Health Assessment exam 2

collecting patient history

• Biographical data: marital status, type housing, insurance, age

• Current health status:  how is the client doing at the present time?

• Past health history:  Surgery, tests, medical diagnosis, allergies

• Family history:  allergies, TB, smoking, cancer, asthma

• Review of systems:  what symptoms does the client have

• Smoking: pack years (#/day x years)

• Psychosocial: is the patient a child w/asthma? Elderly with memory concerns? Do they know how to take their medications?

• Environmental conditions: at home and work with pollutants, irritants, hazards

• Drug and alcohol consumption

• Weight changes, fever, and night sweats (TB screen)

collecting objective data

1. inspect: sound like short of breathe, symmetric chest rise and fall, round in there chest, color changes, change positions as there talking to you.

2. palpate

3. percuss

4. auscultate

• Anatomical landmarks: anterior, posterior and lateral approach; work apex to base; compare and auscultate (listen) side to side

• Position: sitting upright, naked to waist or gown draped over shoulder and drape as necessary

• Timing: General survey and head-to-toe scan 

• remember clean stethoscope!

collecting objective data: inspection

• observe for retractions and use of accessory muscles

• observe the rate, rhythm, depth, and effort of breathing

• count rate discreetly without informing patient (rate changes many times if patient knows it is being counted)

Breathing positions

• upright and relaxed is normal

• tripod positioning: respiratory distress, leaning forward on a stationary object or with elbows on their knees

Inspection: Normal vs barrel chest

Normal healthy adults

• elliptical shaped chest

• transverse diameter is approximately 2x the AP diameter

• AP:T = 1:2

• transverse should be longer

Barrel chest

• transverse diameter is approximately same as AP diameter

• AP:T = 1:1

• older adults can develop barrel chest, or chronic lung disease

Inspection: Pectus excavatum vs Pectus carinatum

Pectus Excavatum

• sunken sternum/ funnel chest

• often present at birth

• the sternum grows inward, causing the chest wall to sink

• if left untreated, can cause pressure on the lungs and heart

Pectus Carinatum

• forward protrusion of the sternum

• usually does not cause symtpoms

• can increase during puberty or growth spurts

• braces or surgery can be done if condition becomes painful for individual otherwise left alone

Inspection

• Lips: observe color, pursed lip breathing?

• Nares: nasal flaring?

• Skin: cyanosis? blue, grey, dusky, or purple

• Nails: Clubbing? COPD

• Chest symmetry or deformity?

• Costal angle – normal <90

costal angle

is formed by the medial borders of the costal margins, typically located visually or by palpation (see picture).

In normal adults, the angle is less than 90° at rest and during exhalation; greater angles may indicate lung hyperinflation, such as in emphysema or bronchiectasis.

Sputum assessment

• yellow or green: does not always mean you have bacterial infection

• Increase fluid intake and humidify the environment to help ease sputum collection.

• For copious secretions (e.g., cystic fibrosis), postural drainage and chest physiotherapy are beneficial.

• Normal sputum is a small amount, light yellow or clear, and odorless; thickness varies with hydration.

• What to ask: color, Oder, consistency, and amount

Palpation: anterior chest vs posterior chest

Anterior chest

• Identify any areas of tenderness or deformity by palpating the ribs and sternum

• Examine thoracic expansion

• Symmetrical?

Posterior chest

• Identify any areas of tenderness, crepitus (air in the tissues) or deformity

Palpation: posterior chest

• Palpate for chest excursion

• Place hands at base of chest with fingers spread and thumbs about 5 cm apart (at 8ᵗʰ and 10ᵗʰ rib posteriorly)

• Place thumbs toward spine to create skin fold between them

• Have patient take deep breath and feel for expansion

• Normal = chest expansion is symmetrical on anterior/posterior aspect of the chest – thumbs should move apart equal distances

Palpation: tactile fremitus

• Feeling for vibration on chest wall when a patient speaks

• Strongest over the trachea

• Diminishes over the bronchi almost nonexistent over the alveoli

• Have patient repeat “ninety-nine” or “one, two, three” in a clear voice

• Use either palmer surface or dorsal surface of hand

• Compare side to side from apex to base

• Increased tactile fremitus is abnormal and typically occurs in lung consolidation (e.g., pneumonia, bronchitis, atelectasis) or lung compression, as solids transmit vibrations better than air.

