous sections.

Objectives

conduct the interview and physical examination based upon the child's developmental stage.

choose an appropriate method of restraint based upon the child's size and developmental stage.

provide developmentally appropriate anticipatory guidance.

Theories of child development

Erickson (http://child-development.hypermart.net/erikson.html)

Freud (http://child-development.hypermart.net/freuddev.html)

Mahler (http://child-development.hypermart.net/mahler-d.html)

Piaget (http://www.funderstanding.com/learning_theory_how3.html)

Developmental milestones

Newborn

Fix and follow a human face

Turn toward human voice

1 month

Raises head slightly when prone

Fixes on face or object and follows with eyes

2 months

Hold head erect temporarily

Grasp object placed in hand and hold briefly

Social smile

Reciprocally vocalizes, coos

Begins to distinguish and respond to caretakers more than others

3 months

Holds head erect when held upright

4 months

Holds head high and raises body on hands when prone

No head lag when pulled erect

Rolls from prone to supine

Opens hands, plays with hands

Looks at mobile, waves arms

Follows objects through 180� range

Initiates social contact; smiles, coos, laughs, squeals; may be upset when parent moves away

Recognizes preparations for feeding

6 months

Rolls over

Sits with support on leans on hands

Bears some weight on legs

Reaches for and grasps objects, transfers object from hand to hand

May be able to hold bottle to feed

May approach tiny objects with a raking motion

Plays with feet

Turns to sounds outside vision and changes activity

Shows stranger anxiety

Takes initiative in interacting with others; may blow bubbles, imitates some sounds

9 months

Sits well

Crawls, creeps on hands, hitches on bottom

Pulls to a stand

Poor pincer grasp, pokes with index finger

Finger feeds partially

Imitates vocalizations, monosyllabic/polysyllabic

Responds to simple questions "What is your name?" "Where is mama/dada?"

Understands a few words: no, bye

Enjoys social games with adults: peak-a-boo, pat-a-cake

Stranger anxiety present

Concept of object permanence - retrieves object under blanket

12 months

Walks with support

Precise pincer grasp, points, bangs two objects together, can put one object inside another

Can say one to three meaningful words, besides "mama" and "dada"

Concept of object permanence

Plays social games, waves bye-bye

May cooperate in dressing and feeding self, uses a cup

15 months

Walks alone, stops and starts, stoops

Feeds self with fingers, drinks from cup

3-6 word vocabulary, uses jargon and gestures

Scribbles spontaneously

Points to one or two body parts when asked. Understands simple commands.

Attends to story being read.

Indicates wants by pulling, pointing, grunting, speaking

Stacks two blocks, gives and takes a toy

Hugs

18 months

Walks fast, walks up stairs with hand held, runs stiffly, walks backwards, climbs onto chair, kicks and throw ball

Stacks 3-4 blocks and knocks them over, places rings on cone

Turns pages in book, looks at pictures and names some objects

4-10 word vocabulary, two word phrases, voices two or more wants, imitative vocabulary greater than vocal,

Pulls toys

Feeds self using spoon, holds and drinks from cup

Imitates crayon stroke on paper

Can dump object from container without demonstration

Hugs doll or stuffed animal, uses household toy (phone) appropriately

Kisses parent on cheek

24 months

Climbs and descends stairs alone, holding rail or adult's hand

Opens doors, climbs on furniture, uses spoon and cup well, kicks ball, throws overhand

Stacks 5-6 blocks, aligns 2-3 blocks after demonstration

Vocabulary of 20 words, two word phrases with pronoun, refers to self by name

Responds to two part command

Makes or imitates horizontal or circular strokes

Imitates adults

Interested in bowel and bladder control, helps with dressing, washes and dries hands

Uses toys appropriately

3 years

Jumps in place, kicks ball, balances and stands briefly in place

Pedals tricycle, alternates feet when ascending stairs, opens doors

Stacks 9 cubes, imitates a bridge made of 3 blocks

Most speech intelligible

Knows name, age, sex

Understands words cold, tired, hungry; may differentiate on-under, bigger-smaller. Uses ball, scissors, key and pencil appropriately

Copies circle,; may copy cross, begins to differentiate colors

Describes action in pictures

Puts on some clothes and shoes

Feeds self

4 years

Alternates feet when descending stairs, hops, jumps forward, stands on one foot 3-5 seconds, climbs ladder, rides tricycle, walks on tiptoes

