• Chapter 1

o Objective Data

 What you as the health professional observe by inspecting, percussing, palpating,

and auscultating during the physical exam

o Subjective Data

 What the person says about himself

• Chapter 3

o Cultural Competence

 Culturally Sensitive

• Possessing basic knowledge of an constructive attitudes toward diverse cultural

populations

 Culturally Appropriate

• Applying underlying background knowledge necessary to provide the best

possible health care

 Culturally Competent

• Understanding an attending to total context of patient’s situation including:

o Immigration status

o Stress factors

o Social factors

o Cultural similarities and differences

• Chapter 4

o Communication Techniques

 Introducing the interview

 Working phase

• Open-ended questions

• Closed or direct questions

 Responses—assisting the narrative

• Facilitation • Empathy

• Silence • Clarification

• Reflection • Confrontation
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 • Interpretation • Summary

• Explanation

 Nonverbal Skills

• Physical appearance • Eye contact

• Posture • Voice

• Gestures • Touch

• Facial expression

 Closing the Interview

o Ten Traps of Interviewing

 Providing false assurance or  Using professional jargon

reassurance
 Using leading or biased questions
 Giving unwanted advice
 Talking too much
 Using authority
 Interrupting
 Using avoidance language
 Using “why” questions
 Engaging in distancing

• Chapter 6

o Assessment of Mental Status

 Mental status is inferred through individual’s behaviors

• Consciousness • Memory

• Language • Abstract reasoning

• Mood and Affect • Thought process

• Orientation • Thought content

• Attention • Perceptions

o Assessment of mental status in the older adult

 The aging process leaves the parameters of mental status mostly intact

• No decrease in general knowledge

• No decrease in vocabulary

 Response time is slower

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 • It take a bit longer for the brain to process information thus taking longer to
react to it

 Recent memory is somewhat decreased

• Remote memory is not affected

 Vision loss may contribute to apathy, social isolation and depression

 Hearing changes

• Affect the way older adults hear consonants since they are high pitched sounds
—high pitched hearing goes first

• Produces frustration, suspicion, and social isolation

• Chapter 7

o Requirements to report elder abuse

 Almost all states have some form of mandatory reporting of suspected abuse of
patients 65 and older

 To report abuse, you need not have proof of abuse or neglect, only reasonable cause
to suspect that elder abuse or neglect may have occurred

• Chapter 8

o Percussion: normal and abnormal notes of air, solid organ and bone

 Air:

• Resonance

o Low-pitched, clear, hollow, medium loud

o Moderate duration

o Normal over lung fields

• Hyperresonance

o Lower pitched, booming, o ABNORMAL in adult lung

louder
 Indicative of
o Longer duration emphysema

o Normal in child’s lungs

• Tympany

o High-pitched, drumlike, loud

o Sustained longest
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 o Normal over the stomach and intestines

 Bone:

• Flat

o High-pitched, dead, very o Normal where no hair is

soft present

o Very short in duration o Bone

 Organ:

• Sull

o High-pitched, muffled thud, soft

o Short duration

o Normal over a dense organ such as the liver or spleen

• Chapter 9

o Documentation/ rating scale pulses

 0—no pulse

 1+ -- weak, thready pulse

 2+--NORMAL

 3+--Full, bounding

• Chapter 10

o Pain Assessment: Quality and Quantity

 PQRSTU

• Where is your pain? • How does pain limit your

function/ activities?
• When did your pain start?
• How do you behave when you
• What does your pain feel like are in pain? How would others
now? know you are in pain?

• How much pain do you have • What does pain mean to you?
now?
• Why do you think you are
• What makes the pain better or happing pain?
worse?

 Acute Pain

• Short-term

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 • Self-limiting

• Follows a predictable trajectory

• Dissipates after injury heals

 Chronic Pain

• Continues for 6months or longer

• Types are malignant (cancer related) and nonmalignant

• Does not stop when injury heals

• Chapter 12

o Normal/ abnormal skin color

 Normal

• Consistent with genetic background

• Varies from pinkish tan to ruddy dark tan or from light to dark brown and may
have yellow or olive green overtones

 Abnormal

• Pallor

o White

• Erythmea

o Intense redness

• Cyanosis

o Bluish

• Jaundice

o Yellowing

• Chapter 14

o Corneal Light Reflex

 Assess the parallel alignment of the eye exes by shining a light toward the person’s
eyes.