• Decreased or absent tactile fremitus occurs in pneumothorax, emphysema, asthma, and pleural effusion, where air or fluid blocks sound conduction

Palpation: alterations

• Lung consolidation: occurs when the normally air filled lung is engorged with fluid or tissue, most commonly in the setting of pneumonia. In the presence of consolidation, fremitus becomes more pronounced.

• Pleural effusion (fluid): Collects in space between lung & chest wall, displacing lung upward. Fremitus over an effusion will be decreased.

percussion

• use indirect percussion method

• start with apices and progress in a symmetrical fashion

• utilize a greek key pattern

• percuss over the intercostal spaces, rather than over the ribs

percussion sounds

• Resonant (healthy lung & bronchitis)

• Clear, long low-pitched sound

• the normal percussion sound over healthy lung tissue.

• Dull (heard over fluid or masses in lungs)

• Short, high pitched, thudding sound which does not vibrate like resonance

• indicates fluid or solid tissue (e.g., pneumonia, pleural effusion, tumor).

• Hyperresonant (heard with air-trapping, emphysema)

• A louder and longer, lower-pitched sound

• abnormal in most adults and suggests excess air (e.g., pneumothorax, emphysema).

• Flatness is normal over ribs but abnormal over lung fields

Auscultation

Stethoscope

• Use diaphragm

• Patient breathes through mouth deeper than normal

• Listen for one full breath cycle

• Start at apices; side to side comparison

auscultation normal breath sounds

Vesicular

• heard over most lung fields

Bronchovesicular

• heard over main bronchus area

Bronchial/ Tracheal

• heard only over trachea

Auscultation: decreased breath sounds

occurs if

• Fluid or puss has accumulated in the pleural space

• Secretions or a foreign body obstructs the bronchi

• Lungs are hyper-inflated

• Shallow breathing

Ausculation: adventitious breath sounds

added sounds that are heard in addition to usual breath sounds

•Discontinuous sounds – crackles

•Continues sounds – rhonchi, wheeze

•Crackles (rales):

⚬May be fine, medium, or coarse; caused by fluid in lower airways; generally not cleared with cough; heard during inspiration. Sounds like rubbing hair between your fingers

•Rhonchi:

⚬Loud, low coarse noises heard during inspiration and expiration; increased with expiration; rumbling/snoring quality; caused by thick secretions or muscular spasm in airways – may clear with cough; caused by passage of air through an obstructed airway

•Wheeze:

⚬High-pitched, musical noise that may be heard during inspiration and expiration, most louder on expiration; caused by high velocity airflow through a narrowed airway

•Stridor: An inspiratory wheeze associated with upper airway obstruction

Respiratory conditions

•Normal – rate 12-20; even volume and rhythm; comfortable

•Bradypnea – rate < 12

•Tachypnea – rate > 20

•Hyperventilation – rate and depth increase

•Sighing – frequently interspersed deeper breath

•Apnea – cessation of breathing

•Cheyne Stokes respirations: are a cyclical pattern of gradually increasing and then decreasing respirations followed by a period of apnea. This is commonly seen in conditions such as heart failure, brain injury, or at the end of life. Cheyne-Stokes respirations: Crescendo-decrescendo pattern with periodic apnea lasting 15 to 30 seconds; can be normal in older adults and children.

•Kussmaul respirations

Lung cancer: known risk factors

• Smoking tobacco

• Secondhand tobacco smoke exposure

• Air pollution exposure

• Radiation therapy to chest

• Personal history of lung cancer

• Family history of lung cancer

• Occupational or environmental exposure to known carcinogens (e.g., asbestos, radon, arsenic, diesel exhaust, uranium, beryllium, cadmium, silica, coal products, vinyl chloride, nickel compounds, chromium compounds, mustard gas, chloromethyl ether)

Lung cancer: uncertain/ unproven risk factors

• marijuana smoking

• f-cigarette smoking

Incentive spirometer

• prevents lung consolidation, pneumonia

• useful for surgical patients, bed bound patients

• instruct patients to inhale fully and at a steady pace - NOT exhale

Peak flow meter

• asthma control

• Peak flow monitoring or Peak Expiratory Flow Rate (PEFR) used to monitor pulmonary function in asthma patients

• Personal best

• Patient must cooperate

     (unable to use for disoriented or sedated patients)

• Ask patient to inhale deeply and then to exhale

     as fast as possible, expelling as much air as possible.