Holds pencil with good control, can cut and paste

Builds tower of 10 or more blocks

Engages in give-and-take conversation

Asks why, when, how; asks about the meaning of words

Names 3-4 primary colors, counts to 5; sings a song; enjoys jokes

Washes and dries hands, brushes teeth, dresses and undresses with supervision, except for laces or buttons, begins to be selective about clothes

Imitates dramatic make-believe in which child plays specific role; imaginative and curious

Gender identification formed

Copies cross and circle, draws person with 2-3 parts

Plays cooperatively with other children, interested in other children's bodies

5 years

Skips, walks on tiptoe, broad jumps

Cuts and pastes; copies triangle; recognizes most letters of alphabet; draws person with head, body, arms and legs

Names 4-5 primary colors, identifies coins

Tells simple story, knows several nursery rhymes

Defines simple words - ball, shoe, dog, spoon

Begins to recognize right and wrong, fair and unfair

Dramatic make-believe with specific role, domestic role-playing

Plays cooperatively

6 years

Bounces ball 4-6 times, throw and catches; skates; rides bicycle

Ties shoelaces

Counts up to 10, prints first name, prints numbers to 10, knows right from left,

Draws person with 6 body parts, wearing clothing

8 years

Can tell time

Reads for pleasure and uses library card

Has sense of humor

Concerned about rules and fair verses unfair

Cares for room and belongings, can be responsible for chores

10 years

Self-confident, sense of mastery and pride in school and extracurricular activities

Has a few close friends, participates in group activities

Understand and complies with most rules at home and school

Assumes reasonable responsibility for health, schoolwork, chores

Specific questions to ask

History

Including prenatal and birth history if the child is under 3 years old. Include the Apgar score.

Past illnesses

Allergies

Immunizations (http://www.bvrhc.org:80/cdcimmun.htm)

Habits

Sleep

Elimination

Exercise

Behavior patterns

Fussiness

Thumbsucking

Nail biting

Response to frustration

Use of alcohol, tobacco, other drugs, coffee, tea, colas

Discipline methods used

Sexuality - interested in girl-boy differences, parental responses, sex education offered, concerns or questions child or parent may have

Medications

Prescription

Over the counter

Cultural or folk remedies

Developmental data

Age at which child reached milestones

Held head erect

Rolled over

Sat alone

Walked alone

Said first words

Used sentences

Controlled bowels

Controlled bladder

Current developmental performance

Periods of increased or decreased growth

Questions concerning developmentally appropriate activities

Newborn (http://www.brightfutures.org/in/inomds.htm#)

Infant (http://www.brightfutures.org/in/insmds.htm#)

Toddler (http://www.brightfutures.org/ec/ectyds.htm#)

Preschooler (http://www.brightfutures.org/ec/ecfyds.htm#)

School age child (http://www.brightfutures.org/mc/mceyds.htm#)

Adolescent (http://www.brightfutures.org/adolescence/admads.htm0

Nutrition

Infants (good tables at the end of the article) (http://vm.cfsan.fda.gov/~dms/wh-hichr.html0

Children age 2-5 (http://www.ianr.unl.edu/pubs/Foods/g1249.htm#SUM)

School age children (http://www.ianr.unl.edu/pubs/Foods/g1086.htm)

Adolescents (http://ificinfo.health.org/insight/teentrnd.htm)

The physical exam (http://www.mc.vanderbilt.edu/peds/core/physexam.html)

Methods of restraint

When examining the head of an infant, with the infant lying supine the parent can hold the infant's arms extended along side the head. For an older child use the same method with another assistant holding the child's legs.

With the child sitting on the parent's lap, legs extended to one side, one arm tucked under the parent's arm that is "hugging" the child, and the other child's arm held securely by the parent.

Measurements

Head circumference female (this example is for Chinese children) http://catalog.com/fwcfc/headcirc1.gif

Height and Weight

Tables of average height and weight. (http://www.babybag.com/articles/htwt_av.htm)

The height is measured supine until the child can stand unsupported.

There are special boards to lay infants upon to measure height. Make sure you straighten the legs.

For older children, you may use a ruler taped to a wall or use the ruler on the balance scale. Have the child stand straight, without shoes and with back to the ruler.

