Physical Diagnosis Exam 1 Part 2 - Vital Signs & Pain Assessment

What are the 4 assessed vital signs and why do we measure them?

1) Temperature

2) Pulse Rate (#/min)

3) Respiratory Rate (#/min)

4) Blood pressure (mmHg)

They are considered BASELINE INDICATORS of patients health status!

What is considered the "fifth vital sign" that is a subjective symptom of many conditions and injuries, with the experience, characteristic, and intensity being unique for each person?

Pain Assessment

T/F: All patients in all health care facilities must have a documented pain assessment.

TRUE

What regulates body temperature?

Hypothalamus

What response is triggered by the production and release of prostaglandins, with endogenous pyrogens released and travel to the hypothalamus when microorganisms invade the body in order to raise core temperature and stunt growth/kill infectious agents?

Fever response (Pyrexia)

In what two ways does the body generate heat?

1) Vasoconstriction (reduce heat loss through skin)

2) Shivering (rapid contraction and relaxation of skeletal muscle)

In what two ways does the body cool down?

1) Vasodilation (increase heat loss thorough the skin)

2) Evaporation of perspiration

What is the measure of heart rate?

Pulse rate

What results when the ventricular heart contraction pushes a pressure wave of blood throughout the arterial system?

Arterial pulse

What is the measure of inspiration and expiration?

Respiratory rate

What is the dominant muscle of respiration which contracts and moves downward during inspiration to increase the intrathoracic space?

Diaphragm

Which intercostal muscles increase the anteroposterior chest diameter during inspiration (AP expansion)? Which decreases the lateral diameter during expiration (Lateral contraction)?

External intercostal muscles

Internal intercostal muscles

What is the peripheral measurement of cardiovascular function?

Blood Pressure

What is the force of the blood against the wall of an artery as the ventricles of the heart contract and relax?

Arterial blood pressure

What is the force exerted when the ventricles contract?

Systolic pressure

Systolic pressure is largely the result of what 3 things?

1) Cardiac output

2) Blood volume

3) Compliance of arteries

What is the force exerted by peripheral vascular resistance when the heart is filling (relaxed state)?

Diastolic Pressure

T/F: Blood pressure is highest during diastole

FALSE

Highest during systole

Lowest during diastole

What is the difference between the systolic and end-diastolic pressures?

Pulse Pressure

If the blood pressure were 120/80 mmHg, the pulse pressure would be ______?

40 mmHg

120 - 80 = 40

What is a common, uncomfortable sensation and emotional experience associated with actual or potential tissue damage?

Pain

Which type of pain is sudden/short duration (hours-days), and is usually associated with surgery, injury or acute illness? Which is persistent, long lasting (weeks, months, or years), usually associated with prolonged disease?

Acute pain

Chronic pain

Transmission of pain impulses from the site of injury (tissue damage) travels to the ____________, then to the brain.

Dorsal horn of the spinal cord

Which of the two fibers mediating nociception is large with sharp/localized pain that is transmitted quickly?

Myelinated A-delta nerve fibers

Which of the two fibers mediating nociception is small with dull/burning/diffuse/chronic pain and is transmitted slowly?

Unmyelinated C-polymodal nerve fibers

In pain transmission, ___________ transmit pain impulses along ___ & ___ fibers, to the _____ of the spinal cord.

Nociceptors

A & C fibers

Dorsal horn

T/F: After the sensory information reaches the dorsal horn of the spinal cord, there is two-way control of nociceptive transmission within the spinal tracts

TRUE

What are produced in response to tissue damage to help move the pain impulse from nociceptors to the dorsal horn of the spinal cord, ascending spinal tracts, thalamus, and cerebral cortex?

Biochemical mediators

What are the 7 biochemical mediators?

1) Bradykinin

2) Prostaglandin

3) Leukotrienes

4) Serotonin

5) Histamine

6) Catecholamines

7) Substance P

BPLSHCS

What is the idea that once pain impulses reach the spinal cord, they can be modified when other stimuli are present from either the brain or periphery?

Perception

What are 4 things involved in pain modification?

1) Endorphins

2) Serotonin

3) Norepinephrine

4) Non-pain impulses (massage)

What two pain perceptions can chronic pain cause?

1) Pain sensitization

2) Pain normalization

What is the facilitation of pain sensation with lower neurologic threshold to create pain experience, leading to more pain or pain from normally non-pain provoking situations?

Pain sensitization

What is the desensitization to pain or willful ignoring of pain, where people ignore pain and "push through" it?

Pain normalization

T/F: Infants are more susceptible to hyperthermia due to larger body surface area for weight ratio, thinner skin, and limited ability to cope with this temperature related stress.

FALSE

-- hypothermia

T/F: Infants have a higher pulse rate and blood pressure than adults but the respiration rate is about the same

FALSE

Infants have both a HIGHER pulse & respiration rate but a LOWER blood pressure than adults

What impulses are less able to be modified by infants?

Pain impulses

Blood pressure in pregnant women commonly decrease beginning at about what week of gestation? It reaches a low point at what point of pregnancy? Diastolic blood pressure then will gradually rise to prepregnant levels by when?