• Forced vital capacity: total number of air exhaled

• blow out as hard as they can

signs and symptoms of hypoxia

• Restlessness – The #1 Sign/Symptom (cant sit still)

• Apprehension, anxiety

• Disorientation

• Decreased Level Of Consciousness

• Increased fatigue Increased pulse, B/P, RR

• Dyspnea

• Arrhythmias

• Pallor

• Cyanosis (late)

• Clubbing (chronic)

• Behavioral changes

General patient goals for respiratory insufficiency

• manage dyspnea

• maintain patient airway

• achieve and maintain adequate lung expansion

• achieve improved activity tolerance

• maintain and improve tissue oxygenation

• maintain and improve gas exchange

Developmental considerations: Infants and children

⚬Susceptible to adverse effects of second-hand smoke

⚬Pregnancy – lower birth weight, decreased head growth, sudden infant death syndrome (SIDS)

After birth – upper and lower respiratory tract infections, asthma, hearing loss, ADHD or other behavioral disorders, etc.

Developmental considerations: pregnant women

⚬Increased oxygen demand from the fetus

⚬Enlarging uterus displaces the diaphragm

⚬Increased estrogen levels relax the chest cage ligaments – allows costal angle widening

developmental considerations: the aging adult

⚬Costal cartilage becomes calcified – thorax less mobile

⚬Respiratory muscle strength declines

⚬Lung in general is more rigid and harder to inflate

⚬Decreased number of alveoli – less available surface area for gas exchange

⚬More at risk for post-op complications

￭Decreased ability to cough, loss of protective reflexes, increased secretions

USPSTF screening recommendations

Grade A:

• The USPSTF recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and US Food and Drug Administration (FDA)-approved pharmacotherapy for cessation to nonpregnant adults who use tobacco.

Grade B:

• The USPSTF recommends screening for latent tuberculosis infection (LTBI) in populations at increased risk.

• The USPSTF recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 50 to 80 years who have a 20-pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.

collecting subjective data of the ears

•EARACHE

⚬OLDCARTS, recent or previous trauma, cold symptoms

•INFECTIONS

⚬History of ear infections

•DISCHARGE

⚬Odor, bleeding, associated pain

•HEARING LOSS

⚬Do people seem to be shouting at you? Coping strategies

•ENVIRONMENTAL NOISE

⚬Work environment, exposure to gunfire, protection

•TINNITUS

⚬Ringing, buzzing, does it affect your everyday life?

•VERTIGO

⚬Room spinning or spinning yourself, worse with change in position?

•PATIENT-CENTERED CARE

⚬Hygiene, use of hearing aids

PMH vs Family History

PMH

• systemic disease

• childhood problems

• surgery

• antibiotic use: resistance, odotoxicity

Family History

• hearing problems

• meniere’s disease

Collecting objective data of the ears

INSPECT AURICLES

• Size/shape/symmetry

• Landmarks

• Skin Color

• Lesions or nodules

INSPECT EXTERNAL AUDITORY CANAL

• Discharge/odor

PALPATE FOR TENDERNESS, NODULES

• Color changes (pale, red, or cyanotic) may indicate vasomotor disorders, fevers, hypoxemia, or cold exposure.

• Abnormally large or small ears can be congenital or due to trauma, with microtia involving a small external ear and absent ear canal.

• Palpate the auricle for tenderness or lesions, starting with the unaffected ear if the client reports pain.

• Palpate the mastoid tip and press on the tragus, noting any tenderness.

• Gently pull the auricle up and down, checking for tenderness.

• Normal result: No pain or tenderness should be reported during palpation.

• Abnormal findings: Pain or tenderness in the auricle may indicate otitis externa, tenderness over the mastoid may suggest mastoiditis, and edematous or sensitive tragus points to possible inflammation of the external or middle ear.