Infants are weighed upon special scales until they are able to stand.

Infant scales

Zero or balance the scale with a diaper or chux.

Always keep one hand over the infant to prevent falling.

If an infant scale is not available, the weight can be determined by weighing an adult holding the infant and without the infant.

Older children are weighed on balance scales just like adults.

Zero the scale first.

After weighing the child's height may be measured.

Variations in vital signs based upon age

Heart rate

Birth                     140

1-6 months            130

6-12 months          115

1-2 years               110

2-4 years               105

6-10 years              95

10-14 years            85

14-18 years            82

Respiration

Premature          40-90

Newborn           30-80

1 year                20-40

2 years              20-30

5 years              20-25

10 years            17-22

15 years            15-20

Blood pressure

newborn          60/30

2 months          95/58

6 months          98/62

8 months        104/65

10 months       108/68

14 months       120/75

Temperature - sites of temperature measurement in children http://www.mosby.com/mosby/open/hcom_wong_w19

Specific examination based upon age

Infant

Toddler

Preschooler

School age child

Adolescent

Anticipatory Guidance

Newborn

Infant

Toddler

Nutrition http://www.babycenter.com/refcap/toddler/toddlerfeeding/9245.html

Food pyramid for 2-6 year olds http://www.babycenter.com/general/toddler/toddlerfeeding/9296.html

Top 10 red flags for motor development problems http://www.babycenter.com/refcap/toddler/toddlerdevelopment/11640.html

Toilet training http://www.babycenter.com/toddler/toilettraining/index/

Sleep

How much sleep does the child need http://www.babycenter.com/general/toddler/toddlersleep/7645.html

Information sources http://www.babycenter.com/toddler/toddlersleep/index

Preschooler

School age child

Adolescent

Key terms

Developmental milestones

Nasal flaring

Nasal salute

Retractions

Stridor

Review questions - see on-line

Take the quiz on children on-line

Mentally Impaired
Objectives:

By the completion of this unit, the student will be able to
1. Recognize when a client is mentally impaired.
2. Describe how to alter physical assessment techniques when assessing the mentally impaired.
1. Recognition
  1. In this section, mentally impaired include all clients who do not respond appropriately to the world around them. The impairment may be obvious or subtle. Do not mistake confusion with the inability to hear clearly.
  2. Remember that a person may only be impaired in one area, for example, short term memory.
  3. Some of the areas to consider when a patient is not responding appropriately include fatigue, impaired hearing or sight, alzheimer's disease, substance abuse, hypoxia, medications, and anxiety and fear.
  4. If you suspect a person is slightly confused, gently explore the subject. You may also ask any significant others who are present.
  5. If you suspect a mental impairment, perform the mental/psychosocial component first.
2. Physical assessment of the mentally impaired
  1. Although you explain procedures to all clients prior to action, this is essential with the mentally impaired. Consider having a person the impaired client trusts present during the examination. Some parts of the examination may have to be deferred if the client is distrustful or agitated.

Elderly ( by R.J.S.Bidwell RN, MSN)
A recent report on aging by the institute of medicine states "The time is right to narrow the gap between the needs of an aging society and the scientific knowledge base". The elder often differ from younger adults in the ways they manifest illness, and in the character, number, and complexity of the disorders that afflict them. Because of the lack of caregiver awareness of these differences, 20 – 40% of significant clinical problems in older clients may escape discovery on routine examinations. The following material, then, builds on traditional physical assessment to include age-related facets of history taking, physical examination, and functional characterization.

Required reading:
Wilson & Giddens: 21, 25-27, 61-63, 91,106, 123, 131, 154-155, 187-189, 227-228, 250, 277, 307-308, 339-340, 343, 383-384, 431-432, 468, 505, 555-556, 588, 612-614, 687, 775-778

