Assessment Techniques & the Clinical Setting

JarvisChapter 8

Learning Outcomes1. Demonstrate the use of inspection, palpation,

percussion, and auscultation during a physical examination.

2. Discuss appropriate infection control measures used to prevent spread of infection.

3. Know key terms.

Key Terms Auscultation

Bell

Diaphragm

Doppler

Inspection

Nosocomial infection

Ophthalmoscope

Otoscope

Palpation

Percussion

Standard precautions

Stethoscope

Transmission-based precautions

Skills for Physical Examination

Inspection: what you see. Observe your patient in a systematic, deliberate manner.

Always comes first. Starts with the general survey. Need good lighting & adequate exposure of

patient. Assess for symmetry between right & left sides of

the body. May need certain instruments:

Otoscope: shines light into the ear canal & on to the tympanic membrane

Ophthalmoscope: illuminates the internal eye structures.

Skills for Physical Examination (cont’d)

Palpation: what you feel with your fingertips & hands (e.g., temperature, moisture, swelling, pulsation, rigidity, crepitation, presence of lumps, presence of pain or tenderness).

Use dorsa (back) of hands & fingers to assess skin temperature (skin is thinner than on palms)

Use finger tips to assess skin texture, swelling, pulsation, presence of lumps

Identify tender areas, palpate these areas last Start with light palpation to, progress to deep palpation if

necessary for organs or mass deeper within a body cavity (e.g., lower abdominal area)

Skills for Physical Examination (cont’d)

Percussion: tapping the patient’s skin with short, sharp strokes to assess underlying structures. Used most frequently to assess the thorax & abdomen.

Direct percussion: striking hand contacts the body (e.g., tapping the patient’s sinus areas)

Indirect percussion: most often used – striking hand contacts the stationary hand fixed on the patient’s skin (e.g., tapping the flank area to assess for kidney pain/tenderness)

Skills for Physical Examination (cont’d)

Auscultation: listening to sounds produced by the body (speech, difficult breathing, coughing) and by using a stethoscope (heart, lungs, blood vessels, abdomen)

Stethoscope: need quiet room; listen for the presence or absence of a sound & the quality of sound heard. Bell: best for soft, low-pitched sounds (e.g., heart

murmurs). Hold lightly against the skin. Diaphragm: used most often; best for high-pitched

sounds (e.g., respirations, bowel, normal heart sounds). Hold firmly against the skin.

Auscultation (cont’d)

Clean bell &/or diaphragm with alcohol between patients to avoid spreading germs.

Warm, quiet room. Never listen through a gown – reach under

the gown with your stethoscope to listen. Once you know what normal sounds the

body makes, you will then be able to identify abnormal sounds.

Infection Control Measures Have a “clean” area for unused equipment

& a “used/dirty” area for equipment after using it.

#1 WASH YOUR HANDS FOR 10-15 SEC Before & after physical contact with each patient In the patient’s presence After contact with body fluids (e.g., blood, wound

drainage, saliva, urine, stools). Wear gloves when potential exists for contact with body fluids.

After touching equipment contaminated with body fluids.

After removing gloves.

Standard Precautions

CDC establishes guidelines for decreasing transmission of bloodborne & other infections in the hospitals.

Standard Precautions (Table 8.2, p. 121) Used with ALL patients regardless of their risk or

infection status. Designed to reduce the risk of transmission of germs

from both known & unknown sources Apply to: (1) blood; (2) all body fluids, secretions, &

excretions (except sweat); (3) nonintact skin; & (4) mucous membranes.

Transmission-Based Precautions

Used for patients with proven or suspected transmissible infections.

Used in addition to Standard Precautions to stop transmission in hospitals

3 types: (may be used alone or in combination) Airborne (e.g., TB) Droplet (e.g., pneumonia) Contact (e.g., Herpes zoster lesions)

General Approach to PE

Start with nonthreatening actions (ht, wt, vital signs) Use a head-to-toe approach Explain each step & how the patient can help Encourage the patient to ask questions Arrange sequence of physical examination to allow as few

position changes as possible. Allow rest periods if needed. When finished, ensure that patient is comfortable, bed is

in low position, side rails are up, and call bell is within reach.

