Health Assessment -- (EXAM I) Assessment Techniques, Vital Signs & Pain

basic four (4) techniques of physical examination

- inspection

- palpation

- percussion

- auscultation

inspection

- inspection ALWAYS comes first

- general inspection: observing the patient from front to back and from each side, checking for symmetry of body parts, obvious injuries or abnormalities, and overall appearance

- systematic inspection: head-to-toe inspection

- focused inspection: check the affected body system

palpation technique

- use touch to examine

- used to find out texture, location of organ, learn of the patient's pain sensation

- always palpate AFTER inspection and auscultation

palpation

may increase the patient's intestinal activity, causing misleading auscultation findings such as increased bowel sounds; performing inspection and auscultation of the abdomen prior to palpation will assist in obtaining accurate findings

palmar surface of the fingers and finger pads

used to determine position, texture, size, consistency fluid, crepitus, a form of a mass, or structure (i.e. use fingerpads for pulsations; fingertips for eliciting reflexes, such as the abdominal reflex)

dorsal surface of the hand

used to determine temperature (i.e. feeling skin temp. and moisture)

ulnar surfaces of hand and fingers

used to determine vibration; can detect thrills

entire hand

used to determine muscle strength

percussion

- uses sound waves to gather information about the information about the density of tissue

- provide information about tenderness or the amount of body fluid within a body cavity

- sound waves arise from vibrations and produce percussion tones

tympanic (percussion tone)

- e.g. gastric bubble

hyperresonant (percussion tone)

e.g. emphysematous lungs

resonant (percussion tone)

e.g. healthy lung tissue

dull (percussion tone)

e.g. over liver

flat (percussion tone)

e.g. over muscle and bones

auscultation

stethoscope does not magnify sound, but it blocks out extraneous sounds

stethoscope

- diaphragm: flat edge, high pitched sounds

- bell: soft pitched sounds (must be used softly)

basic auscultation principles

- eliminate extra noise

- never listen through a patient's gown or clothing

- place the stethoscope on the naked skin (scope to skin)

distinguish auscultation sounds

- intensity refers to the loudness of a sound (soft, loud, or medium)

- pitch is the frequency of sound waves generated per second

- duration is the length the sound is heard

- quality refers to the description of the sound

general approach to examination

consider your emotional state and that of the person being examined (how you talk and treat the patient)

examination on the ill person

be unhurried and gentle

vital signs

- temperature

- pulse or heart rate

- respirations

- blood pressure

- pulse oximetry

- PAIN is often referred to as the fifth vital sign

temperature

- regulated by the hypothalamus

- maintain between 97.2 to 100 F or 36.2 to 37.7 C

C = F - 32 x 5/9

- old adults can have lower temperature

menstruation cycle in women in relation to temperature

progesterone secretion, occurring with ovulation at mid cycle (causes rise in temperature)

Normal temp. readings

- oral

- oral sublingual

- rectal

- normal oral temp in a resting person is 37 C (98.6 F)

Body areas to measure temp.

- oral

- tympanic

- axillary

- temporal

- rectal

factors that can affect body temp.

- release of prostaglandins (inflammation and injury can increase temp)

- shivering

- perspiration

other factors that can affect body temp.

- infection

- damage to the hypothalamus

- vasoconstriction

- vasodilation

oral temperature

- delay oral temperatures by 30 mins after drinking a hot or cold beverage or smoking

rectal temperature

- wear gloves and insert lubricated

tympanic membrane temperature

- minimal chance of cross-contamination

- advantages: speed, convenience, safety, reduced risk for injury and infection and noninvasiveness

temporal artery thermometer

- takes multiple readings and produces average results

pulse

- assessing the pulse gives an indication of the patient's heart function

- a rhythmical throbbing of the arteries as blood is propelled through them, typically as felt in the wrists or neck

Locations of the sites of the pulses

- carotid

- brachial

- radial

- femoral

- popliteal

- posterior tibial

- dorsalis pedis

pulse: palpation techniques

- using pads of the middle three fingers (avoid thumb)