Objectives: Participants will be able to:
1. Effectively assess functional status of the older adult
2. Identify normal physiologic changes associated with aging
3. Identify risk factors associated with the aging population.
1. Cardiovascular
  1. Assessment findings
    1. Early systolic murmur (S4), fatigue
    2. Premature beats and arrhythmias
    3. Under conditions of stress, the pulse is slow to respond and slow to return to normal.
    4. Increased systolic and diastolic BP, may be isolated systolic hypertension
    5. Widened pulse pressure
    6. Vascular tortuosity and prominence in the forehead, neck and extremities, varicose veins, edema
  2. Physiological causes
    1. Valves more rigid and thicker
    2. Conduction deficiencies
    3. Diminished baroreceptors response, myocardium loses elasticity
    4. Blood vessels lose elasticity
    5. Peripheral resistance increases
    6. Peripheral valves weaken, blood vessels kink, decreased activity resulting in decreased venous return
  3. Nursing implications
    1. Take apical pulse for one minute.
    2. Auscultate heart sounds.
    3. Observe for postural hypotension and syncopal episodes.
    4. Provide a safe environment
    5. Take orthostatic blood pressures
    6. Watch for dizziness and falls.
    7. Encourage daily graded exercise.
    8. Teach stress reduction techniques.
    9. Check blood pressure in both arms.
    10. Monitor peripheral circulation: check pulses, color, temperature, edema
    11. Leg exercises, elevate legs when sitting
    12. Monitor for S&S of PVD and stroke
    13. Tell client not to wear garters, tight knee-highs, or rolled stockings. No pillows under the knees.
2. Respiratory
  1. Assessment findings
    1. Increase in AP diameter of the chest
    2. Kyphosis (rounding of the shoulders)
    3. Decreased chest expansion
    4. Decreased depth of respiration
  2. Physiological causes
    1. Intervertebral disk collapse
    2. Demineralization of bone
    3. Costal cartilage calcification
    4. Respiratory muscle weakness
  3. Nursing implications
    1. Teach upper extremity and trunk strengthening exercises.
    2. Monitor for mechanical and respiratory complications of surgery and prolonged bed rest.
    3. Respirations are often hard to see because of decreased chest expansion.
3. Gastrointestinal
  1. Assessment findings
    1. Atrophy of gums with loss of teeth or decay, dry mouth or xerostomia
    2. Decreased appetite and thirst, early satiety
    3. Coughing or choking, dysphagia, heartburn or reflux
    4. Constipation / fecal impaction, fecal incontinence
  2. Physiological causes
    1. Poor dental care, bone loss, decreased saliva production, multiple medications
    2. Diminished esophageal peristalsis, delayed emptying, gag reflex diminished, hiatal hernia
    3. Decreased intestinal motility, decreased anal sphincter tone
  3. Nursing implications
    1. Monitor for adequate nutrition. Change diet if appropriate. Encourage and provide fresh fluids. For xerostomia, sugar free hard candy or OTC salivary lubricants may help.
    2. Monitor for signs of dehydration.
    3. Monitor for choking. Provide small frequent meals. Teach client to remain upright one hour after meals. Encourage low-fat, low caffeine use.
    4. Encourage adequate fiber and fluids. Encourage mobility.
      Teach bowel training. Discourage chronic use of laxatives.
4. Genitourinary
  1. Assessment findings
    1. Increased nocturia, urgency and frequency
    2. Dehydration
    3. Increased toxic effects from certain medications and dyes
    4. Decreased glycosuria in diabetes
    5. Incontinence: Urge, overflow, stress http://text.nlm.nih.gov/nih/cdc/www/71txt.html
    6. Males: Difficulty initiating urine stream. Delayed erection and achievement of orgasm.
    7. Females: Painful intercourse, delayed orgasm
  2. Physiological causes
    1. Diminished sensation, hormone response, decreased bladder capacity
    2. Decreased thirst sensation, increased body water storage
    3. Decreased renal clearance
    4. Increased renal threshold
    5. Decreased bladder capacity
    6. Decreased bladder innervation
    7. Weakened musculature and sphincter tone
    8. Possible enlarged prostate http://www.betterhealth.com/mens/prostate/0,4264,1661,00.html
    9. Diminished hormonal and sensory cues
    10. Vaginal changes http://www.betterhealth.com/HK/ArticleMain/0,1349,156-416-970,00.html
