Physical Examination Pressure Ulcers in Elderly

A pressure sore (bed sore) is an injury to the skin and/or the tissues under the skin. Constant pressure on an area of skin reduces blood supply to the area. Most commonly this will be the sacrum, coccyx, heels or the hips, but other sites such as the elbows, knees, ankles or the back of the cranium can be affected.

Cause pressure sores include:

•     Constant pressure on the skin and tissues. This is by far the most common cause of pressure sores.
•     Sliding down in a bed or chair, forcing the skin to fold over itself ("shear force").
•     Being pulled across bed sheets or other surfaces (friction burns).
•     Irritation of the skin from things such as sweat, urine, or feces.

As we get older, our skin gets more thin and dry and less elastic, so it is easier to damage. Poor nutrition-common among older people and people who cannot move easily-makes these natural changes in the skin worse. Skin in this condition may easily develop a pressure sore.

Symptoms of a pressure ulcer are:

•     Red skin that gets worse over time
•     The area forms a blister, then an open sore

Pressure sores most commonly occur on the

•     Elbow
•     Hips
•     Heels
•     Ankles
•     Shoulders
•     Back
•     Back of head

Pressure sores are grouped by their severity. Stage I is the earliest stage. Stage IV is the worst.

• Stage I: A reddened area on the skin that, when pressed, does not turn white. This is a sign that a pressure ulcer is starting to develop.
• Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated.
• Stage III: The skin now develops an open, sunken hole called a crater. There is damage to the tissue below the skin.
• Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints.

 
Physical Examination Pressure Ulcers in Elderly

1. General Condition
Generally, patients come to the sick and agitated or anxious as a result of damage to the integrity of the skin is experienced.

2. Vital Signs
Normal blood pressure, rapid pulse, increased temperature and respiration rate increased.

3. Examination of the Head and Neck

a) Head and Hair
Examination includes the shape of the head, deployment and change hair color as well as an examination of the wound. If there is injury to the area, causing pain and skin damage.

b) Eye
Includes symmetry, conjunctiva, pupil reflexes to light and impaired vision.

c) Nose
Includes examination of the nasal mucosa, cleanliness, nostril breathing does not arise, there is no discharge.

d) Oral
Note the presence of cyanosis or condition dry lips.

e) Ear
Note the form of hearing loss due to foreign bodies, bleeding and wax. In patients who bet the rest by his side, is likely to occur in areas of ulcer ears.

f) Neck
Knowing the position of the trachea, carotid pulse, presence or absence of jugular vein and gland enlargement linfe.

4. Examination Chest and Thorax
Inspection form of the thorax and lung expansion, auscultation respiratory rhythm, vocals premitus, the extra noise, heart sounds, and extra heart sounds, percussion thorax to look for abnormalities in the thorax area.

5. Abdomen
Form flat or flat stomach, bowel sounds decrease due to immobilization, there are masses because of constipation, and abdominal percussion hypersonor if abdominal distention or tense.

6. Urogenital
Inspection abnormalities in the perineum. Usually clients with paraplegia ulcers and catheter attached to urinate.

7. Musculoskeletal
A fracture in the bone will cause the client bet rest in a long time, so
a decline in muscle strength.

8. Examination of Neurology
The level of consciousness assessed with GCS system. Value could decrease if there is pain (neurogenic shock) and heat or high fever, nausea, vomiting, and stiff neck.

9. Physical Assessment of Skin

Assessment involves the skin around the area of ​​the skin including the mucous membranes, scalp, hair and nails. Appearance of skin that needs to be assessed is the color, temperature, humidity, dryness, skin texture (rough or smooth), lesion vascularity.
That must be considered by the nurse is:

a) The color, affected by blood flow, oxygenation, temperature and pigment production.
The lesions were divided into two: a) the primary lesion, which occurs due to a change in one component of skin. b) secondary lesions are lesions that appear after the primary lesion. Preview lesions that must be considered by the nurse that the color, shape, location and kofigurasinya.

b) Edema
During the inspection of the skin, the nurse records the location, distribution and color of the region edema.

c) Humidity
Normally, humidity increases due to increased activity or high ambient temperatures of dry skin can be caused by several factors, such as dry or moist environments that are not suitable, inadekuat fluid intake, the aging process.

d) Integrity
That must be considered is the location, shape, color, distribution, if there is drainage or infection.

e) Cleanliness skin

f) vascularization
Bleeding from the blood vessels and produces petechie echimosis.

g) Palpation of skin
To note that the lesions on the skin, moisture, temperature, texture or elasticity, skin turgor.