- if rhythm is regular count number of beats in 30 seconds and multiply by 2

- for irregular pulse count for full minute

heart rate

- healthy adult is 70 beats per minute (ranges from 60 to 100 beats per minute)

- a heart rate < 60bpm is bradycardia

- a heart rate > 100bpm is tachycardia

pulse: characteristics

- amplitude of the pulse: indicates strength of the ventricular contractions

- pulse contour or configuration is the amount of force of blood ejected

- pulse rhythm is the pattern of beats and is characterized as regular or irregular

heart/pulse rhythm

sinus dysrhythmia: one irregularity commonly found in children and young adults

heart force: strength/amplitude of the pulse

- weak, thready pulse reflects a decreased stroke

- full, bounding pulse denotes increased stroke volume

respirations

- no dyspnea, or difficulty breathing

- rate between 12 to 20 breaths per minute is normal

- bradypnea: less than 12

- tachypnea: more than 20

Blood Pressure

- force of blood pushing against side of its container vessel wall

- systolic pressure: maximum pressure felt on artery during left ventricular contraction, or systole

- diastolic pressure: elastic recoil, or resting, pressure that blood exerts constantly between each contraction

Pulse pressure

difference between systolic and diastolic (reflects stroke volume)

Blood pressure ranges

- 90 and 119 mmHg (systolic normal)

- 60 and 79 mmHg (diastolic normal)

blood pressure factors

<90 mmHg systolic or <60 mmHg diastolic (hypotension)

Orthostatic hypotension

- occurs when the systolic pressure decreases by more than 20 mmHg or diastolic pressure decreases by more than 10 mmHg with a position change from a lying or sitting position

Measuring BP

- cuff length: should cover 80% to 100% arm circumference of the patient

cuff width: 40% of the arm circumference of the patient

effect of cuff size on BP measurement

- small cuff: high blood pressure

- cuff that is too large/wide: reads pressure as too low

auscultory gap

- the silent gap is a period of diminished or absent Korotkoff sounds during the blood pressure measurement

Common Errors in BP measurement

Have person rest supine for 2 to 3 mins, take baseline readings of pulse and BP and then repeat with person sitting and standing

BP in older adults

tends to be higher

oxygen saturation

oxygen saturation is a measurement that tells the nurse how much oxygen is in the blood as a % of the maximum it can carry

normal SpO2

between 95% to 98% is normal for a healthy person with no lung disease and no anemia

development of pathologic pain

two main pathways:

- nociceptive and/or neuropathic processing

nociceptors

specialized nerve endings designed to detect painful sensations (a & c fibers)

A fibers

myelinated and larger in diameter

C fibers

unmyelinated and smaller and transmit signal slowly

nociception phases

phase I: transduction (releases variety of chemical mediators)

phase ii: transmission (pain impulse moves from the level of spinal cord to brain

phase iii: perception (consciousness of pain signal)

phase iv: modulation (built-in mechanism to slow down the process or stop of a painful stimulus

neuropathic pain

Conditions that may lead to development (Diabetes mellitus, herpes zoster (shingles), HIV/AIDS, sciatica, trigeminal neuralgia, phantom limb pain, and/orchemotherpy

sources of pain

- visceral: originates from large interior organs

- deep somatic pains comes from blood vessels, joints, tendons, muscles and bones

- cutaneous pain: derived from skin surface

- referred pain: felt at a particular site but originates from a different location

duration of pain

- acute

- chronic

developmental competence: the aging adult

- Most common pain-producing conditions for aging adults include: pathologies such as arthritis, osteoarthritis, osteoporosis,peripheral vascular disease, cancer, peripheralneuropathies, angina, and chronic constipation

- Dementia does not impact ability to feel pain, but it does impact person's ability to effectively use self-report tools

developmental competence: PAINAD scale

evaluates:

- breathing

- vocalization

- facial expression

- body language

- consolability

peripheral neuropathy

symmetric damage to peripheral nerves resulting in pain without stimulation

(numbness, tingling, shooting pain)

chemotherapy-induced peripheral neuropathy

occurs during or after chemotherapy treatment (numbness, burning, shooting pain)