8 weeks

Mid-pregnancy

Term

What are the 5 pain experiences a pregnant women may experience?

1) Back pain (lax ligaments, weight gain, hyperlordosis, and anterior tilt of pelvis)

2) Cramping or pressure (signs of premature labor or Braxton Hicks contractions)

3) Epigastric pain (pressured form gravid uterus may cause)

4) Round ligament pain (stretching of the ligaments by the enlarging uterus)

5) Pressure on the bladder (from weight of the enlarging uterus)

What type of pregnancy pain is related to the dilation of the cervix, stretching of the lower uterine segment, pressure on adjacent structures, and hypoxia of the uterine muscle cells during contractions?

Labor pain

What type of pregnancy pain is due to pressure of the fetal head against the pelvic floor, vagina, and perineum?

Delivery pain

T/F: Many pregnant women have chronic health conditions associated with their pain, and there is no evidence that these patients have a diminished perception of pain.

FALSE

Older adults

Why do many elderly/older patients not report their pain? (4)

1) Believe its a NORMAL part of aging

2) Do not want to be a NUISANCE

3) May lead to EXPENSIVE TESTING or HOSPITALIZATION

4) Hesitant to take pain MEDICATIONS

What are personal & social history questions that should be asked about pain?

1) Previous experience w/ pain and its effects (typical coping strategies for pain control)

2) Family concerns & cultural beliefs about pain

3) Attitude towards use of opioids, anxiolytics, and other pain medications for pain control (fear of addiction)

4) Current/Past use of illicit substance

With children, what accommodations/questions should you ask? (4)

1) Use the Childs words (example owie)

2) Ask what they tell parents

3) Ask what makes this hurt in past or feel better

4) Watch pain behaviors that parent identifies

With pregnancy, what accommodations/considerations should you be aware of? (2)

1) Discomfort associated with increasing fetal size

2) Investigate all known medical conditions/physical limitations to identify sources for persistent/acute pain

In the older population, what accommodations/considerations should you be aware of? (3)

1) Investigate all known medical conditions/physical limitations to identify sources for persistent/acute pain --> same as pregnancy

2) Use words older adult uses for pain (ex: achy) --> Like child

3) When cognitively impaired, have family member describe cues to patients expression of pain

What can temperature provide an important clue to?

Severity of patients illness

What are the 5 routes in which a temperature can be taken? Which is the most accurate?

1) Tympanic/Intra-aural (MOST ACCURATE)

2) Forehead (affected by external air temperature)

3) Oral

4) Rectal

5) Axillary

What is the normal body temperature? At what level is it considered a fever? At what value is it true hyperpyrexia (high fever)?

98.6 F

above 99 F

105 F

T/F: Men normally have a lower temperature than women.

FALSE

Women lower temperature than men

What type of fever (pyrexia) is a fluctuating baseline between normal and fever over the course of the day?

Intermittent

What type of fever (pyrexia) may come and go with temperature fluctuating, but never returning to normal levels?

Remittent

What type of fever (pyrexia) is prolonged fever with little or no change over a 24 hr period?

Continuous/Sustained

What type of fever (pyrexia) is a type of intermittent fever that re-spikes after days or weeks of normal temperature, and is common with animal bites and diseases like malaria?

Relapsing

What type of fever (pyrexia) is an intermittent or remittent fever that is considered this type only IF temperature ranges widely throughout the day, between the highest and lowest temperatures?

Hectic

Where is pulse best palpated?

Over an artery close to the surface of the body that lies over bones

What two areas will we focus on for finding pulse?

Radial & Dorsalis Pedis

What 4 things should we report when it comes to pulse?

1) Rhythm

2) Amplitude

3) Contour

4) Rate

Rhythm should be regular for pulse rate, but if an irregular rhythm is detected, what must you do?

Count for the full 60 seconds instead of counting 30 and multiplying by 2

What is the measure for how strong the force of the pulse is? What is the rating scale for this value and the normal/expected value?

Amplitude

0 = absent, not palpable

1 = diminished, barely palpable

2 = NORMAL (expected)

3 = Full, increased

4 = bounding, aneurysmal

What is the waveform, or shape of the expanding and contracting artery, with normal meaning its pliable, and abnormal meaning its non-compliant and arteries won't have normal waveform?

Contour

What is the average resting pulse rate in adults? What is the it varies generally between? How does this change in athletes?

70-80 bpm

(ranges between 60-100 bpm)

-- can be LOWER in athletes

What is a pulse rate value MORE than 100 bpm? LESS than 60 bpm?

Tachycardia

Bradycardia

How does one assess the respiratory rate of a patient?

Inspect the rise and fall of chest or excursion of abdomen

-- count number of breaths (inspiration & expiration) that occur in 1 minute (OR 30s and multiply by 2)

What is a faster than normal respiration rate? Slower than normal?

Tachypnea

Bradypnea

What is respiration rate that is affected by body's position (ex: sitting to standing)?

Orthopnea

What is the absence of breathing?

