Initial Physical Exam

Initial Physical Examination and General Survey

  • Purpose and Overview: Look at patient and what do you see?

    • The initial physical examination begins with a general survey, assessing non-verbal signs of distress, level of consciousness (LOC), mental status, and body temperature.

    • General inspection involves observing the patient immediately upon contact to gather comprehensive observational data.

  • General Appearance and Inspection Parameters:

    • Overall Health Status: Assessment of whether the patient appears healthy or ill.

    • Skin Color and Condition: Evaluation for pallor, cyanosis, flushing, intactness, or the presence of open wounds and lesions.

    • Apparent Age: Comparison of whether the patient looks older or younger than their stated age.

    • Hygiene and Dress: Assessment of cleanliness, grooming, and appropriateness of dress for the environment.

    • Odors: Detection of any distinct physical or breath odors.

    • Body Structure: Evaluation of body position, posture, and weight-to-height ratio.

    • Body Movements: Assessment of mobility, gait, involuntary movements, or motor symmetry.

    • Emotional State and Behavior: Observation of mood, affect, responsiveness, and demeanor.

    • Distress Assessment: Crucial initial requirement to screen immediately for any acute physical or mental distress.

Level of Consciousness (LOC) Assessment

  • Continuum of Consciousness Levels:

    • Alert: Fully awake, oriented, and responsive to normal environmental stimuli.

    • Lethargic: Drowsy or sluggish, but easily aroused by touch or voice.

    • Obtunded: Difficult to arouse, requires constant stimulation to maintain attention, and remains confused when awake.

    • Stuporous: Requires vigorous, repeated, or painful stimuli to produce a minimal motor or verbal response.

    • Comatose: Completely unarousable, with no purposeful response to internal or external stimuli.

    • Early Warning Indicators: Restlessness, agitation, and confusion serve as key early signs of physiological or neurological distress.

  • Standardized Diagnostic Sequence and Tests for LOC:

    • Eye Opening: Assess spontaneous eye opening upon entry into the room.

    • Response to Name: Assess verbal response and eye contact when calling the patient's name.

    • Response to Touch: Assess physical arousal when touching the patient's shoulder or hand.

    • Response to Stimuli: Assess reaction to elevated physical and verbal stimuli, such as gentle shaking paired with loud shouting.

    • Response to Painful Stimuli: Typically performed in critical care settings such as the Intensive Care Unit (ICU) or Emergency Room (ER):

      • Nail Bed Pressure: Applying direct pressure to the nail bed.

      • Trapezius Squeeze: Firmly pinching the trapezius muscle.

      • Supraorbital Notch Pressure: Applying upward pressure into the notch above the eye socket.

      • Sternal Rub: Applying firm downward pressure with knuckles to the sternum.

      • Corneal Reflex: Touching the cornea; normal response is a protective reaction/blink.

      • Cold Caloric Test: Instilling cold water into the ear canal; a normal response involves the eyes turning toward the stimulus.

Comprehensive Mental Status Assessment

  • Historical Context and Baseline Factors:

    • Medical Conditions: History of underlying medical conditions that precipitate or mimic mental illness, such as thyroid disorders or adrenal insufficiency.

    • Medication History: Thorough review of prescribed, over-the-counter, or recreational drugs to contextualize cognitive and behavioral presentations.

    • Family History: Screening for genetic psychiatric conditions, including anxiety, depression, and schizophrenia.

    • Psychosocial Background: Evaluation of pre-existing parameters including sense of self, interpersonal relationships, and support systems.

    • Coping Mechanisms: Patient self-reports regarding how they manage stress, anger, and sadness.

  • Clinical Assessment Domains:

    • Orientation: Baseline evaluation assessing four standard dimensions:

    • Person: Knowledge of own identity.

    • Place: Awareness of current physical location.

    • Time: Recognition of date, day, season, or year.

    • Situation: Understanding of why they are being evaluated or hospitalized.

    • Memory Assessment:

    • Short-Term Memory: Ability to recall recent events or temporary information.

    • Long-Term Memory: Ability to recall past historical events, dates, or remote personal information.

    • Calculations Assessment:

    • Direct practical testing, such as asking the patient to make change or presenting them with a handful of coins to determine if they have enough money to buy a sandwich.

    • Communication Challenges and Testing:

    • Evaluating specific sensory and motor capacities: seeing, hearing, speaking, reading, and writing.

    • Ability to read and follow written directions.

    • Ability to write a complete sentence.

    • Ability to copy visual spatial designs, such as drawing a clock face or intersecting geometric shapes.

    • Judgment and Abstract Reasoning:

    • Judgment Testing: Asking how the patient would react in a practical scenario (e.g., asking what they would do if walking through a parking lot and a car was speeding directly toward them).

    • Abstract Reasoning Testing: Asking the patient to interpret a common proverb.