  3. Nursing implications
    1. Ensure easy access to bathroom or commode.
    2. Assess for UTI even if asymptomatic.
    3. Encourage 1,500 – 2,000 ml of fluids daily. Monitor for dependent edema. Assess weight, I&O, and condition of mucous membranes.
    4. Evaluate creatinine clearance before administering nephrotoxic drugs.
    5. Monitor blood glucose, not urine tests.
    6. Suggest medical evaluation of incontinence.
    7. Teach bladder training: http://www.nih.gov/nia/health/pubpub/urinary.htm , toileting program, Kegel exercises, terach patient to Crede bladder after voiding. http://www.niddk.nih.gov/health/urolog/uibcw/exerc/exerc.htm ,
    8. Males: Provide privacy while voiding. Have client stand upright and tip forward.
    9. Explain that orgasm and satisfaction may require longer stimulation and foreplay. Encourage use of water-soluble lubricant with intercourse.
5. Integumentary
  1. Assessment findings
    1. Skin: thin dry, fragile, decreased turgor, increased wrinkles
    2. Injuries slow to heal
    3. Decreased perspiration
    4. Lesions: seborrheic keratosis, senile angioma, pigmentation deposits, senile keratosis, basal cell carcinoma
    5. Nails: thickened, yellowed, and ridged
  2. Physiological causes
    1. Thinning of skin layers, decrease in gland activity, loss of subcutaneous fat
    2. Diminished capillary flow, may be nutritionally compromised
    3. Decreased sweat gland activity, environmental injury
    4. Cellular changes
  3. Nursing implications
    1. Suggest fewer baths and the use of unscented soaps. Encourage and provide fresh fluids.
    2. Monitor for tearing, bruising and pressure ulcers. Protect from trauma. Inspect the skin frequently. Caution client to avoid chemical (detergents and cleansers) and thermal (sun, cold exposure, hot items) irritants.
    3. Monitor for signs of heat intolerance. http://www.nih.gov/nia/health/pubpub/hyperthe.htm
    4. Differentiate cancerous from precancerous lesions.
    5. Teach nail-care, cleansing and trimming. Suggest podiatry consult.
6. Musculoskeletal
  1. Assessment findings
    1. Decrease in height, kyphosis
    2. Decrease in muscle mass, tone, and strength
    3. Diminished mobility, flexibility, and range of motion
    4. Diminished balance and reaction time
    5. Joint pain http://www.betterhealth.com/HK/ArticleMain/0,1349,159-419-892,00.html
  2. Physiological causes
    1. Weakened spinal structures, shrinking of vertebral disks, bone demineralization, osteoporosis http://www.betterhealth.com/HK/SubjectMain/0,1344,186,00.html
    2. Decreased muscle fibers, decreased physical activity, decreased capillary circulation, decreased innervation, decreased physical activity
    3. Joint and cartilage erosion, bony overgrowths
  3. Nursing implications
    1. Protect from injury: good lighting, clean, dry floors, side rails. Encourage high calcium, low phosphorous diet supplemented with 400 I. U. of vitamin D. Encourage moderate exercise.
    2. Maintain range of motion and physical activity (especially weight bearing). Provide assistive devices (cane, walker) if needed to encourage ambulation. Schedule exercise periods.
    3. Activities to promote range of motion. Analgesics for pain.
7. Neurological
  1. Assessment findings
    1. Sleep disturbances: More wakeful periods, need for naps, insomnia. http://cancernet.nci.nih.gov/clinpdq/supportive/Sleep_disorders_Physician.html
    2. Vibratory and proprioception decreases especially in the lower extremities. http://www.nih.gov/nia/edb/whasbook/chap4/chap4.htm
    3. Slowed reaction time
    4. Learning takes longer
    5. Mild, recent memory losses or confusion
    6. Depression http://text.nlm.nih.gov/nih/cdc/www/86txt.html
  2. Physiological causes
    1. Stages of sleep altered
    2. Chronic or acute disorders
    3. Medication effects
    4. Decreased physical activity
    5. Conduction deficiencies
    6. Reduced cerebral perfusion
    7. Alteration in naturally occurring chemicals and hormones
  3. Nursing implications
    1. Evaluate for physical discomforts.
    2. Evaluate for sedative or hypnotic abuse.
    3. Encourage decreased caffeine intake.
    4. Suggest that client avoid evening naps.
    5. Encourage increased daily activities.
    6. Maintain standards of safety.
    7. Allow time for client to process questions.