10. examination Support

1) A complete blood
Certain increase in hemoglobin concentration early show, with respect to the displacement or loss of fluid and to detect nutritional deficiencies clients. If there leukocytosis due to loss of cells in the inflammatory response to injury and edema. Serum glucose increased due to the stress response.

2) Biopsy wound
To determine the number of bacteria.

3) Swab culture
To identify the type of bacteria on the surface of the ulcer.

4) Preparation of clinical pictures
Created to demonstrate the nature and extent of skin disorders or ulcers and used for improvement after therapy.

Physical Examination for Meningitis

Meningitis 

Meningitis is a disease caused by the inflammation of the protective membranes covering the brain and spinal cord known as the meninges. It is most often caused by infection (bacterial, viral, or fungal), but can also be produced by chemical irritation, subarachnoid haemorrhage, cancer and other conditions. The severity of illness and the treatment for meningitis differ depending on the cause. Thus, it is important to know the specific cause of meningitis.

Viral Meningitis
Enteroviruses, the most common cause of viral meningitis, are most often spread from person to person through fecal contamination (which can occur when changing a diaper or using the toilet and not properly washing hands afterwards).

Bacterial Meningitis
Bacterial meningitis is contagious. The bacteria are spread through the exchange of respiratory and throat secretions (i.e., kissing).

The most common symptoms of either form of meningitis include:

• Fever.
• Severe and persistent headache.
• Stiff and painful neck, especially when trying to touch the chin to the chest.
• Vomiting.
• Confusion and decreased level of consciousness.
• Seizures.

Other symptoms of meningitis include:

• Sluggishness, muscle aches and weakness, and strange feelings (such as tingling) or weakness throughout the body.
• Eye sensitivity and eye pain from bright lights.
• Skin rash.
• Dizzy spells.

Physical Examination for Meningitis

1. Activity / Rest

• Symptoms: feeling unwell (malaise), limitations posed condition.
• Signs: Ataxia, problems walking, paralysis, involuntary movement, general weakness, limitations in range of motion.

2. Circulation

• Symptoms: the history of cardiology, such as endocarditis, some heart diseases Conginetal (brain abscess).
• Symptoms: increased blood pressure, decreased pulse rate, pulse pressure weight (associated with increased ICP and the influence of the vasomotor center). Tachycardia, distritmia (acute phase) as distrimia sinus (in meningitis)

3. Elimination

• Signs: The existence of urinary incontinence and retention.

4. Food and Fluids

• Symptoms: Loss of appetite, difficulty swallowing (acute period)
• Signs: Anorexia, vomiting, poor skin turgor, dry mucous membranes.

5. Hygiene

• Signs: Dependence on all the needs of self-care (acute period)

6. Neurosensory

• Symptoms: headache (may be the first symptom, and usually heavy), paresthesia, feels stiff in all the nerves are affected, loss of sensation (cranial nerve damage). Hyperalgesia / increased sensitivity (minimitis). Seizures arise (minimitis bacteria or brain abscess) disturbances in vision, such as monocular (early phase of multiple infections). Photophobia (on minimtis). Deafness (on minimitis / encephalitis) or maybe hypersensitivity to noise, the hulusinasi smell / touch.
• Signs:
  • Mental status / level of consciousness; lethargy to severe confusion to coma, delusions and hallucinations / psychosis organic (encephalitis).
  • Memory loss, difficulty in making decisions (can be a symptom of growing hidrosephalus communicant, following bacterial meningitis)
  • Aphasia / difficulty in communicating.
  • Eyes (size / pupil reaction): unisokor or do not respond to light (increased ICP), nystagmus (eyes move continuously).
  • Upper eyelid ptosis falling). Characteristic facial (face), changes to the motor and sensory functions (cranial nerves V and VII exposed)
  • Generalized seizures or locally (on the brain abscess). Temporal lobe seizures. Experiencing muscle hypotonia / flaccid paralysis (acute phase of meningitis). Spastic (encephalitis).
  • Hemiparese hemiplegic (meningitis / encephalitis)
  • Brudzinski's sign positive, positive Kernig sign, an indication of meningeal irritation (acute phase)
  • Regiditas face (meningeal irritation)
  • Deep tendon reflexes disturbed, positive Brudzinski
  • Abdominal reflexes decreased.