Differential Diagnosis for Disorientation

  • Dementia:

    • Onset and Course: Progressive onset with irreversible cognitive decline.

    • Clinical Manifestations: Loss of reason and judgment, impaired abstract thought (financial management and calculations), impaired comprehension, reduced ability to learn new information, difficulty performing Activities of Daily Living (ADLs) or routine tasks, and loss of language skills.

  • Delirium:

    • Onset and Course: Acute onset, transient, and clinically reversible.

    • Etiology: Triggered by underlying medical conditions, such as electrolyte imbalances, Urinary Tract Infections (UTIs), elevated serum ammonia levels, alcohol or narcotic withdrawal, or severe sleep deprivation.

    • Prevalence and Risk Factors: Occurs in up to 80%80\% of ICU patients and up to 50%50\% of hospitalized patients over 65 years65\, \text{years} of age. A pre-existing history of dementia significantly increases the risk of developing delirium.

      • Elderly taking opioids post surgery, kidneys stop filtering and their is a build up of medication

      • Can get better with 24 to 48 hrs but continue to improve for weeks

  • Depression:

    • Clinical Presentation: Marked loss of interest in usual or favorite activities.

    • Age Considerations: Depression is NOT a normal consequence of aging; screening must be conducted for all patients regardless of age.

    • Demographic Risk: Males greater than 65 years old65\, \text{years old} represent a high-risk group for suicide.

Vital Signs Sequence and Principles

  • Core Components:

    • Temperature

    • Pulse

    • Respirations

    • Blood Pressure

  • Standard Administrative Order: Vital sign assessments are typically executed in the precise order: Temperature →\rightarrow Pulse →\rightarrow Respirations →\rightarrow Blood Pressure.

Body Temperature Regulation and Physiology

  • Thermoregulatory Physiology:

    • Body temperature is the direct product of normal cellular metabolism.

    • Central regulation is controlled by the hypothalamus.

    • Normal Parameters:

      • Expected normal temperature range: 96.4∘F to 99.1∘F96.4^\circ\text{F}\text{ to }99.1^\circ\text{F}.

      • Normal average temperature: 98.6∘F98.6^\circ\text{F} or 37∘C37^\circ\text{C}.

  • Integrated Regulatory Systems:

    • Integumentary system

    • Circulatory system

    • Endocrine system

    • Central and peripheral nervous systems

    • Musculoskeletal system (via involuntary shivering)

  • Special Physiological Mechanisms:

    • Shivering generates 4 to 5 times4\text{ to }5\text{ times} the heat produced by normal baseline metabolic activity.

    • Neonates are unable to shiver; they rely on specialized brown adipose tissue (brown fat) which breaks down metabolically to generate thermal energy.

    • Infants and elderly populations possess fewer active sweat glands, making them overheat more easily.

Temperature Measurement Routes and Methods

  • Clinical Measurement Routes:

    • Pulmonary Artery Catheter: Provides the ultimate gold standard assessment for true body core temperature.

    • Oral Route:

      • Pros: Safe, accurate, familiar to patients, non-invasive.

      • Cons: Influenced by recent ingestion of hot or cold substances or recent smoking; contraindicated in confused or actively seizing patients; glass thermometers require 3 to 5 minutes3\text{ to }5\, \text{minutes} .

    • Temporal Route:

      • Pros: Non-invasive, reflects core body temperature, highly effective in pediatric populations and ICU settings, minimal physical contact.

      • Cons: Technique-sensitive; diaphoresis (excessive sweating) impairs reading accuracy.

    • Tympanic Route:

      • Pros: Quick, non-invasive.

      • Cons: Requires precise probe insertion into ear canal; requires physical ear manipulation (pull pinna up and back for adults; pull pinna down and back for infants and children); impacted by heavy cerumen build-up; contraindicated if patient presents with active ear pain or ear drainage.

    • Axillary Route:

      • Pros: Non-invasive, easiest method for infants and young children.

      • Cons: Not recommended for adults; questionable overall accuracy; glass thermometers require 3 minutes3\, \text{minutes}; requires precise direct placement against bare skin.

    • Rectal Route:

      • Pros: Highly accurate core temperature reading; second best core measurement after pulmonary artery catheters.

      • Cons: Most invasive; requires Left Sims' position; necessitates water-based lubricant; insert 1 to 1.5 inches1\text{ to }1.5\, \text{inches} angled toward the patient's umbilicus; must be continuously held in place; contraindicated in infants due to risk of rectal or intestinal perforation; unsafe for combative or confused patients.

      • Specific Medical Contraindications: Low white blood cell (WBC) count or low platelet count (elevated infection/bleeding risk); active anticoagulant therapy (heparin, warfarin); history of rectal surgery; cardiac or neuro conditions (risk of vagal stimulation); severe diarrhea, fecal impaction, or hemorrhoids.

