Initial Physical Examination (Health Assesment #4)

when you do health history paper she doenst want any physical examination in paper at all, paper is strictly history

General appearance or Inspection (looking(

• Do they look healthy or ill? 

• Skin color and condition – pale, cyanotic, flushed, intact, or open wounds/lesions 

• Do they look older or younger than their stated age?

• Hygiene 

• Dress 

• Odors 

•    Body structure, including position, posture, and

•        weight to height ratio

• Body movements 

• Emotional state and behavior 

• IT IS IMPORTANT TO ASSESS FOR ANY SIGNS OF PHYSICAL OR MENTAL DISTRESS

ASSESS LEVEL OF CONSCIOUSNESS (LOC)

alert (person, place, time, situation)

lethargic (sluggish, inactive, responsd to stimuli but brief)

obtunded (disminished response to stimuli)

struporous (absense of spontanous movements, diminished repsosnivess)

cornatose (stage of deep unconsiouness for period of time)

TESTS FOR L.O.C

• Assess eye opening to presence in room 

• Assess response to name 

• Assess response to touch 

• Assess response to stimuli (shaking and yelling)

• Assess response to painful stimuli (these are done typically in the ICU or ER)

  • Nail bed pressure

  • Trapezius squeeze 

  • Pressure up into supraorbital notch

  • Sternal rub 

  • Corneal reflex – patient should react

  • Cold caloric test  – patient should turn toward stimulus 

MENTAL STATUS ASSESSMENT:  FROM THE HISTORY  YOU/WE WILL ALREADY KNOW …

a structured way for a healthcare provider to observe and describe a person's current psychological and cognitive functioning

Any medical conditions that can precipitate or mimic mental illness – thyroid disorders, adrenal insufficiency

Even the medication history can help you understand what you are seeing

Any family history of mental illness - Anxiety, depression, and schizophrenia can be genetic

You may have already assessed the patient’s sense of self, relationships, and support systems

You may have also already asked the patient how they manage stress, deal with feelings of anger, sadness

MENTAL STATUS ASSESSMENT USUALLY BEGINS WITH ORIENTATION TO:

Person (last thing to go)

• Place (2nd thing to leave)

• Time (1st thing inidvisuals loose first, what year it is?)

• Situation (3rd thing to go, what are we doing right now?)

MENTAL STATUS CONT…..  MEMORY ASSESSMENT

Short-term- repeat names of three unrelated objectives; assess 5-10 min later

Long term- already acesssing because we done history on the, askng where tehir born and family history

MENTAL STATUS CONT…  CALCULATIONS ASSESSMENT

Ask them to make change or give them a handful of change and have them figure out if they have enough money to buy a sandwich

MENTAL STATUS CONT…  COMMUNICATION ASSESSMENT CHALLENGES

Can the patient see, hear, speak, read, write – you will never know unless you ask or test the patient’s abilities

Are they able to read and follow directions?

Can they write a complete sentence?

Can they copy a clock face or intersecting shapes?

MENTAL STATUS CONT….  JUDGMENT AND ABSTRACT REASONING

• Ask the patient about what they would do in a common situation:  What would you do if you were walking through a parking lot and a car was speeding toward you? 

• Ask the patient to interpret a proverb (practice makes perfect. better late than never)

IT IS IMPORTANT TO DIFFERENTIATE CAUSES OF DISORIENTATION : dementia

progressive onset, irreversible decline

Results in loss of reason/judgement, loss of abstract thought (math/finances), comprehension, learning, performing ADLs/tasks, and use of language

IT IS IMPORTANT TO DIFFERENTIATE CAUSES OF DISORIENTATION - delirium

cute onset, reversible 

• Medical reason for it (electrolyte imbalance, UTI, elevated ammonia levels, alcohol or narcotic withdrawal, sleep deprivation

• Can occur in up to 80% of ICU patients and in up to 50% of patients over 65 

• History of dementia increases risk

-neurocongitive disorder

IT IS IMPORTANT TO DIFFERENTIATE CAUSES OF DISORIENTATION- depression

loss of interest in usual/favorite activities

• Remember … depression is NOT a normal consequence of aging

• Screen ALL patients regardless of age 

• High risk for suicide in males > 65 years old

VITAL SIGNS…..WHAT ARE THEY??

• Temperature

• Pulse

• Respirations

• Blood pressure

     TYPICALLY DONE IN THIS ORDER

TEMPERATURE

Product of normal body metabolism

Regulated by the hypothalamus

EXPECTED NORMAL TEMP RANGE: 96.4 TO 99.1

NORMAL AVERAGE:  98.6º OR 37ºC

TEMPERATURE

INVOLVES MULTIPLE REGULATORY MECHANISMS

Integumentary system

Circulatory system

Endocrine system

Central/peripheral nervous system

Musculoskeletal system through shivering

How many ways can you take a temperature?

• Oral 

• Temporal 

• Tympanic 

• Axillary (inaccurate)

• Rectal (sims pos. accurate) done unconsiouss alot

TEMPERATURE METHODS … WHICH IS BEST?

Most temperature assessment tools are not very accurate and should not be used to make clinical judgments (i.e., when cooling a patient after MI or when warming a patient with hypothermia).