 Direct the person to stare straight ahead as you hold the light about 12 inches away

 Note the reflection of the light on the corneas; it should be in exactly the same spot
on each eye

o Diagnostic Positions Test

5
  Leading the eyes through the six cardinal positions of gaze

 Elicits any muscle weakness during movement

 Patient holds head steady while you move your finger or pen

• Follows with only the eyes

 A normal response is parallel tracking in both eyes

o Confrontation Test

 This is a gross measurement of peripheral vision

 It compares the person’s peripheral vision with that of your own assuming yours is
normal

• Chapter 15

o Changes in hearing related to aging

 The cilia lining the ear canal become coarse and stiff

• Causes decreased hearing because it impedes sound waves traveling toward the
tympanic membrane

• Also causes cerumen to accumulate and oxidize which greatly reduces hearing

o Cerumen itself is dryer because of atrophy of the apocrine glands

 Impacted cerumen

• A common but reversible cause of hearing loss

 A person living in a noise-polluted area has a greater risk of hearing loss

 Presbycusis

• A type of hearing loss that occurs with aging, even in people living in a quiet
environment

• Chapter 16

o Normal/ Abnormal older adult oral assessment

 Normal

• The soft tissues thin due to • The presence of dentures

atrophy especially in the cheek
and tongue o Cover secondary taste
sites
o A loss of tastebuds result
• Ulcerations
• Decrease in salivary secretion
that is needed to dissolve • Oral monilasis
flavoring agents
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 • Increased risk for malignant • Tooth hypersensitivity
oral lesions
• Some tooth loss may occur due
• Tooth surface is abraded to bone resorption

• Gums recede

• Chapter 17

o Procedure for a self-breast exam

 The best time is right after the menstrual period, or the 4th through 7th day of the
menstrual cycle

 If the woman is pregnant or menopausal advise them to perform a BSE on the same
day each month

 Stress that self-examination will familiarize the woman with her own breasts and
their normal variation

 Palpation can be performed in front of the mirror

 Palpation can be performed in the shower

 Palpation can be performed supine

• Chapter 18

o Signs and Symptoms of long term respiratory disease

 “barrel chest”

• Occurs in chronic emphysema

 Neck muscles are hypertrophied

• Occurs with COPD

 Many people with COPD sit in the tripod position

• Leaning forward with arms braced against their knees, chair or bed

o Normal changed in the respiratory system of the older adult

 Costal cartilages become calcified which produces a less mobile thorax

 Respiratory muscle strength declines after age 50

 A more significant change is the decrease in elastic properties within the lungs

• Less distensible and lessening their tendency to collapse and recoil

 The lung is more rigid and harder to inflate

 Decreased vital capacity

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  There is less surface area for gas-exchange

o Adventitious Lung Sounds

 Sounds not normally present in the lungs

 Caused by air colliding with secretions in the tracheobronchial passageways or by

the popping open of previously deflated airways

 Crackles

• Caused by fluid

• Starts at the bases

 Wheeze

• From Constricted airway

 Atelectatic crackles

• Short popping crackles that sound like find crackles but do not last long beyond
a few breaths

 Rhoncii

• Gurgling when congested in airways (common cold)

• Chapter 19

o Auscultation of heart sounds

 In a Z pattern

 APE TO MAN

• Aortic Area • Tricuspid Area

• Pulmonic Area • Mitral Area

• Erbs Point

o Carotid Artery Assessment

 Timing closely coincides with ventricular systole

 Located in the groove between the trachea and the sternocleidomastoid muscle

• Medial to and alongside that muscle

• Chapter 20

o Peripheral Vascular Assessment

 Inspect and Palpate the Arms

8
 • Skin • Radial Pulse

• Profile signs • Ulnar pulse

o Nails • Brachial Pulse

• Capillary refill • Eiptrochlear lymph node

• Symmetry • Modified Allen Test

 Inspect and Palpate the Legs

• Skin and hair • Posterior tibial pulse

• Symmetry • Dorsalis pedis pulse

• Temperature • Pretibial edema

• Calf muscle • Leg veins

• Inguinal lymph nodes o Assess while patient

stands
• Femoral pulse
o Manual compression test
• Popliteal pulse

o Signs and Symptoms of Venous Stasis

 Subjective

• Aching pain in calf or lower leg

• Worse at the end of the day

• Worse with prolonged standing or sitting

 Objective

• Firm brawny edema • Venous stasis causes increased

venous pressure, which then
• Coarse, thickened skin causes red blood cells to leak
out of veins and into skin
• Pulses normal
• As the red blood cells break
• Brown pigment discoloration down they leave hemosiderin
(iron deposits) behind, which
• Dermatitis are brown pigment deposits

o Acute Venous Symptoms

 Location

• Calf

 Character

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 • Intense, sharp; deep muscle tender to touch

 Onset and Duration

• Sudden onset (within 1 hr)