For patients in distress, focus on the body areas appropriate to the problem, collecting a mini-data base.

13

S

General Survey, Measurement,

Vital Signs

JarvisChapter 9

Learning Outcomes

1. Discuss the 4 areas of a general survey and changes in the aging adult.

2. Assess height, weight and BMI of an adult client and document.

3. Assess and interpret vital signs and oxygen saturation of an adult client and document.

4. Relate factors, risk factors, and lifestyle modifications that affect blood pressure.

5. Discuss key terms.

Key Terms

Eupnea

Apnea

Bradypnea

Tachypnea

Cheyne-Stokes

Bradycardia

Tachycardia

Rate & rhythm

Pulse pressure

Stroke volume

Mean arterial pressure (MAP)

Systolic pressure

Diastolic pressure

Hypothermia

Hyperthermia

Sinus rhythm

Sinus arrhythmia

Hypertension

Orthostatic hypotension

Cardiac output

General Survey

Objective data of physical characteristics & overall impression of the client with first encounter

4 areas of the general survey include: Physical appearance: age, sex, LOC, skin color,

facial features & symmetry, any distress Body structure: stature (height), nutrition,

symmetry, posture, position, body build, contour Mobility: Gait, range of motion, involuntary

movement Behavior: Facial expression, mood & affect,

speech, dress, personal hygiene

Measurement

Height Weight BMI = weight (kg)/height (m)2

OR

weight (lbs)/height (in) x 703

Vital Signs

Temperature Pulse Respirations Blood pressure

Temperature

Regulated by hypothalamus Stable temperature required for cellular metabolism Oral mean temp: 98.6° F (37° C) Oral normal range: 96.4° F-99.1° F

35.8° C-37.3° C Rectal temp: 1° F higher (0.4°-0.5° C higher) Axial temp: 1° F lower (0.4°-0.5° C lower) Lower in older adults: mean 97.2° F (36.2° C)

Temperature (cont’d)

Oral temp: place thermometer at base of tongue in sublinguinal pockets; tell client to keep lips closed

Axillary temp: safe & accurate for infants & young children; clients who cannot close mouth

Rectal temp: use for comatose or confused patients when other routes are not practical – wear gloves & insert lubricated rectal probe about 1 inch (2-3cm) into the rectum

Tympanic membrane thermometer: senses body’s core temperature in the eardrum – safe, noninvasive, nontraumatic, quick, with minimal chance of cross-contamination between patients

Pulse Rate & Rhythm

Stroke volume (SV): amount of blood the left ventricle pumps into the aorta with each beat – average 70 mL

Pulse: pressure wave generated by each heart beat – rate & rhythm can be palpated in radial artery

If rhythm is regular, count # of beats starting with 0 for 30 sec. & multiply by 2 = heart rate

If rhythm is irregular (arrhythmia), count # of beats for 60 sec. to determine heart rate

Normal range: 50-90

Bradycardia: <50 bpm

Tachycardia: >90 bpm

Pulse Force & Elasticity

Stroke volume (SV) x Rate (R) = Cardiac output (CO) – amount of blood ejected every minute by the left ventricle into the aorta

Force of heart’s SV is measured by 3-point scale with peripheral pulses: 3+ = full, bounding 2+ = normal 1+ = weak, thready 0 = absent

Elasticity: condition of the artery – normally feels springy, resilient

Respirations

Normally regular & automatic

Normal range: 10-20 per minute

Count respirations discretely for 30 sec. if normal, 60 sec. if patient has breathing problems

Ratio of pulse to respirations: 4:1

Blood Pressure (BP)

Force of the blood ejected from left ventricle into the aorta -- normal range 90/60-120/80

