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General Survey study of the whole person, covering the general health state and any obvious physical characteristics a) Components of General Survey I. Physical Appearance
- Age → the person appears his or her stated age
- Sex → exual development is appropriate for sex and age. If the individual is transgender, note the stage of transformation
- Level of consciousness → alert and oriented to person, place, time, and situation (A&Ox3); responds appropriately to your questions.
- Skin Color → even tone, skin intact (no lesions)
- Facial Features → symmetric in movement
- Overall → no signs of acute distress II. Body Structure
295 FINAL EXAM BLUEPRINT
Evidence-based Health Assessment Evidence-based Health Assessment a) Priority Levels
- 1st level: emergent, life threatening, immediate
- ABCs + V: airway, breathing, cardiac/circulation + vital signs
- 2nd level: next in urgency; requiring prompt intervention to forestall further deterioration
- i.e. mental status change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal lab values, infection/safety/security risk
- 3rd level: important to patient’s health but can be addressed after more urgent issues; interventions for 3rd level problems are more long term b) Types of Assessment
- Complete: complete health history and full physical examination; current and past health state; forms baseline; yields 1s diagnosis
- Well person → person’s health state, perception of health, strengths/assets such as health maintenance behaviors, coping patterns, support systems, current developmental tasks, any risk factors, lifestyle changes
- Ill person → all the above + description of person’s health problems, perception of illness, response to problem
- Usually collected in a primary care setting - Focused: limited/short-term problem
- “mini” database, smaller in scope and more targeted
- Concerns mainly one problem, one cue complex or one body system - Follow-up: status of any identified problems should be evaluated at regular and appropriate intervals
- What change has occurred? Is the problem getting better or worse? Which coping strategies are used? - Emergency: an urgent, rapid collection of crucial information
- Often compiled concurrently with lifesaving measures
- Diagnosis must be swift and sure
- I.e. substance overdose in ED (what/when/how much?) General Survey Priority Levels Types of Assessment: Complete, Focused, Follow-up, Emergency
Temperature, Pulse, Respirations, Blood Pressure Technique Equipment Interview Phases Types of Interview Questions Communication: Therapeutic, Verbal, Non-verbal Definitions and Examples of Signs and Symptoms
- Stature → height in normal range for age
- Nutrition → weight in normal range for age/body fat distribution is even
- Symmetry → body parts look equal/relative proportion to each other
- Posture → person stands comfortably erect
- Position → the person sits comfortably with arms relaxed at sides and head turned to examiner
- Body, build, contour → arm span equals height
- Obvious physical deformities → note any congenital defects III. Mobility
- Gait → person can maintain balance without assistance
- Range of motion → note full mobility of each joint; movement is deliberate, accurate, coordinated IV. Behavior
- Facial expression → person maintains eye contact; expressions appropriate
- Mood and affect → person is comfortable and cooperates
- Speech → articulation clear/understandable
- Speech pattern → stream of talking fluent; even pace
- Dress → clothing appropriate for climate; looks clean; fits to body
- Personal hygiene → person appears clean/groomed V. Measurement
- Weight → standardized balance on electronic scale
- Height → algn the extended headpiece with top of head; shoeless; standing straight
- BMI → marker of optional healthy weight; indicator of obesity/malnutrition
- Waist circumference → excess abdominal fat is risk for disease over and above that of BMI The Interview The Interview a) Interview phases
- Introductory phase a. Introduce yourself, state your role, if you are gathering a complete health history give reason
- Working phase a. Data gathering phase, ability to form questions appropriately; record responses b. Ask open-ended questions, narrative information c. Lean forward, listen, be interested, look for cues, eye contact