Best core temperature assessment is with a pulmonary artery catheter

Next best is a rectal temperature 

Shivering can produce

4-5 times the heat produced through normal body metabolism

Neonates can’t shiver so they have special brown adipose tissue that can be broken down if more heat is needed

Also infants and the elderly have fewer

active sweat glands so they can overheat more easily

ORAL TEMPERATURE pros

• Safe, accurate

• Familiar

• Non-invasive

oral temp cons

• Caution with recent ingestion of hot or cold or recent smoking

• Not good for confused patient or a patient who is seizing

• Glass thermometer takes 3-5 minutes

TEMPORAL TEMPERATURE pros

• Non-invasive

• Core temperature

• Good in ICU or with children 

• Minimal patient contact

temporal temp cons

• Has to be done correctly to ensure accuracy

• Diaphoresis can affect reading 

TYMPANIC TEMPERATURE pros

• Quick

• Non-invasive

tympanic temp cons

• Must get the probe into the ear canal just right

  • Have to pull pinnae up and back in an adult

  • Have to pull pinnae down and back in a child or infant

• Presence of cerumen could impact results 

• Should not use for a patient experiencing ear pain or drainage from the ear

AXILLARY TEMPERATURE pros

• Easiest method for infants and children

• Non-invasive

AXILLARY TEMPERATURE cons

• Not recommended method for adults 

• Questionable accuracy

• Glass thermometer takes 3 minutes

• Must place carefully, make sure direct contact on the skin

RECTAL TEMPERATURE pro

Accurate core temperature 

RECTAL TEMPERATURE cons

• Most invasive

• Requires positioning of patient on left side (left Sims’ position)

• Have to use water-based lubricant 

• Insert 1 to 1.5 inches, angle up toward patient umbilicus 

• Secure/hold the thermometer in place the whole time 

• SHOULD NOT use on infants – could perforate rectum/intestine

• Not good for confused/combative patient for the same reason

RECTAL TEMPERATURE

• Contraindicated in patients with: 

  • low white blood cell or platelet count (increased risk for infection or bleeding)

  • anticoagulant therapy (heparin or warfarin) 

  • history of rectal surgery 

  • cardiac or neuro patients (due to risk of vagal stimulation)

  • diarrhea/fecal impaction or hemorrhoids.

an axillary temperature reading will register

• 1.0 ºF or 0.5 ºC less than an oral temperature reading would be at that same moment

• A rectal temperature reading will register ~ 1.0 ºF or 0.5 ºC more than an oral temperature reading would be at that same moment

NORMAL FLUCTUATIONS IN TEMPERATURE:

Temperature is higher in the late afternoon or evening and can vary 0.5 – 1.5 ºF

During ovulation and lasting through menses women’s temperature can bump up 0.5 to 1.0  ºF – related to the hormone progesterone

Elderly patients often have a slower

basal metabolic rate and therefore may have a normal core body temperature as low as 96ºF

• Therefore, an elderly patient may have an infection and still have a temperature reading within the normal range

REASONS FOR AN ELEVATED TEMPERATURE INCLUDE:

• Infection

• Hypothalamus problem

• Overactive thyroid 

• Environmental conditions or overexposure

• Over-exertion

• Medications and illegal drugs

• Overdressing

WHAT TO DO IF YOUR PATIENT HAS AN ELEVATED TEMPERATURE?

What is the patient’s baseline? 

Was it worse at noon than it is now at 4pm?

Is this something new?
How does the patient look/feel?

How are the rest of the vitals?

Is there a reason for the fever?

Notify your instructor, your RN, and ultimately the primary care provider of all of your findings

REASONS FOR A LOW TEMPERATURE INCLUDE:

• Severe infection (sepsis)

• Hypothalamus problem

• Underactive thyroid

• Slowed metabolism in the elderly 

• Immobility

• Sleep – can drop as low as 95º F

• Environmental conditions or overexposure

• Medications

• Underdressing

WHAT TO DO IF YOUR PATIENT HAS A LOW TEMPERATURE?

Go through the same questions in your mind: 

• Baseline? 

• New or chronic? 

• How are the rest of the vitals? 

• How does the patient look/feel?

• What do you think is going on?

• Notify the primary care provider of your findings

YOU WILL NEED TO DO A TEMPERATURE CONVERSION FOR THE TEST:Fahrenheit to Celsius

• Formula:  (Fahrenheit temperature – 32) x 5, divided by 9

• Example:  John has a temperature of 102°F.  This would equal ____________ Celsius 

• 102 – 32 = 70

• 70 x 5 = 350 

• 350 divided by 9 = 38.88 or 38.9°C

YOU WILL NEED TO DO A TEMPERATURE CONVERSION FOR THE TEST-Celsius to Fahrenheit

• Formula:  (Celsius temperature x 9) divided by 5,     then add 32

• Example:  The nurse tells the mother of baby Jenny the temperature reading was 39.2 °C.  The mom says, “that doesn’t sound right.  Are you sure?”  The nurse quickly converts the temperature to ___________ Fahrenheit.

• 39.2 x 9 = 352.8 

• 352.8 divided by 5 = 70.56 

• 70.56 + 32 = 102.56 or  102.6°F 

TIP ON HOW TO QUICKLY CHECK YOUR MATH

• For every 0.5 degree incremental increase in Celsius temperature the Fahrenheit temperature will increase by 0.9 degrees

• For example:

        37.0ºC =  98.6ºF

          37.5ºC =  99.5ºF

        38.0ºC = 100.4ºF

        38.5ºC = 101.3ºF                CONSIDERED A FEVER OR FEBRILE

        39.0ºC = 102.2ºF