 Aggravating factors

• Pain may increase with sharp dorsiflexion of foot

 Relieving factors

• None

 Associated Symptoms

• Red, warm, swollen leg

o Assessments of arterial insufficiency

 Modified Allen test

• Occlude the ulnar and radial arteries of one hand and have person make a fist
several times to blanch the skin. Then have the person relax their hand and
release the pressure on the ulnar artery watch the color return to hand

 Can also elevate feet til they blanch and then have the person sit up with legs over
the side of the table

• The color should return within 10 seconds

 Capillary refill of fingers and toes

o Signs and Symptoms of Venous Insufficiency

 Back up of blood flow causing dilated and torturous (varicose) veins

o Lymph Drainage

 Allow the flow of clear, watery fluid from the tissue spaces into the circulation

 Filtering the lymph and engulf pathogens

• Protecting potentially harmful substances from entering circulation

 Therefore with local inflammation the nodes in that area become swollen and tender

• Chapter 21

o Abdominal assessment normal/abnormal and techniques

 Techniques

• Inspect

• Auscultate
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 • Percuss

• Palpate

 Normal/Abnormal

• Abnormal

o Ascites

 Fluid in the abdomen

o CVA Tenderness

 Assessment of the kidney

 Place hand over the 12th rib at the costovertebral angle on the back
 Thump that hand with the ulnar edge of your other fist

 Normal

• A thud is felt but no pain

 Abnormal

• Sharp pain occurs with the inflammation of the kidney

• Chapter 22

o Knee Assessments

 Bulge sign

• For welling in the suprapatellar pouch, the bulge sign confirms the presence of
small amounts of fluid as you try to more the fluid from one side of the joint to
the other

• Firmly stroke up on the medial aspect of the knee two of three times to displace
any fluid

• Tap the lateral aspect

• Watch the medial side in the hollow for a distinct bulge from a fluid wave

• Normally, none is present

 Ballottement of the Patella

• Reliable when larger amounts of fluid are present

• Use your left hand to compress the suprapatellar pouch to move any fluid into
the knee joint

• With your right hand, push the patella sharply against the femur

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 • If no fluid is present, the patella is already snug against thefemur

• Chapter 23

o Assessments of cerebellar function

 Test Cranial Nerves

• I—olfactory o Motor Function

o Test sense of smell with o Sensory Function

the patient’s eyes closed
o Patient closes eyes and
o Place a familiar smell by you gently touch the face
the patient’s nostril with a cotton ball

• II—Optic • VIII—acoustic

o Test visual fields and o (vestibulocochlear)

visual acuity
o Whisper Test
• III—Oculomotor
o Rinne Test
• IV—Trochlear
o Weber Test
• VI—Abducens
• IX—Glossopharyngeal
o Motor Function
o “ahhhhh”
o Sensory Function
• X--Vagus
o Corneal reflex
o Motor Function
o PERRLA
o Sensory Function
o Six cardinal fields
o “ahhhh”
• V—Trigeminal
• XI—Spinal Accessory
o Ask patient to clench
teeth as you try to open o Turn head with and
the mouth without resistance

• VII—facial • XII—Hypoglossal

o Stick tongue out

 Inspect and Palpate the Motor System

• Muscles

o Size

o Strength

o Tone

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 o Involuntary Movement

• Cerebellar Function

o Balance Tests

 Gait

 Tandem walking

 Romberg’s Test

 Shallow Knee Bend

o Coordination and skilled movements

 Rapid alternating movements

 Finger-to-finger test

 Finger-to-nose test

 Heel-to-shin Test

• Sensory System

o Alert, cooperative and comfortable

o Deep tendon reflexes

 Measures the intactness of the reflex arc at specific levels as well as the normal
override on the reflex of the higher cortical levels

 Reinforcement

• Ask the person to form an isometric exercise in a muscle group somewhat away
from the one being tested

 Hyperreflexia

• Exaggerated reflex seen when the monosynaptic reflex arc is released from the
usually inhibiting influence of higher cortical levels

• Occurs with upper motor neuron lesions

 Hyporeflexia

• Absence of a reflex

• Lower motor neuron problem

• Occurs with a herniated disk

o Steregnosis

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  Tests the person’s ability to recognize objects by feeling their forms, size, and
weights.

