Session 1 General Survey & Vital Signs Biosciences …€¢ Direct –the striking hand contacts...

BIOE221

www.endeavour.edu.au

Session 1

General Survey & Vital Signs

Biosciences Dept.

© Endeavour College of Natural Health www.endeavour.edu.au 2

Session Objectives

o Identify the role of clinical examination and its relevance

to complementary medicine.

o Understand the professional and ethical conduct

required during clinical examination of a client.

o Describe the clinical examination environment -

equipment, set-up and safe practice.

o Describe the components of a complete physical

assessment.

o Describe the process for the subjective assessment of

pain.


Session Objectives cont

o Describe the basic techniques of inspection, palpation,

percussion and auscultation.

o Describe the variations in clinical examination findings

that occur across the lifespan.

o Perform various physical examinations inclusive of

• General Survey

• Vital Signs (Temperature, Pulse, Respiration)


So why do we need clinical

examination?• Develop and refine our differential diagnosis

• Assess whether we can manage the client within our

scope of practice

• Guides treatment planning

• Monitors treatment effectiveness

• Facilitates communication


Conduct during Clinical Examination

o The Endeavour College Wellnation Clinics Handbook

states:

“Clinical observation and practice is a key feature of the

Endeavour courses of study. Students are expected to

show ethical and cultural awareness and behave

appropriately in all clinical settings when interacting with

clients, staff and fellow students and concerning issues of

confidentiality.”


Conduct during Clinical Examination

o Respect & Dignity • As physical contact will be required in order to perform

examinations students need to demonstrate professional attitude and respect for fellow students

• Demonstrate a social and cultural respect for fellow students

• As a certain amount of clothing may need to be removed for some examination techniques draping and dignity of student client needs to be ensured

o Consent• Every examination will be described to obtain informed consent

o Confidentiality• Maintain confidentiality of measured results and personal

medical information


The Clinical Exam Environment

o The examination room should be warm, quiet, private and have good lighting.

o The examination table should be easily accessible from both sides and at appropriate height for examiner

o Equipment should be accessible and organized

o Adjustable height stool - for examiner or client

o Clean linen on table/ for draping


The Equipment

o Thermometer

o Stethoscope

o Sphygmomanometer

o Pen torch

o Reflex Hammer

o Otoscope & speculae

o Tape measure

o Draping

o Tongue depressors

o Scales and height

measuring apparatus

o Alcohol prep swabs/

mediwipes

o Handwash

o Gloves

o Waste bins


WHS & Infection Control

Workplace Health & Safety (WHS) considerations include:

o Positioning of equipment and client’s personal belongings to prevent trips and falls.

o Manual handling, including assisting clients where needed.

o Use of Standard Precautions to ensure infection control

• Personal hygiene and hand washing

• Cleaning and disinfecting equipment between uses

• Use of personal protective equipment e.g. gloves

• Ensuring a clean environment

• Appropriate handling and disposal of waste products

Note:

Hand hygiene is also

performed after the

removal of gloves

(QLD Dept. of Health, 2013)

Routine Hand Hygiene


Handwashing Procedure


Use handwashing technique

with soap and water when

your hands are visibly soiled.


Hand-rubbing Procedure


Use alcohol based hand rub

for all general clinical contact

and procedures .


Role of Clinical Examination

o Clinical examination is one component of the complete

health assessment of a client. It involves the skills of

observation and physical assessment.

The complete health assessment consists of:

The clients health history

Observation

Physical examination

Diagnostics


The Health History

The clients health

history commonly

includes the following

information

o Biographic data

o Reason for seeking

care

o Present health state or

history of current illness

o Past health history

o Medications

o Family health history

o Systems review

o Functional assessment


The General Survey

o The general survey is

a study of the whole

person, covering the

general health state

and obvious physical

characteristics

o It gives an overall

impression that forms

the baseline for

further assessment

4 Parts of the General

Survey

Physical appearance

Body structure

Mobility

Behaviour


The General Survey

Physical Appearance

• Age, Gender

• Level of

Consciousness

• Skin colour

• Facial features

Body Structure

• Stature

• Weight, Height, BMI

• Waist/Hip ratio

• Posture

Mobility

• Gait

• Range of motion

Behaviour

• Facial Expression

• Mood and Emotion

• Speech

• Dress & Appearance

• Personal hygiene


Complete Physical Assessment

o The examination and measurement of the characteristics

and features of the body and its systems.