7. Pain / Leisure

• Symptoms: headache (throbbing madly, frontal) may be exacerbated by tension neck / back stiffness, pain on ocular movement, throat pain.
• Signs: Looks kept awake, behavioral distraction / agitated crying / complaining.

8. Breathing

• Symptoms: A history of sinus or lung infections.
• Signs: Increased work of breathing (early stage), mental changes (lethargy to coma) and restless.

9. Security

• Symptoms:
  • A history of upper respiratory tract infection or other infections, including sinus middle ear mastoiditis, dental abscess, abdominal or skin, lumbar function, surgery, fracture of the skull / head injury.
  • Immunizations are just getting under way; exposed to meningitis, exposed to measles, herpes simplex, animal bites, foreign bodies carried away.
  • Impaired vision or hearing
• Signs:
  • Increased body temperature, diaphoresis, shivering
  • General weakness; flaccid muscle tone or plastic
  • Sensory disturbances.

4 Techniques in Physical Examination

Techniques in Physical Examination

1. Inspection

Inspection is the examination done by looking at the body, which was checked through observation. Adequate light is necessary for nurses to distinguish colors, shapes and body hygiene clients. Focus inspections on any part of the body include: size, color, shape, position, symmetrical. And to compare the results of normal and abnormal body parts with each part of the body. Example: yellow eyes (jaundice), there is a goitre in the neck, bluish skin (cyanosis), and others.


2. Palpation

   

Palpation is a technique that uses the sense of touch. Hands and fingers are sensitive instruments used to collect data about, for example: temperature, turgor, shape, moisture, vibration, size.

The steps that need to be considered during palpation:

• Create a comfortable and relaxed environment.
• Nurses should be in state hands warm and dry.
• Fingernails nurse, had to be cut short.
• All parts are palpable pain at the end.

Ie, the presence of tumor, edema, crepitations (broken bones), and others.


3. Percussion

Percussion is tapping the examination with certain parts of the body surface to compare with other body parts (left and right) with the aim of producing sound.
Percussion aims to identify the location, size, shape and consistency of the tissue. The nurse uses his hands as a means to produce sound.

The sounds that are found on percussion:

• Sonor: percussion sounds normal tissue.
• Dim: percussion sound tissue, which is more dense, such as in the lungs in pneumonia.
• Deaf: percussion sound tissue, dense as on percussion area of ​​the heart, liver area percussion.
• Hipersonor / timpani: percussion sound more hollow areas, such as lung Caverna area, the client chronic asthma.

4. Auscultation

The physical examination is done by listening to the sound produced by the body. Typically use a tool called a stethoscope. The things heard are: heart sounds, breath sounds, and bowel sounds.

Abnormal sound that can be auscultated in breath are:

Rales: sound produced from the sticky exudate while subtle channels of respiratory expands on inspiration (rales fine, medium, coarse). For example, the client pneumonia, tuberculosis.
Ronchi: low and very rude tone sounded both during inspiration and expiration time. Characteristic ronchi is lost when the client coughs. For example, in pulmonary edema.
Wheezing: sound an audible "ngiii .... k". can be found in the phase of inspiration and expiration. For example, in acute bronchitis, asthma.
Pleural Friction Rub; sound that sounds "dry" sound like rubbing sandpaper on wood. For example, the client with pleural inflammation.