    8. Decrease the number of simultaneous stimuli.
    9. Divide tasks into shorter segments.
    10. Mini Mental Status Exam http://www.medinfo.ufl.edu/year1/bcs/clist/mental.html
    11. Keep teaching sessions short.
    12. Minimize environmental stress.
    13. Encourage visitors.
    14. Avoid room changes.
    15. Offer orienting objects: calendars, clocks, newspapers.
    16. Write instructions simply.
    17. Suggest diversionary activities.
    18. Encourage social interaction.
    19. Consider psychiatric consult.
    20. Consider antidepressant drugs.
8. Special senses
  1. Hearing http://www.nih.gov/nia/health/pubpub/hearing.htm
    1. Assessment findings
      1. Speech discrimination difficulty
      2. Decreased ability to hear high-pitched sounds (presbycusis)
    2. Physiological causes
      1. Ear wax impaction
      2. Degenerative changes http://www.betterhealth.com/HK/ArticleMain/0,1349,170-476-1149,00.htm
      3. Less resilient tympanic membrane
    3. Nursing implications
      1. Recommend formal hearing test.
      2. Check for cerumen impaction.
      3. Instruct in the proper use of hearing aid. http://www.betterhealth.com/HK/ArticleMain/0,1349,170-476-1006,00.html
      4. Face client directly with adequate lighting.
      5. Reduce background noises.
  2. Vision http://www.nih.gov/nia/health/pubpub/eyes.htm
    1. Assessment findings
      1. Dry eyes
      2. Problem reading at close range
      3. Pupils slow to react to light
      4. Pupils react unequally to light, Clouding of lens http://www.betterhealth.com/HK/ArticleMain/0,1349,156-416-978,00.html
      5. Requires more light to see, Slow adaptation to dark, Poor night vision
      6. Diabetics: Inability to accurately read blood glucose strips. http://www.betterhealth.com/HK/ArticleMain/0,1349,168-474-430,00.html
    2. Physiological causes
      1. Decreased tear production
      2. Lens hardens
      3. Possible diminished muscle response
      4. Corneal changes
      5. Decreased light perception threshold
      6. Yellowed keratin deposits, alteration in blue-green discrimination
    3. Nursing implications
      1. Assess for corneal irritation. Encourage the use of artificial tears.
      2. Encourage eye exams and use of eyeglasses or magnifying glass.
      3. Realize that pupil check on a neuro exam may be misleading.
      4. Document unequal pupil size as part of baseline assessment.
      5. Provide adequate, indirect, non-glare lighting. Provide night light.
  3. Touch
    1. Assessment findings
      1. Diminished sensitivity to pain, heat, and pressure.
      2. Diminished ability to distinguish items by touch (stereognosis)
    2. Physiological causes
      1. Conduction deficiencies
    3. Nursing implications
      1. Remind client that he faces a greater chance of accident or injury.
      2. Encourage use of other senses.
      3. Suggest avoiding temperature extremes without sufficient protection.
      4. Suggest frequent position changes.
      5. Teach daily skin inspection.
  4. Taste/smell
    1. Assessment findings
      1. Poor nutrition
      2. Decreased appetite
      3. Foods taste bland
    2. Physiological causes
      1. Reduced taste buds and olfactory receptors
    3. Nursing implications
      1. Encourage use of herb seasoning, lemon, and spices (non-salty).
      2. Encourage social dining.
      3. Encourage nutritional supplements.
9. Health History
  1. Be aware of "Geriatric Risks"
  2. Falls: Risk factors
    1. Sensory impairment such as vision
    2. Proprioceptive, vestibular dysfunction
    3. Neurological disorders
    4. Cardiovascular conditions
    5. Medications
    6. Acute illness
    7. Environmental factors
  3. Incontinence
    1. 15 – 30% of older adults living at home
    2. Up to 50% of ECF residents
    3. Physical, psychological, and financial burden
    4. Determine whether transient or established
  4. Delirium
    1. Acute change in mental status
    2. Usually occurs during acute medical illness or may be the first sign
    3. Distinguished from dementia by its rapid onset
    4. Associated with disorders that affect brain function such as hypoxia, fever, arrhythmias, anemia, and medications.
  5. Poor nutrition
    1. Sore mouth or ill fitting dentures
    2. Difficulty chewing or swallowing
    3. History of fractures
    4. Mood/mental status
    5. Medications