• Anthropometrics – height, weight, BMI, hip/waist ratio

• Vital signs – Temperature, pulse, BP, respiratory rate

• General survey – Appearance, structure, mobility, behaviour

• System analysis – Inspection, palpation, percussion, auscultation


Physical (Clinical) Examination

o Physical examination focuses on observation and

physical assessment of a client

• The assessment techniques learned will be important tools for

the practitioner of any complementary medicine modality to add

to their assessment repertoire.

• The information obtained from observation and physical

assessment can be used to assist in client diagnosis and

management, which may include the need for referral.


Order of Physical Examination

When approaching the process of performing a physical

examination of a client, you will most often use the

following order:

Inspection

Percussion

Palpation

Auscultation


Inspection

ALWAYS COMES FIRST

o LOOK - Concentrated watching

• first of the individual as a whole and then of each of the body

systems

o Begins the moment you first meet the client and develop

a “general survey”

o Compare both sides of the body

o Needs good lighting, adequate exposure

o Used before any other technique / equipment is used

• e.g. otoscope, penlight, tongue depressor


Percussion

Tapping the person’s body with short, sharp strokes to

assess underlying structures using characteristic sounds

indicative of tissue density.

Used to:

o Map out the location and size of an organ

o Determine the density (air, fluid or solid) of the structure

by the characteristic sound e.g. solid organ = dull

o Elicits pain if the underlying structure is inflamed e.g.

sinus or kidneys


Percussion Techniques

o 2 percussion techniques:

• Direct – the striking hand contacts directly with the body wall

• Indirect – the striking hand contacts the stationary hand fixed to

the persons skin

Characteristics of percussion

Resonance Clear & Hollow Adult thorax

Hyper-resonant Booming Child Thorax

Tympany Drum like Abdomen

Dull Muffled thud Solid organs

Flat Absolute dullness Bone or tumour


Palpation

o Palpation usually follows and often qualifies findings you

noted during inspection and percussion.

o Applies your sense of touch to assess:

• Texture, temperature, moisture

• Organ location and size

• Swelling, vibration, pulsation, rigidity or spasticity, crepitus

• Presence of lumps or masses

• Presence of pain or tenderness


Palpation Techniques

1. Fingertips

• Feeling for skin texture,

swelling, pulses, presence of

lumps

2. Grasping action of the fingers

and thumb

• To detect the position, shape

and consistency of an organ

or mass

3. Dorsum of the hands and fingers

• For determining the

temperature

4. Base of fingers or ulnar surface

of hands

• For assessing vibration

Technique:

Slow and systematic

Light to deep

Intermittent pressure


Auscultation

o Auscultation involves listening with a stethoscope to the

sounds produced by the body such as the breathing,

heart sounds or bowel sounds.

o Stethoscopes do not magnify sound so the fit and quality

of the stethoscope is important

• When fitted and worn correctly, they reduce outside noise to

allow the user to better hear the body’s sounds

• The slope of the earpieces should point forward towards your

nose


The Stethoscopeo There are 2 sides to the stethoscope head

• The diaphragm is best for high pitched sounds

– e.g. breath, bowel, and normal heart sounds

• The bell is best for soft, low-pitched sounds

– e.g. extra heart sounds or murmurs

• Minimise extraneous noise

– E.g. noise in the room, body hair, clothes rubbing


Variations in Physical Assessment

o Assessment techniques sometimes need to be adapted

to suit the individual client

• Disability restricting ideal positioning

• Extreme age of client – very young/ elderly

• During pregnancy

o Normal ranges of measurement vary with changes in the

life cycle

• Infancy/ early – middle childhood

• Adolescence / early adulthood

• Middle adulthood/ late adulthood


Anthropometrics

Anthropometrics involves the measurement of the human

body. Basic measurements are included as part of the

complete health assessment of an individual, most often as

an integral part of the general survey.