Apnea

Where is blood pressure most often measured? How must the patient be positioned?

Right arm over the brachial artery

-- Patient is SEATED

T/F: Blood pressure taken in the supine position tends to be lower than those taken in sitting position.

TRUE

What is a condition where blood pressure drops significantly upon standing form a laying/crouched/sitting position, and in worst cases may cause loss of consciousness?

Orthostatic Hypotension

How does one determine the palpable systolic pressure? (2)

1) Deflate cuff completely

2) Inflate until radial pulse is no longer palpable and note the mmHg

When you go to take the blood pressure of a patient, you will re-inflate the cuff until it is ___ - _____ mmHg above the palpable systolic blood pressure. Then, deflate the cuff slowly, about ___ - ___ mmHg per second?

20-30 mmHg

2-3 mmHg

What is the low-pitched sounds produced by the turbulence of blood flow int he artery?

Korotkoff sounds

T/F: Only the diaphragm, not the bell, of the stethoscope can be used in order to take blood pressure

FALSE

diaphragm OR bell

What indicates the systolic pressure reading during blood pressure?

Two consecutive beats

What is the point at which the initial crisp sounds become muffled during blood pressure?

Mid-diastolic (first diastolic)

What is the point at which the sounds disappear during blood pressure?

End-diastolic (second diastolic)

What is the Korotkoff sounds heard that may disappear and reappear 10-15 mmHg below the systolic pressure reading?

Auscultatory gap

What are the two blood pressure readings recorded?

First systolic & the second diastolic sounds (ex: 120/80)

NOTE: repeat the process bilaterally, it may vary by as much as 10 mmHg

What is a normal blood pressure value? Prehypertension? Stage 1 HTN? Stage 2 HTN?

Normal = <120/<80

Prehypertension = 120-139 / 80-90

Stage 1 HTN = 140-159 / 90-99

Stage 2 HTN = >160/>100

NOTE: go off highest number value, so if said the patient has a 145/88, it would be Stage 1 HTN even though its diastolic falls in the Prehypertension category

What affect does cardiac dysrhythmias have on blood pressure?

Requires taking average of several BPs

What affect does Aortic regurgitations have on blood pressure? (TQ)

May obscure DIASTOLIC reading

What affect does Venous Congestion have on blood pressure? (TQ)

LOWER than normal SYSTOLIC

HIGHER than normal DIASTOLIC

NOTE: May be pathological or due to slow/repeated cuff inflation

T/F: Blood pressure abnormalities are less common with newer valves

TRUE

When the chief complaint is pain, the _____ & ___________ may assist in the diagnosis of a paitents condition. If the pain is related to a diagnosed condition, assessment of its character and intensity is necessary for ________.

Location & Related Symptoms

PAIN CONTROL

NOTE: remember that there may be more than one cause of pain

T/F: It doesn't matter what pain scale you use from visit to visit with a patient because they all give you the same results.

FALSE

-- consistent use of a particular scale will contribute to a consistent interpretation

When using self-report pain rating scales, pain intensity may vary in different sites or different activities (ex: moving, coughing, deep breathing), so pain intensity should be linked to ______ & ______ and reassessed regularly to monitor progress for objective measures of improvement

Location & Activity

What are 4 key pain behaviors to look for/listen for?

1) Guarded (protective behavior), hands over painful area, distorted posture, irritability

2) Facial mask of pain (distorted expression)

3) Vocalizations (groaning, crying, quiet)

4) Body movements (head rocking, pacing, inability to keep hands still)

What are 5 other conditions/symptoms associated with pain?

1) Vital sign changes

2) Pallor (pale) & Diaphoresis (sweating)

3) Pupil dilation

4) Dry mouth

5) Decreased attention span & Greater confusion

The pulses of newborns are easily palpable, with rates close to ______ bpm that may occur in neonates, and the pulse decreases relativly rapidly to _______ bpm after a few hours of age?

200 bpm

120 bpm

T/F: The newborn's pulse rate is less variable than that of older infants with activities such as feeding, sleeping, and waking

FALSE

-- newborn's pulse rate is MORE variable

When measuring the respiratory rate of an infant, how long should it be counted for? What is the expected rate for neonates?

count respiratory rate for 1 minute

-- neonates vary from 40-60 breaths per minute (but up to 80 may be noted)

T/F: Babies delivered by cesarean section may have a MORE rapid respiratory rate than babies delivered vaginally.

TRUE

What is often used to perform blood pressure in infants?

Electronic sphyngomomanometer with a Doppler

What is the normal range of newborn/infant blood pressure?

60/30 -- 96/62

T/F: In infants/newborns, a sustained increase in blood pressure is almost always significant

TRUE

What pain assessment is best validated for premature infants, but appropriate for full-term neonates and infants?

Premature Infant Pain Profile (PIPP)

What pain assessment assesses preterm and full-term infant procedural pain? What value indicates pain?

Neonatal Infant Pain Scale

3+ indicates pain

What pain assessment assesses procedural and surgical pain in newborns and infants?

CRIES scale