Assessment, Urgent Changes & Care Settings

Vocabulary practice flashcards for Exam 1 - Set 3 covering functional assessment, system highlights, stroke recognition, heart failure, and care transitions.

Functional Assessment Core Principle

Assess function directly rather than assuming ability from diagnosis or age.

ADLs, IADLs, and AADLs

ADLs are basic self-care activities. IADLs are more complex tasks needed for independent living. AADLs are higher-level activities related to roles, recreation, work, or community participation.

Physical Performance Measures

Assessment measures that use direct observation to help identify risk for functional decline and falls.

Timed Up and Go (TUG) Sequence

Stand from a chair -> walk a short marked distance -> turn -> walk back -> sit down.

Timed Up and Go (TUG) Purpose

Quick assessment of functional mobility, gait/balance, and fall risk. Interpret with the person's baseline, device use, and clinical context.

Morse Fall Scale: Item 1 (Fall History)

Assesses recent or history of falling.

Morse Fall Scale: Item 2 (Secondary Diagnosis)

Assesses whether the patient has more than one medical diagnosis.

Morse Fall Scale: Item 3 (Ambulatory Aid)

Assesses ambulatory aid category: None/bedrest/nurse assist vs crutches/walker/cane vs furniture.

Morse Fall Scale: Item 4 (IV or Saline/Heparin Lock)

Assesses the presence of IV access.

Morse Fall Scale: Item 5 (Gait/Transferring)

Assesses whether gait and transferring are normal, weak, or impaired.

Morse Fall Scale: Item 6 (Mental Status)

Assesses whether the patient accurately recognizes own limitations.

Morse Fall Scale Scoring & Incontinence

Incontinence can increase fall risk, but it is NOT a separate scored Morse item.

Cardiovascular System Assessment

Includes history, chest symptoms, medications including OTC/herbs, stress, vital signs, heart sounds, and labs/diagnostics.

Respiratory System Assessment

Includes dyspnea characteristics, smoking/exposure history, cough, energy, orthopnea, lung sounds, posture, and relevant testing.

Gastrointestinal (GI) Assessment

Includes oral cavity/teeth/dentures, diet, appetite, nausea/vomiting/indigestion, bowel pattern, constipation contributors, and medications. In older adults, indigestion can sometimes reflect cardiac ischemia.

Genitourinary (GU) Assessment

Includes diabetes/hypertension history, incontinence type/frequency, nocturia, voluntary flow, and pad use.

Neurologic System Assessment

Includes speech, memory, cognition, communication, sleep, balance, motor/sensory function, orientation, pupils, and grip strength.

Musculoskeletal System Assessment

Includes ROM, posture, daily activities, arthritis, mobility devices, and osteoporosis/fall risk.

Sensory System Assessment

Includes vision, hearing, taste, smell, and touch. Check cerumen and hearing-aid use when hearing changes are reported.

Integumentary System Assessment

Includes color, hydration, circulation, intactness/wounds, nutrition/weight, and hair/nail changes.

Presbyopia

A visual condition whose typical clue is near-focus difficulty.

Cataract

A visual condition whose typical clues are clouding of the lens, where glare/blurred vision may occur.

Macular Degeneration

A visual condition whose typical clue is loss/deterioration of central vision used for reading/faces.

Glaucoma

An optic-nerve disease often associated with increased intraocular pressure; requires evaluation/testing.

Evaluation of Visual Symptoms

New visual symptoms require evaluation; do not diagnose from a single clue.

Laboratory Interpretation Context

Example: albumin $2.9\,g/dL$ is low. Interpret laboratory abnormalities in the full clinical context; do not confuse a lab finding with an observed clinical event such as a fall.

Exam Priority: Aging vs. New Change

Know what is NORMAL aging versus a NEW abnormal change. New decline in function, cognition, mobility, intake, or behavior deserves assessment rather than attribution to age.

Stroke/TIA Emergency Symptoms

Sudden unilateral weakness/numbness/paralysis, speech or comprehension changes, visual changes, dizziness/loss of balance, or a sudden severe unexplained headache.

Stroke/TIA Immediate Action

Activate 911/emergency response and note the time symptoms began or the last-known-well time. Do not delay for routine follow-up.

Stroke Types and Primary Risk Factor

Ischemic (thrombotic/embolic) and hemorrhagic. Hypertension is a major modifiable risk factor.

Hemispheric Stroke Physical Weakness Patterns

Right hemisphere stroke: Often left-sided weakness/neglect. Left hemisphere stroke: Often right-sided weakness.

Hemispheric Stroke Behavioral Patterns

Right hemisphere stroke: May be impulsive, quick, or overestimate abilities. Left hemisphere stroke: May be slow/cautious and easily frustrated.

Hemispheric Stroke Safety & Communication Profiles

Right hemisphere stroke: Poor judgment/safety awareness can increase injury risk. Left hemisphere stroke: Aphasia/language problems are common.

Hemispheric Stroke Nursing Approaches

Right hemisphere stroke: Use calm structure; break tasks into simple steps; emphasize safety. Left hemisphere stroke: Speak slowly/distinctly; use simple sentences; allow response time; monitor swallowing.

Stroke Care Interventions for Either Hemisphere

Encourage use of the affected side when appropriate, reduce distractions during teaching, alternate rest/activity, include patient/family in goals, and arrange rehabilitation/follow-up.

Heart Failure Worsening Signs

Breathlessness/dyspnea, orthopnea, edema/swelling, cough/wheeze, fatigue, confusion, reduced appetite/nausea, increased heart rate, and rapid weight gain.

Heart Failure Patient Teaching

Daily weights under consistent conditions, medication adherence, sodium guidance, activity/rest balance, smoking cessation, follow-up, and patient-specific instructions for when to report weight/symptom changes.

Heart Failure Threshold Guidance

Older slides may give fixed sodium or weight thresholds. For the exam, use the class guide's emphasis on patient-specific reporting thresholds unless a question explicitly asks for the slide value.

Atypical Coronary Disease / MI Symptoms in Older Adults

Dyspnea, dizziness, confusion, unexplained jaw discomfort, nausea, or indigestion/epigastric discomfort, in addition to chest pressure/pain.

Action for Suspected Acute MI

Suspected acute MI symptoms require emergency evaluation; do not assume indigestion is benign when other concerning features are present.

Infection and Temperature Assessment

Interpret temperature against the older adult's usual baseline and other symptom/function changes. A clinically important infection may not always present with a dramatic fever.

Basis of Discharge Planning

Discharge planning is based on medical stability PLUS function, safety, rehabilitation needs, cognition, caregiver support, home environment, and ability to manage ADLs/IADLs.

Short-Term Skilled Nursing Rehabilitation Criteria Example

After hip-fracture surgery, a medically stable patient who still needs daily rehabilitation and assistance with ADLs and cannot safely return home may need short-term skilled nursing rehabilitation.

Assessment of Patients Living Alone

Living alone does not automatically mean a person is unsafe or dependent; assess actual function and resources.

Transitions of Care Communication Requirements

Communicate medications, functional status, cognitive status, goals, follow-up, equipment needs, warning signs, and caregiver needs when moving between hospital, home, assisted living, SNF, hospice, or other settings.