Tools of PA

1. inspection

2. palpation

3. percussion

4. auscultation

what are the 4 tools/techniques of physical assessment?

inspection

• begins the moment you meet the pt & continues throughout the exam

• use the pt as his/her own control

color & rashes

what does natural light help you see on inspection?

contours & irregularities

what does tangential light help you see on inspection?

age, sexual development, level of consciousness, skin, facial features, signs of distress

what should you be looking at when inspecting physical appearance?

stature, nutrition, symmetry, posture, position, obvious physical deformities, body build/BMI

what should you be looking at when inspecting body structure?

increased, 23

Asians have ________ % body fat & overweight starts at ____ BMI

increased

females have _______ % body fat

increased, low

the elderly have _______ % body fat w/ ____ muscle mass

over

BMI _____-estimates the % body fat of the very muscular

25

the lowest risk BMI is ___

abdominal circumference

• measurement in obesity which may indicate increased risk of comorbidities (insulin resistance, metabolic syndrome, NIDDM, HTN, dyslipidemias)

• measured at the top of the iliac crest

1:1

what is the waist-to-hip ratio for men?

>0.6:1

what is the waist-to-hip ratio for women?

gait, range of motion, involuntary movements

what should you be looking at when inspecting mobility?

facial expression, mood & affect, speech, dress, personal hygiene, frank odors

what should you be looking at when inspecting behavior?

T

T/F: documentation of general survey is required for Medicare compliance & most insurance billing

1. general state of health, affect

2. height, development, & nourishment

3. apparent distress, posture, expression

what should be included in documentation of the general survey that is required for Medicare compliance?

pulsations, vibrations, assessment of size, texture, temperature, mobility, tenderness

what should you feel for when palpating?

fingertips/pads

what part of the hand is best when palpating to distinguish texture & shape?

dorsal surface

what part of the hand is best when palpating for temperature variations?

ulnar surface

what part of the hand is best when palpating for vibrations?

thumb w/ index finger

what part of the hand is best when palpating for enlargements, grasping tissue, or feeling hair texture?

1. depress 0.5-0.75in

2. use lightest touch possible

3. close eyes or look away to concentrate & enhance perception

describe how to lightly palpate

percussion

cause & effect relationship, the impact of one object against another, can be direct or indirect

direct percussion

• used primarily to assess or elicit pain

• can be used to provoke reflexes

auscultation

• to listen

• body sounds: heart, lungs, abdomen, blood vessels, movement of air, fluid, friction rubs

• either direct (ear to body) or indirect (augmented stethoscope)

bell

• part of the stethoscope used to detect or enhance faint or low frequency sounds, murmurs, & bruits

• smaller than the diaphragm

• rest lightly on the skin surface without any pressure

flat diaphragm

• part of the stethoscope used to listen to higher pitched sounds

• comes in different diameters for adult & pediatric pts

• press firmly on the skin to create a seal

corrugated diaphragm

• stethoscope diaphragm w/ increased surface area

• amplifies heart sounds & murmurs

  • especially in pts who have emphysema, obesity, or thickened chest walls

• allows for detection of the faintest low frequency gallops, murmurs, & bruits

• can aid those who have minor hearing loss

• must use light pressure

1. body temperature

2. heart rate/pulse rate

3. respiratory rate

4. blood pressure

5. oxygen saturation/pulse ox

what are the vital signs?

1. signs of inflammation, cellulitis

2. presence of lymphadenopathy

3. concurrent systemic sx

when is it indicated to take a patient’s temperature?

T

T/F: if an immune disorder is known/suspected, an elevated temp may be the only warning sign

97.6-99.6

what is the normal range for an oral temperature?

98.6-100.6

what is the normal range for a rectal temperature?

98.2-100.2

what is the normal range for a core/tympanic temperature?

~1deg below oral

what is the normal range for an axillary temperature?

type of thermometer, technique/placement, normal diurnal variation, environmental temperature, food/drink, smoking, menstrual cycle, age, activity

what things can influence a temperature?

1-1.5

what is the normal diurnal variation in temperature?

early morning

when is temperature the lowest?

late afternoon - early evening

when is temperature the highest?

0.5-1

temperature is ____deg higher from ovulation to menses

97.2

what is the average temperature for geriatrics?

15min

to minimize errors in temperature readings, wait to take until ____ after a pt has just had very hot/cold foods or liquids

10-15min

to minimize errors in temperature readings, wait to take until ____ after a pt has just smoked

sustained

fever that varies little from day to day <0.5deg F

intermittent

fever that returns to normal b/t exacerbations (Hodgkin’s, malaria)

remittent

fever that varies at least 0.5deg daily & do not return to normal (typhoid, some forms of chronic TB)

relapsing

fever that may last for days interspersed w/ equally long afebrile periods (Dengue fever, Lyme, Hodgkin’s, Typhoid, or rat-bite fever)

99-100.4

what is the range for a low grade fever if temperature is taken orally?

100.5-104

what is the range for a moderate fever if temperature is taken orally?

>104

what is the range for a high fever if temperature is taken orally?

hyperpyrexia

core temp above 105deg, medical emergence, risk for febrile seizure

93.2-95

what is the temperature range for mild hypothermia?

86-93.4

what is the temperature range for moderate hypothermia?

below 86

what is the temperature range for severe hypothermia?

palpate w/ pads of 1st 3 fingers, not the thumb, & apply pressure gradually until the strongest pulsation is felt & observe

describe the method of taking the radial pulse

brachial, carotid, popliteal, pedal, femoral, axillary, posterior tibial, temporal

what are other places to feel the pulse besides radial?

60-100

what is a normal heart rate?

T

T/F: if the heart rate is regular, then just count for 30sec and multiply by 2

F

T/F: if the pulse is irregular you can still just count for 30sec and multiply it by 2 to get the heart rate

bradycardia

pulse is less than 60bpm

tachycardia

pulse is greater than 100bpm

medications, athletic status, age, activity, respirations

what are some influences on pulse rate?

12-20/min

what is the normal rate of respirations in an adult?

at least 20/min

what is the normal rate of respirations in a child?

abdominal

when the pt is supine, respiration movements are more pronounced in the _____ region

thoracic

when the pt is sitting, respiration movements are more pronounced in the ______ region

age, gender, race, weight, exercise, medications, lifestyle, equipment conditions, operator error

what things can influence blood pressure?

pt is asymptomatic, systolic BP >100, and diastolic BP >60 w/ the pt in all positions

you should take BP readings on a syncope pt every 5min until:

auscultatory gap

• in cases of moderate - severe HTN

• artifact

• silent interval b/t the systolic & diastolic BP

• ~20-30mmHg

determine the systolic pressure palpation then inflate an additional 30mmHg or inflate to 230mmHg before measurement

how do you remedy the auscultatory gap?

T

T/F: the auscultatory gap rarely occurs above 230mmHg

oxygen saturation

• measured by a pulse oximeter

• measures amount of light absorbed by hemoglobin in RBCs of the blood being pulsed

96-100%

what is the normal arterial range for pulse ox?

decreased peripheral pulses, peripheral cyanosis, decreased body/extremity temperature, decreased BP, excessive movement or tremor of digit, presence of dark nail polish or bruising under the nail, lighting

what things can influence oxygen saturation readings?

anemia, peripheral vascular disease, venous stasis, COPD

what diseases can affect pulse ox readings?