 With the eyes closed, place a familiar object in the person’s hand and ask the person
to identify it

o Graphesthesia

 Ability to “read” a number by having it traced on the skin

 With the person’s eyes closed, use a blunt object to race a single digit number or a
letter on the palm

o Kinesthesia

 Tests the person’s ability to perceive passive movements of the extremities

o Reflexes Post Stroke

o Signs and Symptoms of peripheral neuropathy

 Peripheral neuropathy is worse at  Possible causes are diabetes,

the feet and gradually improves chronic alcoholism and nutritional
as you move up the leg deficiency

 As opposed to a specific nerve  Loss of vibratory sense

lesion, which has a clear zone of
deficit for its dermatome  Loss of sense of touch, temperature
and pain
 Loss of sensation involves all
modalities  The further out you go, the worse it
gets
 Loss is most decree distally (feet
and hands)

o Signs and Symptoms of increased intracranial pressure

 Damage to any of the brain areas results in a loss of function

• Motor weakness, paralysis, loss of sensation or impaired ability to understand

and process language

 Damage occurs when highly specialized neurologic cells are deprived of their blood
supply, such as when a cerebral artery becomes occluded or when vascular
bleeding of vasospasm occurs

• Chapter 24

o Risk factors of prostate cancer

 More common in North America and North Western Europe

 Less common in Central and South America, Africa and Asia

14
  Incidence rates are high for black American men than other racial groups more likely
to be diagnoses later and at more advanced stages (2X higher than for white)

 Inherited DNA may account for 5-10% of prostate cancers

 Diets heavy in red meat or high-fat dairy products

 Prostate cancer may increase with obeisity

• Chapter 25

o Early Detection colon cancer

o Occult blood tests (stool)

 Negative response is normal

 If the stool is hematest positive it indicated occult blood (false positive if person ate
significant amount of red meat 3 days before)

 Black stools may be tarry due to occult blood from gastrointestinal bleeding or
nontarry from iron medications

 Gray stool occurs with hepatitis

 Red blood stools occurs with gastrointestinal bleeding or localized bleeding around
the anus

o Polyp

 A protruding growth from the rectal mucus membrane that is comment

 May be pedunculated (on a stalk or sessile (mound on surface)

 Soft nodule difficult to palpate

 Proctoscopy is needed as well as biopsy to screen for malignant growth

o Hemorrhoid

 Painless, flabby papules due to varicose vein of the hemorrhoidal plexus

 External hemorrhoid

• Originates below the anorectal junction covered by anal skin when thrombosed
it contains clotted blood, becomes painful, swollen, shiny, blue, itchy and it
bleeds when one deficates. When it heals it leaves a painless ,flabby skin sac
around the anal orifice

 Internal Hemorrhoid

• Originates above the anorectal junction and is covered by a mucous membrane

15
  All hemorrhoids result from increased portal venous pressure; occurs with straining
at stool, chronic constipation, pregnancy, obesity, chronic liver disease, low fiber
diet (common in western societies)

o Rectal Fissure

 A painful longitudinal tear in the superficial mucosa at the anal margin (most occur in
the posterior midline area)

 Frequently accompanied by a papule of hyperplastic skin called sentinel tag, on the

anal margin

 Often result from trauma (passing hard stool)

 Person has bleeding and pain, rectal sphincter spasms and may make area painful to
examine, may need anesthesia

o Rectal Prolapsed

 Rectal mucous membrane protrudes through the anus appearing as a moist red
doughnut with radiating lines

 When it is incomplete only the mucosa bulges

 When complete it includes an anal sphincter

 Occurs after a valsalva maneuver

o Signs and symptoms of fecal impaction

 A collection of hard, desiccated feces in the rectum obstruction

 Results from decreased bowel motility in which more water is reabsorbed from the
stool, also occurs with retained barium from gastrointestinal x-ray examination

 Person may complain of constipation or of diarrhea as a fecal stream passes around

the impaction

o Prostate Cancer Screening

 Pg 730

 The surface should feel smooth and muscular; search for any distinct nodule or
diffuse firmness

• Chapter 26

o Cells in female reproductive tract are estrogen dependant: how does this relate to
menopause?

 Physical Changes

• Uterus shrinks in size because of decreased myometrium

• Ovaries atrophy 1-2 cm and are not palpable after menopause

16
 • Ovulation may occur sporadically

• Sacral ligaments relax and the pelvic musculature weakens so the uterus droops

• Cervix shrinks and looks paler with a thick glistening epithelium

• Without sexual activity the vagina atrophies to ½ its former length and width

• The vaginal epithelium atrophies, becomes thinner, direr, and itchy, resulting in
a fragile mucosal surface that is at risk for bleeding and vaginitis

• PH becomes more alkaline and decreased glycogen content

• Pubis looks smaller because of atrophy of fat pads

• Labia and clitoris gradually decrease in size

• Pubic hair becomes thin and sparse

o Some medication can change the vaginal environment what would s/s of this change
be?

o Early detection of ovarian cancer

 Because it is asymptomatic women over 40 should have a thorough pelvic

examination every year

17