Collecting objective data of the ears continues

INSPECTION WITH OTOSCOPE

• External ear canal: patency, color,  drainage, lesions, and foreign objects

• Tympanic membrane: color, integrity,  landmarks

• Normal color is shiny and translucent

• Pearly gray (want to see this)

• Straighten the adult ear canal by pulling pinna upward and backward

• Straighten the ear canal of a child by pulling the pinna down

• Have client tilt head away from ear being examined

• Choose largest speculum that fits comfortably in the ear

• Hold otoscope like a pencil in your dominant hand

• Use free hand to pull ear up and back (adults + children over age 3)

• Slowly insert speculum and visualize ear

Inspection of the ear: abnormal findings

• Perichondrial hematoma (cauliflower ear): Swollen, deformed ear resembling a “cauliflower” from blunt trauma, leading to blood clot formation and fibrosis (see picture).

• Perichondritis: Inflammation of the tissue overlying the ear cartilage that manifests as an erythematous, edematous, warm, and painful ear.

• Skin lesions or tumors on the external ear, such as basal or squamous cell carcinoma, are abnormal, often linked to prolonged sun exposure.

• Purulent drainage usually signals with tympanic membrane perforation.

• Bloody drainage may result from otitis media, head trauma, or surgery.

• Clear drainage may indicate a cerebrospinal fluid (CSF) leak, which requires urgent referral if glucose is detected, indicating CSF leakage.

• Battle’s sign: Hematoma behind the ear; indicates head trauma to the temporal bone.

• Tophi: Hard, painless, irregular-shaped nodule on the pinna, indicating gout or benign fibromas.

• Sebaceous cysts form from blocked sebaceous gland ducts and are considered abnormal.

• Enlarged lymph nodes anterior to the tragus or over the mastoid may suggest malignancy or infection, like acute otitis media or otitis externa.

comparision of AOM, OME, and OE

Hearing tests

Audiometric testing is most accurate (quantitative)

• assesses a persons ability to hear sounds of various frequencies

Whispered voice test

• detects high tone loss

• Evaluates hearing by having the client repeat a whispered two-syllable word from 2 feet away, with difficulty hearing or repeating the words indicating potential high-frequency hearing loss, often from loud noise exposure.

Tuning fork test

• weber: sound should be equally loud in both ears. Uses a 512-Hz tuning fork placed on the client's forehead, top of the head, or front teeth to check for sound lateralization, with normal results showing no lateralization (sound heard centrally), while lateralization to the affected ear indicates conductive hearing loss and to the unaffected ear suggests sensorineural hearing loss

• rinne: sound should be heard twice as long by air conduction than by bone conduction. Involves striking a tuning fork, placing it on the mastoid process to test bone conduction, then moving it in front of the ear to test air conduction, with normal results showing air conduction heard twice as long as bone conduction (AC > BC).

• conductive hearing loss: something is blocking the conduction of sound. ex: ear wax, overgrowth of bones, bug in your ear

• sensory nueral loss: disease, loud noise exposure

Developmental considerations for the ears: Infants and children

• EUSTACHIAN TUBE IS SHORTER AND WIDER, POSITION MORE HORIZONTAL

• Easier for pathogens to migrate to middle ear

• EXTERNAL EAR CANALS SHORTER AND HAVE SLOPE OPPOSITE TO ADULTS

• OVERALL, HIGHER RISK OF MIDDLE EAR INFECTIONS THAN ADULTS

Developmental considerations for the ears: adults vs aging adult

Adult

• OTOSCLEROSIS – CONDUCTIVE HEARING LOSS BETWEEN 20-40

• Bone formation and fixation impedes transmission

Aging adult

• CILIA BECOME COARSE AND STIFF

• HEARING AIDS = HIGHER INCIDENCE OF CERUMEN IMPACTION

• PRESBYCUSIS – SENSORINEURAL

subjective data of the nose

• discharge

• frequent colds

• sinus pain

• trauma: can you breathe through both nostrils

• epistaxis (nosebleeds): frequency, amount, one or both nostrils, treatment

• allergies: pets, envriomental, use of nasal spray, drops, inhalers

• altered smell

• snoring patterns

subjective data of the mouth and throat

SORES OR LESIONS

• Single vs multiple, treatment

SORE THROAT

• Recent cold, any other flu-like symptoms

BLEEDING GUMS

TOOTHACHE

• Heat vs cold sensitivity

HOARSENESS

• Voice changes

DYSPHAGIA

• Difficulty in swallowing

ALTERED TASTE

SMOKING, ALCOHOL CONSUMPTION

• Frequency and type

PATIENT-CENTERED CARE

• Dental care pattern

• Dental examination frequency

• Dentures or other mouth implants

Objective data of the nose, mouth, and throat

INSPECT EXTERNAL NOSE

• MIDLINE POSITION

• NASAL FLARING

INSPECT INTERNAL NOSE

• Color

• Discharge

• Masses/Lesions

• Swelling of turbinates

• Septum intact

ABNORMAL FINDINGS:

• Deviated septum

• Perforated septum

• Occluded nasal cavity

internal inspection of the nose

• rhinitis

• hay fever + allergies

• CSF leak

• bacterial sinusitis

• nasal polyps

• nosebleeds

• Red, swollen nasal mucosa with clear discharge indicates rhinitis; if sudden onset, it's likely coryza (common cold).

• Coryza may progress to purulent discharge if a secondary bacterial infection develops.

• Pale, edematous mucosa with clear discharge suggests allergies or hay fever.

• Clear, watery discharge after head trauma that tests positive for glucose may indicate cerebrospinal fluid (CSF) leak—requires urgent referral.

• Red, swollen mucosa with purulent discharge, especially unilateral, suggests bacterial sinusitis.

• Pale, smooth, round, shiny masses in the middle meatus are nasal polyps; they are usually bilateral (unilateral may indicate malignancy).

• Recurrent nosebleeds may signal underlying issues such as blood disorders, environmental factors, medication use (e.g., anticoagulants), or malignancy.

Sinuses

• palpate frontal and maxillary sinus

• percuss sinuses for tenderness

• Inspect the face for swelling around the nose and eyes; absence of swelling is normal.

• Swelling above or below the eyes may indicate acute sinusitis due to inflamed, pus-filled paranasal sinuses.

• To palpate frontal sinuses: Press gently under the eyebrows, avoiding the eyes.

• Observe for pain during palpation, which may suggest sinus inflammation.

• Percuss the same area using your finger and note any pain or abnormal sounds.

• Pain or tenderness is abnormal and may indicate sinusitis or infection.

• A dull sound may indicate fluid, often from allergies.

Mouth

• inspection of mouth, lips, gums, teeth, mucosa

• muscosa and palate pink

• lips smooth without lesions

• alignment of teeth and condition

• hygiene, missing teeth

• pharynx pink

• breath should smell fresh

• Foul-smelling breath (halitosis) may indicate gastroesophageal reflux disease, tooth decay, poor hygiene, or infections of the gums, tonsils, or sinuses.

• Acetone or fruity breath suggests diabetic ketoacidosis, malnutrition, or a low-carb diet.

• Musty breath (fetor hepaticus) can signal liver failure.

• Ammonia-scented breath may occur in end-stage renal failure due to urea buildup.

Mouth and lip abnormalities

• unilateral clef lip and palate

• surgical correction

• bilateral cleft lip and palate

inspection of the mouth: lips

• pallor or cyanosis: may indicate anemia, vitamin deficiency, or oxygenation issues

• dry, cracking: may result from dehydration, environmental exposure, or frequent licking.

• swelling (angioedema): from allergic reactions are a medical emergency

• angular cheilitis: (cracked mouth corners) can be due to nutritional deficiencies, drooling, or fungal infections.

• oral lesions:

• Herpes simplex: vesicles on red bases that crust and are painful (see picture).

• Syphilitic chancre: round, painless ulcer.

inspection of the mouth: tongue

• enlarged tongue: An enlarged tongue may indicate conditions such as myxedema, acromegaly, Down syndrome, or amyloidosis; transient causes include glossitis, edema, or abscess.

• glossitis: A red, smooth tongue with absent papillae suggests glossitis, often due to vitamin B12, iron, or niacin deficiencies, or chemotherapy side effects

• candidiasis (thrust, yeast overgrowth): A thick, white, curd-like coating on the tongue that leaves a red raw surface when scraped indicates candidiasis

• leukoplakia: Thin, pearly white lesions on the tongue sides that do not scrape off are leukoplakia, a premalignant condition

• canker sore: A painful, small, round white ulcer with red borders is an aphthous ulcer

• ankyloglossia: A short lingual frenulum is observed; this is congenital.