o Common measurements include

• Height

• Weight

• Waist circumference

• Waist:hip ratio


Height and Weight

o Height is measured using a standard height measure

device known as a stadiometer. The patient should have

bare feet, be standing flat footed with back comfortably

straight, and eyes looking straight ahead. Take the

measurement from the highest point of the head in this

position. Document the height in centimetres (cm)

o Weight is measured using a standard balance or

electronic scale. The patient should remove their shoes

and all excess clothing before stepping onto the scale.

Document the weight in kilograms (kg) to one decimal

place e.g. 85.5kg


Waist Circumference

Waist circumference is measured

using a standard tape measure

located at the highest point of the

iliac crest (approximates to the

navel). Ensure the patient is

standing upright, with the abdomen

exposed and relaxed to its natural

position.

Increased risk of cardiovascular

disease is determined when the

waist circumference is:

Women: 80-88cm or above

Men: 94-102cm or above

(NHMRC, 2013)


Anthropometric Calculations

o Waist:Hip Ratio

• Take a second measurement around the widest part of the hips

and buttocks:

Waist (cm) / Hips (cm) = Waist:Hip Ratio

A result >0.85 (F) and >0.90 (M) indicates central abdominal

obesity in adults only.

o Body Mass Index (BMI)

• To calculate the BMI:

Weight (kg) / Height (m2) = BMI kg/m2

<18.5 underweight 18.5-24.9 normal weight

25-29.9 overweight >30 obese


Observing Behaviour

Observing behaviour is an important component

of the general survey and should be undertaken

from the first moment you meet the client.

o Abnormal behaviours may indicate

• Anxiety, depression or grief

• Distrust or potential hostility

• Psychological disorders

• Neurological disorders

• Pronounced illness or pain


Observing Behaviour

o Facial Expression

• Maintains eye contact with appropriate expressions or the

situation

o Mood and Affect

• The person is comfortable and cooperative and interacts

pleasantly

o Speech

• The speech is clear, understandable and appropriate

o Dress

• Clothing is clean, culturally and age appropriate, and

appropriate for the climate


Assessing Pain

“Pain is defined as an unpleasant sensory and emotional

experience associated with actual or potential tissue

damage…Pain is always subjective” (Jarvis, 2016, p.166)

o A subjective assessment of pain has been shown to be

clinically reliable. Pain assessment should include:

• An initial assessment of pain

– (PQRST Method)

• The patients subjective report of the pain intensity

– (0-10 numeric pain scale or Faces Pain Scale)


PQRST Method

Provocation/palliation What caused/s the pain?

What makes it better or worse?

Quality/Quantity What does it feel like?

Is it sharp, dull, stabbing, burning, crushing,

throbbing, shooting?

Region/Radiation Where is the pain?

Does the pain radiate/refer somewhere else?

Severity Scale Use a validated pain scale such as the 0-10

Numerical Pain Scale.

For children use the Faces Pain Scale

Timing When did the pain start?

How long did the pain last for?

How often does the pain occur?

(Jarvis, 2016, p. 167)


Pain Scales

o Numeric Pain Intensity Scale (Adults)

o Faces Pain Scale (Children)

(Jarvis, 2016, p.170)


Vital Signs

There are 4 vital signs (T,P,R,BP)

Temperature

Pulse

Respiration

Blood Pressure

Baseline observation of vital signs should be performed on

all patients. Changes to the vital signs in terms of the

reference ranges or qualities may indicate disease or

disorder.