    6. Checklist to DETERMINE Nutritional Health
      - Disease, chronic or acute
      - Eating habits
      - Tooth loss
      - Economic hardship
      - Reduced social contacts
      - Multiple medications or drugs
      - Involuntary weight loss or gain
      - Needed assistance with self-care
      - Eighty years of age or older
  6. Inappropriate medication use
    1. Older adults are the largest consumers of Rx and OTC drugs
    2. Instruct client to bring in all prescribed and OTC medications
    3. Identify a diagnosis for each medication being used and visa versa.
    4. Medication risk factors include:
      1. Multiple diseases
      2. Multiple health care providers
      3. OTC drug use
      4. Sharing medications
      5. Rationing medications
      6. Cost of medications
      7. Polypharmacy
10. Questions to target potential age related impairments
  1. …problems with urine leaking?
  2. ...fallen in the last six months?
  3. …often feel sad, blue, or depressed?
  4. …travel places away from home alone?
  5. …enough money to buy medications?
  6. …skip your medications?
  7. …skip meals often?
11. Functional Status
  1. Most accurate assessment is direct observation but not always practical.
  2. Ask if can perform various tasks and level of independence.
  3. "Get up and go" test.
  4. Activities of daily living (ADL).
  5. Instrumental levels of daily living (IADL).
12. Preparation for the exam
  1. Note level of independence.
  2. Note who is answering the questions.
  3. Be aware of any sensory impairments; especially hearing.
  4. Physical assessment of the older adult with emphasis on normal physiologic changes associated with aging and respective nursing considerations.
13. Key Terms
  1. Arcus senilis
  2. Presbycusis
  3. Presbyopia
  4. Senile keratosis
  5. Xerostomia
1. Review questions - see on-line
Abuse
1. Domestic violence
  1. Definition http://www.domesticviolence.org/define.html
  2. Wheel of violence http://www.domesticviolence.org/wheel.html
  3. Signs of abuse http://www.domesticviolence.org/warning.html
  4. Cycle of violence http://www.domesticviolence.org/cycle.html
  5. Hotline - 995-1000
2. Child abuse
  1. Definition http://www.calib.com/nccanch/pubs/factsheets/whatis.htm
  2. Types of abuse http://www.childhelpusa.org/abuse.htm
  3. Signs of abuse http://www.kidsource.com/kidsource/content3/news3/child.abuse.signs.all.2.html
  4. Behaviors related to sexual abuse http://www.commnet.edu/QVCTC/student/LindaCain/sexabuse.html
  5. How to report http://www.acf.dhhs.gov/programs/cb/rpt_abu.htm
    1. Kansas - 800-922-5330
      1. (out of state) 913-296-0044
    2. Missouri - 800-392-3738
      1. 573-751-3448 (out of state)
      2. Hotline - 800-392-3738
3. Elder abuse
  1. Definition http://www.oaktrees.org/elder/define.shtml
  2. Recognition http://www.oaktrees.org/elder/recog.shtml
  3. Hotline- 800-392-0210
The actively dying patient: signs and symptoms
1. Determining prognosis - cannot pinpoint time of death, there are signs/symptoms that indicate death is imminent
2. Psychological and spiritual symptoms
  1. Fear of the dying process
  2. Fear of abandonment
  3. Fear of the unknown
  4. Nearing death awareness
  5. Withdrawal from family, friends and/or caregivers
  6. Increased focus on spiritual issues
3. Physical symptoms
  1. Confusion, disorientation, delirium
  2. Weakness and fatigue
  3. Increased drowsiness, sleeping and decreased responsiveness
  4. Decreased oral intake
  5. Decreased or lack of swallow reflex
  6. Surges of energy
  7. Restlessness and/or terminal agitation
  8. Fever
  9. Change in bowel elimination including constipation/diarrhea
  10. Incontinence
4. Universal symptoms of imminent death
  1. Decreased urine output
  2. Cold and mottled extremities
  3. Vital sign changes
  4. Respiratory congestion including respiratory bubbling
  5. Breathing pattern changes
5. The dying child - more difficult to accept death of a child. It is not the natural order.
6. The death vigil
  1. Family desires/preferences determine who is at the bedside if possible
  2. Common fears - the family member will die alone
7. Signs and symptoms of death
  1. Absence of heart beat/respirations
  2. Release of stool and urine
  3. No response
  4. Pupils fixed
  5. Body color pale and waxen
  6. Body temperature drop
  7. Eyes remain open
  8. Jaw may fall open
8. Cultural considerations