• hairy leukoplakia: is benign and caused by elongated papillae, often after antibiotic use

• ventral lesions: surface may indicate malignancy, especially in alcohol and tobacco users.

• lateral tongue ulcerations: tongue are common sites for lingual cancers linked to alcohol and tobacco

• geographic tongue: shows red patches with pale yellow ridges; it is harmless and of unknown cause

• fissured (scrotal) tongue: has grooves radiating from the midline; it is harmless and often inherited, distinct from syphilitic glossitis.

• hemangiomas: Engorged blood vessels or hemangiomas on the tongue are abnormal; hemangiomas are benign vascular overgrowths.

inspection of the mouth: buccal mucosa

• leukoplakia:Leathery, painless white patches (leukoplakia) can appear on the buccal mucosa, often linked to snuff use.

• fordyce spots: Yellow patches (Fordyce spots) are sebaceous glands and are normal findings (see picture).

• parotid gland inflammation: Erythematous, swollen, and tender Stensen’s duct orifice indicates parotitis. Parotid gland swelling, especially unilateral, may be seen in conditions like mumps.

• aphthous ulcers: Small, round white ulcers with a red halo on the buccal mucosa are aphthous ulcers.

• xerostomia (dry mouth): Excessively dry mucosa (xerostomia) occurs with decreased salivary flow due to hypovolemia, mouth breathing, Sjögren syndrome, or gland obstruction.

inspection of the mouth: gums

• gingivitis: Red, tender, swollen gums that bleed easily indicate gingivitis, often due to poor hygiene, dentures, or scurvy (see picture).

• periodontitis: is chronic inflammation with gum recession, pocket infection, and possible purulent drainage from poor dental care.

• brown gums: may signal Addison disease (adrenal insufficiency)

• trench mouth: A grayish membrane on inflamed gums suggests Vincent stomatitis (trench mouth), a bacterial infection

• gum recession: common in older adults, those with poor hygiene, aggressive brushing, or teeth grinding; night guards can help slow recession in grinders.

• gingival hyperplasia:( gum tissue overgrowth) is abnormal, usually painless, and occurs during pregnancy, with braces, dental plaque, or certain medications like phenytoin.

teeth and gum abnormalities

Geographic tongue

• not significant

• may cause sensitivity

“Meth mouth”

• extensive dental caries, gingivitis, tooth cracking

• methamphetamine causes vasoconstriction and decreased saliva production and increases sugar and straight craving

• increased bacterial growth, increased acidity

objective data of throat

• Inspect and grade tonsils 0-2+

• Pink, discharge or drainage present

• Assess position of uvula when patient says “ahhh”-should be midline

• Cranial Nerve XII-hypoglossal-extension of the tongue, check for symmetry

inspection of the throat

• red with white patches: viral pharyngitis or infectious mononucleosis

• red/swollen with yellow patches: strep throat

• grayish membrane over tonsils: possible diphtheria or severe infection

• hoarse vouce and red throat: infection or voice strain

• large tonsils: possible abscess or sleep apnea risk

developmental considerations for the nose, mouth, and throat: infants and children

•Salivation starts at 3 months old

⚬Drooling until they learn to swallow

•20 deciduous teeth

⚬Erupt between 6-24 months of age

⚬Should all appear by 2 ½ years of age

⚬Lost between 6-12 years old

•Nose develops shape during adolescence (12-13 years old)

developmental considerations for the nose, mouth, and throat: Pregnant women

• Nasal stuffiness and epistaxis (nose bleeds) may occur

• Increased vascularity

• Gums may be sensitive and more likely to bleed with tooth brushing

developmental considerations for the nose, mouth, and throat: the aging adult

• Nose may appear more prominent – loss of subcutaneous fat

• Decrease in smell after 60 years of age – decrease in # of olfactory nerve fibers

• Decrease in salivary secretion, reduction in taste function

• Increased risk for malignant lesions

• Dental changes

• Receding gums- tooth erosion, exposed nerve which increases tooth sensitivity

• Tooth loss – decay, osteoporosis, tobacco use

• Risks related to these conditions: 

• Malnutrition, and insufficient vitamin & mineral intake

• Impaired swallowing