Temperature

Heat Production

o Metabolism

o Exercise

o Food digestion

o External factors

Heat loss

o Radiation

o Evaporation / sweat

o Convection

o Conduction

Body temperature is regulated by the hypothalamus. A

stable core temperature of 37.2oC is optimal for metabolism

and is achieved by balancing heat production and loss


Sites for Taking a Temperature

The temperature can be taken via the oral, axilla, rectal or tympanic routes. In clinical routine clinical practice the most commonly used routes are”

o Oral – mercury in glass or digital thermometer (35.8-37.3oC)

– Accurate and convenient – 2 minutes

– Not after hot/cold drinks or smoking

o Ear – tympanic membrane thermometer

– Measures infra-red emissions from tympanic membrane

– 2-5 seconds

– Safe/ quick/ good for all ages


Changes in Temperature Hyperthermia (fever) - >37.4oC

o Pyrogens secreted by

• Toxic bacteria - infection

• Tissue breakdown e.g. from trauma, surgery, heart attack,

cancer

o Neurological conditions that can “reset” the thermostat higher

• e.g. stroke, cerebral oedema, brain trauma/ tumour/ surgery

o Over– exposure to heat

• Heat exhaustion/ heat stroke

Hypothermia - <35.5oC

o Usually due to accidental prolonged exposure to cold

• 30 -32°C → loss of consciousness

• 28°C → heart failure / death


Pulse Rate

o As the heart contracts it pumps blood into the Aorta. This bolus of blood is known as the stroke volume, and is about 70mls in the average adult.

o The force of the stroke volume against the arterial walls creates a pulse wave, which can be felt as the pulse by palpating peripheral arteries.

o Pulse is strongest in the arteries closest to the heart, weaker in the arterioles, and disappears in the capillaries.


Pulse Ranges & Interpretation

AGE RATE

Neonates 0 – 1 month 70 – 190 bpm

Infants 1 – 11 months 80 – 160 bpm

Children 1 – 2 years 80 – 130 bpm




Children >10yrs – Adults 60 – 100 bpm

Well-trained athletes 40 – 60 bpm

Tachycardia (in adults) >100 bpm

Bradycardia (in adults) <60 bpm

http://www.nlm.nih.gov/medlineplus/ency/article/003399.htm


Variables of a Pulseo Rate (beats per min) – Count for 30 secs x 2 if regular

o Rhythm (regular or irregular)

o Force (stroke volume)

• 0 = absent

• 1+ = weak or thready

• 2+ = normal

• 3+ = full or bounding

o Elasticity (of the arterial wall)


Radial Pulse(Jarvis 2004)

The radial pulse lies medial to the radius and lateral to the palmaris longus

tendon, a the wrist.

• Locate the palmaris longus tendon which is aligned to the 3rd phalanx.

• Place the pads of 2 or 3 fingers in the groove between the radius and the

palmaris longus tendon. Count the beats for 15 secs x 4 if regular, or for a

full minute if irregular.


Respiration Rate

o Normal respiration is relaxed, regular, automatic and

silent

o When counting respirations, do so unobtrusively as rate

may change once the patient becomes aware that your

counting. Observe the rise and fall of the chest.

o Count for 30 seconds (x2) or 60 seconds

o Record as respirations per minute


Respiration Rate

o 3 variables need to be observed:

• Rate (breath /minute)

• Rhythm (regular or irregular)

• Effort (relaxed or forced)

o Normal range:

• Adults: 10-20 BPM

• Teens: 12-22 BPM

• Neonate: 30-40 BPM

46


References

o Jarvis, C. (2016) Physical Examination and Health Assessment (7th ed.). Missouri: Elsevier.

o Tortora, G., & Derrickson, B. (2014). Principles of Anatomy and Physiology (14th edn). Hoboken, NJ: John Wiley.

o Queensland Dept. of Health (2016). Guidelines: Hand Hygiene, Brisbane: Queensland Government.

o National Health & Medical Research Council (2013). Clinical Practice Guidelines for Management of Overweight and Obesity in Adults, Adolescents and Children in Australia. Melbourne: NHMRC.


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Session 1 General Survey & Vital Signs Biosciences …€¢ Direct –the striking hand contacts...

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