    • Diagnostic Limitations: Most standard non-invasive temperature assessment tools are not very accurate and should not be used to make critical clinical judgments (e.g., cooling a patient post-myocardial infarction or warming a patient with hypothermia).

Special Clinical Considerations and Temperature Variations

  • Relative Route Variations:

    • Axillary temperature registers approximately 1.0∘F1.0^\circ\text{F} or 0.5∘C0.5^\circ\text{C} lower than an oral temperature reading taken at the exact same moment.

    • Rectal temperature registers approximately 1.0∘F1.0^\circ\text{F} or 0.5∘C0.5^\circ\text{C} higher than an oral temperature reading taken at the exact same moment.

  • Normal Physiological Fluctuations:

    • Hormonal Factors: During ovulation and continuing through menses, elevated progesterone levels elevate body temperature by 0.5 to 1.0∘F0.5\text{ to }1.0^\circ\text{F}.

    • Diurnal Variations: Temperatures peak in the late afternoon and early evening, fluctuating between 0.5 to 1.5∘F0.5\text{ to }1.5^\circ\text{F} throughout the day.

    • Geriatric Considerations: Elderly individuals often present with a slower basal metabolic rate, yielding normal core baseline temperatures as low as 96∘F96^\circ\text{F}. Consequently, an elderly patient with a severe active infection may register a temperature reading that falls completely within the standard normal range.

Temperature Extremes: Causes and Nursing Interventions

  • Hyperthermia (Elevated Temperature / Fever):

    • Etiologies: Infection, hypothalamic lesions/dysfunction, hyperthyroidism, extreme environmental exposure, excessive physical exertion, pharmacological agents or illegal drugs, and overdressing.

    • Clinical Nursing Actions: Determine baseline values; track temporal progression (e.g., comparison of 12:00 PM vs 4:00 PM values); assess if the change is acute; evaluate subjective patient feelings and physical presentation; review remaining vital signs; investigate potential root causes; systematically notify clinical instructors, primary registered nurses, and primary care providers.

  • Hypothermia (Low Temperature):

    • Etiologies: Severe overwhelming systemic infection (sepsis), hypothalamic dysfunction, hypothyroidism, age-related metabolic slowing in elderly individuals, prolonged immobility, and normal sleep states (where temperature can drop to 95∘F95^\circ\text{F}).

    • Clinical Nursing Actions: Evaluate baseline trends; distinguish acute vs chronic presentation; re-evaluate complete vital sign profile; evaluate clinical presentation; determine potential underlying pathophysiology; immediately report findings to the primary care provider.

What to do if your patient has an elevated temp

  • What is baseline

  • Was it worse at noon than it is at 4pm

  • Is this new

  • How does the patient look feel

  • How are the other vitals

  • Is there a reason for fever


Mathematical Temperature Conversions and Calculations

  • Conversion Formulas:

    • Fahrenheit to Celsius Formula:     Celsius=(Fahrenheit−32)×59\text{Celsius} = \frac{(\text{Fahrenheit} - 32) \times 5}{9}

    • Celsius to Fahrenheit Formula:     Fahrenheit=Celsius×95+32\text{Fahrenheit} = \frac{\text{Celsius} \times 9}{5} + 32

  • Calculation Examples:

    • Fahrenheit to Celsius Example:

    • Given a temperature of 102∘F102^\circ\text{F}, convert to Celsius:

    • 102−32=70102 - 32 = 70

    • 70×5=35070 \times 5 = 350

    • 3509=38.88∘C≈38.9∘C\frac{350}{9} = 38.88^\circ\text{C} \approx 38.9^\circ\text{C}

    • Celsius to Fahrenheit Example:

    • Given a temperature of 39.2∘C39.2^\circ\text{C}, convert to Fahrenheit:

    • 39.2×9=352.839.2 \times 9 = 352.8

    • 352.85=70.56\frac{352.8}{5} = 70.56

    • 70.56+32=102.56∘F≈102.6∘F70.56 + 32 = 102.56^\circ\text{F} \approx 102.6^\circ\text{F}

  • Mathematical Check Rule and Febrile Equivalencies:

    • For every 0.5∘C0.5^\circ\text{C} incremental increase in Celsius, Fahrenheit increases by 0.9∘F0.9^\circ\text{F}.

    • Equivalency Table:

    • 37.0∘C=98.6∘F37.0^\circ\text{C} = 98.6^\circ\text{F} (Normal Average)

    • 37.5∘C=99.5∘F37.5^\circ\text{C} = 99.5^\circ\text{F}

    • 38.0∘C=100.4∘F38.0^\circ\text{C} = 100.4^\circ\text{F}

    • 38.5∘C=101.3∘F38.5^\circ\text{C} = 101.3^\circ\text{F} (Considered a fever or febrile state)

    • 39.0∘C=102.2∘F39.0^\circ\text{C} = 102.2^\circ\text{F}