Physical Assessment ( Due maxomum 3 hours)

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Chapter 7 Beginning the Physical Examination: General Survey, Vital Signs, and Pain

General Survey

First impression

Nonverbal cues

Assess many factors

General appearance

Apparent state of health

Demeanor

Facial affect or expression

Grooming

Posture and gait

General Appearance #1

Apparent State of Health

Make general judgment

Acute or chronic

Frail or fit and robust

Looks his or her age

Unhappy or happy

Fatigued or rested

General Appearance #2

Level of Consciousness

Awake, alert, responsive

Orientation to person, place, time

Facial Expression

At rest

During conversation, examination, with others

Eye contact

Movements symmetric

General Appearance #3

Posture, Gait, Motor Activity, and Speech

Preferred posture

Restless or quiet

Changes position often

How fast/slow are movements

Apparent involuntary motor activity

Immobile or stiff joints

Speech: articulate, garbled, rapid, slow

General Appearance #4

Posture, Gait, Motor Activity, and Speech (cont.)

Fatigue: nonspecific symptom with many causes; sense of weariness or loss of energy

Depression, anxiety, hepatitis, infectious mononucleosis, hypothyroidism, diabetes mellitus, and others

Weakness: demonstrable loss of muscle power

Possible neuropathy or myopathy

General Appearance #5

Odors of the Body and Breath

Alcohol

Acetone

Pulmonary infections

Uremia

Liver failure

Fruity

General Appearance #6

Skin color and obvious lesions

To be covered in Chapter 9

Dress, grooming, and personal hygiene

Clothing appropriate for weather

Clean, properly buttoned

Clothing appropriate for age and/or social group

Tattoos, piercings

Hygiene and grooming appropriate for age, lifestyle, occupation

General Appearance #7

Signs of Distress

Cardiac or respiratory distress

Clutching chest, pallor, diaphoresis, labored breathing, shortness of breath, tripod position

Pain

Facial expression, grimacing, crying

Anxiety or depression

Anxious face, fidgety movements, poor eye contact, flat affect, psychomotor slowing

Question #1

Although a subjective finding, _______ is often referred to as the fifth vital sign.

A. Temperature

B. Pain

C. Pulse

D. Affect

Answer to Question #1

Although a subjective finding, _______ is often referred to as the fifth vital sign.

B. Pain

The basic vital signs include temperature, heart rate, respiratory rate, and blood pressure. Pain assessment is commonly missed and often not managed effectively. In order to ensure frequent pain assessment, it has been labeled the “fifth vital sign” especially in the hospital or rehabilitation setting.

Vital Signs #1

Integral part of the assessment

Usually checked in beginning of assessment

Can be rechecked during system assessment if not within normal parameters.

Consist of blood pressure, heart rate, respiratory rate, and temperature.

Blood Pressure #1

Vital Signs #2

Blood pressure

Choose correct size of sphygmomanometer.

If cuff is too small (narrow), BP will read high.

If cuff too large (wide), BP will read low on small arm and high on large arm.

Ensure equipment is functioning correctly and in good repair.

Blood Pressure #2

Vital Signs #3

Steps to ensure accurate blood pressure

Instruct the patient to avoid smoking or drinking caffeinated beverages for 30 minutes before BP is measured.

Check to be sure room is quiet and comfortable.

Ask patient to sit quietly for at least 5 minutes in chair.

Selected arm: free of clothing, no arteriovenous fistulas, scarring from prior arterial cutdowns, lymphedema, or mastectomy.

Vital Signs #4

Steps to ensure accurate blood pressure (cont.)

Palpate the brachial artery for viable pulse.

Position the arm so that the brachial artery is at heart level.

If below heart level, will be higher

If above heart level, will be lower

If patient is seated, rest arm on table a little above patient’s waist.

Vital Signs #5

Vital Signs #6

Unrecognized auscultatory gap may lead to serious underestimation of systolic pressure.

Vital Signs #7

Vital Signs #8

Blood pressure (cont.)

Errors that result in false high readings

Cuff too small (narrow)

Cuff too loose or uneven

Arm below heart level

Arm not supported

Inflating or deflating cuff too slowly (high diastolic)

Deflating cuff too quickly (low systolic and high diastolic)

Vital Signs #9

Blood pressure (cont.)

Errors that result in false low readings

Cuff too large (wide)

Arm above heart level

Repeating assessments too quickly

Inaccurate level of inflation

Pressing stethoscope too tightly against pulse

Classification of Normal and Abnormal Blood Pressure #1

Classification of Normal and Abnormal Blood Pressure #2

Low Blood Pressure

Interpret relatively low levels by comparing to past readings and current clinical condition

Orthostatic hypotension: drop in blood pressure noted when patient moves from a lying to standing position

Drop in systolic reading of at least 20 mm Hg

Drop in diastolic reading of at least 10 mm Hg

Special Circumstances #1

Weak or inaudible Korotkoff sounds

Check placement of stethoscope.