Systolic BP: maximum pressure felt on the artery when the left ventricle is contracting (systole)

Diastolic BP: resting pressure that the blood exerts constantly between each contraction (diastole)

Pulse pressure: difference between systolic & diastolic BPs Mean arterial pressure (MAP): average pressure reached

inside the arteries; usually ranges between 77-97 mmHg. Calculate: (DP x 2) + SP / 3

5 Factors Determining BP

Cardiac output (C): increased CO = higher BP; decreased CO = lower BP

Peripheral vascular resistance: vasoconstriction = smaller arteries & more resistance = higher BP; vasodilatation = larger arteries & less resistance = lower BP

Circulating blood volume: increased blood volume (AKA fluid overload or hypervolemia) = higher BP; decreased blood volume (AKA fluid deficit, hypovolemia, dehydration) = lower BP

5 Factors Determining BP (cont’d)

Viscosity: thickness of blood (usually related to % of RBCs or hematocrit (HCT)) – thick blood = higher BP

Elasticity of blood vessel walls: stiff, noncompliant walls (e.g., arteriosclerosis) = increased resistance = higher BP

Assessment of BP

Measured with stethoscope & sphygmomanometer (BP cuff)

Width of cuff should equal 40% of circumference of arm; length should equal 80% of circumference

Cuff too narrow = falsely high BP

Cuff too large = falsely low BP

Allow 5 minutes to rest before assessing BP

For complete physical exam, assess BP in both arms

If 2 BP values are different, use the higher value

Use bell or diaphragm of stethoscope to assess BP

Assessing for Orthostatic (Postural) Hypotension

Drop in systolic BP of >20 mmHg or increased pulse of >20 bpm when changing from a lying or sitting position to standing position

Causes: peripheral vasodilatation w/o compensatory increased CO, prolonged bedrest, older age, hypovolemia, drugs to treat hypertension

Suspect with c/o dizziness on standing or fainting (syncope) – patients are at risk for falls

Assess BP & pulse in lying, sitting, & standing positions – record BP using even numbers

General Survey, Measurement, & Vital Signs in the Aging Adult

General survey: sharper body contour, flexion of the spine, wider stance, shorter steps

Measurement: decreased body wt d/t shrinking of muscles & loss of subcutaneous fat; fat is redistributed to abdomen & hips; height decreases d/t shortening of spinal column; kyphosis & flexion in hips & knees

Vital signs: less likely to have fever; higher risk for hypothermia d/t loss of fat; pulse rate WNL, but may be irregular; rigid arterial walls d/t arteriosclerosis; decreased in vital capacity & more shallow respirations with increased respiratory rate; systolic BP increases but diastolic BP usually does not – leads to increased pulse pressure

Measurement of Oxygen Saturation

Pulse Oximeter: measures arterial oxygen saturation – amount of oxygen binding to hemoglobin molecules

Normal range: 95%-100%

Using a Doppler

Doppler ultrasound: used to detect blood flow through peripheral arteries

Used to detect sounds (BP) or peripheral pulses that are hard to hear or feel

Primary (Essential) Hypertension

High BP (>120/80) d/t unknown causes

95% of HTN (hypertension) cases is primary HTN

Prehypertension: 120-139/80-89

Stage 1 hypertension: 140-159/90-99

Stage 2 hypertension: >160/100

Risk Factors for HTN

Smoking High cholesterol, high triglycerides Diabetes mellitus Age >60 years Black adult & postmenopausal women Family history of CV (cardiovascular) disease Obesity Stress Strong emotions – fear, anger, pain which stimulates the

sympathetic nervous system

Lifestyle Modifications for HTN Prevention & Management

Stop smoking Lose weight Limit alcohol (ETOH) intake Increase physical activity Reduce sodium (salt) intake Maintain adequate potassium (K), calcium (Ca) &

magnesium (Mg) intake Reduce intake of saturated fat & cholesterol