Consider possibility of shock.

Arrhythmias

Verify findings with ECG.

White coat hypertension

Try to relax patient and re-measure later during visit.

The obese or very thin patient

Use correct size cuff.

Special Circumstances #2

The hypertensive patient with unequal blood pressure in the arms and legs

Compare BP in arms and legs.

Compare volume and timing of radial and femoral pulses.

Coarctation of the aorta and occlusive aortic disease

Hypertension in upper extremities

Low blood pressure in legs

Diminished or delayed femoral pulses

Question #2

False low blood pressure readings can occur with all except:

A. Deflating cuff too quickly

B. Cuff too large (wide)

C. Pressing stethoscope too tightly against pulse

D. Repeating assessment too quickly

Answer to Question #2

False low blood pressure readings can occur with all except:

A. Deflating cuff too quickly

Deflating the cuff too quickly may result in a false high reading. A false low reading may occur when the cuff is too large, the assessment is repeated too quickly; the level of inflation is inaccurate; or the stethoscope is pressed too tightly against the pulse.

Heart Rate and Rhythm #1

Heart rate

Commonly use radial pulse

If rhythm appears regular and rate normal, count for 30 seconds and multiply by 2

If rate is unusually fast or slow, count for 60 seconds

Normal range for adults: 60 to 100 beats per minute

Heart Rate and Rhythm #2

Rhythm

Regular or irregular

If irregularities are noted, assess apical pulse

Do early beats appear in a regular rhythm?

Compare to breathing

Regularly irregular or irregularly irregular

ECG should be checked to assess irregular rhythms

Heart Rate and Rhythm #3

Respiratory Rate and Rhythm

Observe:

Rate

Rhythm

Depth

Effort of breathing

Obtain rate without letting patient know.

Normal adult: 12 to 20 breaths per minute

Temperature #1

Temperature fluctuates throughout day

Average temperature depends on method used

Oral: 37°C (98.6°F)

Rectal: 37.4°C to 37.5°C (99.3°F to 99.5°F)

Axillary: 36°C (97.6°F)

Hyperpyrexia: >41.1°C (106°F)

Hypothermia: <35°C (95°F) rectally

Temperature #2

Options available for obtaining temperature

Oral (not recommended for unconscious, restless, or patients who cannot close their mouth)

Rectal

Tympanic membrane

Temporal artery

Axillary

Temperature #3

Fever

Abnormal elevation in body temperature

Chills

Feeling cold, shivering

Night sweats

Feeling hot and sweating accompany a falling temperature

Occurs with tuberculosis and malignancy

Acute and Chronic Pain #1

Pain

One of the most common symptoms

Often under-assessed and under-treated

Acute pain

Occurs suddenly with recent injury or illness

Chronic pain

Pain that persists for more than 3 to 6 months

Recurring at intervals of months or years

Acute and Chronic Pain #2

Assessing the patient’s history

Onset

Location

Duration

Characteristic symptoms

Associated manifestations

Relieving factors

Treatments

Health disparities

Acute and Chronic Pain #3

Types of scales to assess pain

Visual Analog Scale

Numeric Rating Scale

Verbal Pain Rating Scale

Combination of pain scales

Pain Scale

Acute and Chronic Pain #4

Types of pain

Nociceptive or somatic pain

Related to tissue damage

Neuropathic pain

Related to direct injury to PNS or CNS

Psychogenic and idiopathic pain

Psychogenic refers to many factors that influence patient’s report of pain. Idiopathic is pain without identifiable etiology.

Acute and Chronic Pain #5

Pain management

Focus on the Four A’s to monitor patient outcomes:

Analgesia

Activities of daily living

Adverse effects

Aberrant drug-related behaviors

Record Findings

Use vivid and graphic adjectives.

Avoid cliches.

Record vital signs taken at time of examination.

Health Promotion #1

Temperature

Educate patients on various routes, how to correctly obtain temperature, and correct use of equipment.

Educate patients on risk factors for hyperthermia and hypothermia.

Pulse

Some medications require checking the pulse before administration.

Teach patients how to check one carotid pulse.

Health Promotion #2

Respirations

Educate the patient on how to count properly.

Record rate, rhythm, and amplitude.

Blood pressure

Ensure the patient is using the correct cuff.

Home sphygmomanometers should be checked periodically to ensure accurate readings.

Encourage the patient to keep a journal to record readings.

Question #3

To help with management of the patient’s pain, a nurse should focus on the Four A’s to monitor patient outcome: analgesia, ADLs, adverse effects, and acceptable drug-related behaviors.

A. True

B. False

Answer to Question #3

To help with management of the patient’s pain, a nurse should focus on the Four A’s to monitor patient outcome: analgesia, ADLs, adverse effects, and acceptable drug-related behaviors.

B. False

The Four A’s include analgesia, ADLs, adverse effects, and aberrant drug-related behaviors.