- Summary/closure phase a. Ask if there is anything else they want to mention b. Give a summary back to px, have client agree, include a plan of action, plan for future examinations b) Types of interview questions
- Ask one question at a time; open ended c) Communication
- Therapeutic → interaction that helps advance the physical/emotional health of patient; active process; use various strategies; enhance px comfort levels, safety and trust
- Verbal → paraphrase what the client has told you; silence when listening
- Non-verbal → touch, eye contact, be culturally competent, space/distance between px d) Definitions and examples of signs and symptoms
- Signs → objective abnormality that you can detect on exam or in lab reports
- Record person’s exact words for why they are seeking care; do NOT translate into medical diagnosis
- Symptoms → subjective sensation that person feels Vital Signs
Health History a) Purpose → collect subjective data, what person tells you about themselves, combined with objective data; combined wit physical exam and lab data = complete picture of person’s past and present health
- Collect: biographical data, reason for seeking healthcare, present health or history of present illness, past histor medication reconciliation, family history, review of systems, functional assessment of ADLs b) Review of Systems
- Evaluate past and present health of each body system; double check if any significant data was omitted; evaluate healt promotion practices
- Head-to-Toe exam: → General overall health state: present weight gain or loss, fatigue, weakness, fever, chills, sweats or night sweats → Skin: pigment, color change, change in mole, excessive dryness or moisture, pruritus, excessive bruising, rash, lesion → Hair: recent loss or change in texture → Head: headache, head injury, dizziness or syncope → Eyes: difficulty with vision, eye pain, diplopia or double vision, redness or swelling, discharge, glaucoma, cataracts → Ears: earaches, infection, discharge, tinnitus, vertigo → Nose/sinuses: discharge characteristics, frequent cold, sinus, nasal obstruction or pain, nosebleeds, allergies, hay fever → Mouth/throat: mouth pain, sore throat, bleeding gums, toothache, lesions, dysphagia, altered taste, voice change → Neck: pain, limitation of motion, lumps, swelling, enlarged nodes) → Breast: pain, lump, nipple discharge, rash, history of breast disease, surgery Blood Pressure Systolic pressure is the maximum pressure felt on the artery during left ventricular contraction, systole Diastolic pressure is the elastic recoil, resting, pressure that the blood exerts constantly between each contraction Cardiac output = stroke volume x heart rate (amount of blood ejected by the heart in one minute)
- Technique/equipment
- Stethoscope and aneroid sphygmomanometer (cuff consists of an inflatable rubber bladder inside the cloth cover)
- Allow 5 min rest before taking BP
- Px may be sitting/lying; bare arms at heart level
- Px feet flat on floor; no crossed legs
- Palpate brachial artery located above antecubital fossa
- Deflated cuff center about 2.5cm above the brachial artery (2 fingers)
- Length of bladder should be equal to 80% of arm circumference
- Palpate brachial artery, inflate cuff until pulsation disappears; then go up by 30 mmHg (that’s the baseline)
- Deflate cuff, wait 30 seconds, place steth over brachial; rapidly inflate cuff, deflate slow (2 mmHg per heartbeat
- Note first sound and final sound → Korotkoff sounds
- Normal/abnormal findings for adults/older adults
- Small cuff → false high
- Big cuff → false low
- Hypotension → abnormally low BP; < 90/
- Hypertension → abnormally high BP; > 120 - 139/80-89 pre-HTN and 140/90 is start of HTN
- Orthostatic hypotension → inadequate cerebral perfusion when changing position from supine to prone to sitting or standing Health History Purpose Review of Systems Spiritual, Cultural, Nutritional Assessment Cultural Competence BMI Macronutrients and Calories Smoking Pack Years Average 120/
→ Axilla: tenderness, lump, swelling → Respiratory system: history of lung disease, chest pain, sob, wheezing, sputum, hemoptysis, pollution exposure → Cardiovascular: chest pain, pressure, tightness, fullness, palpitation, cyanosis, dyspnea, orthopnea, nocturnal, edema, murmurs, hypertension, cad, anemia → Peripheral vascular: coldness, numbness, tingling, swelling of legs, discoloration of hands and feet, varicose veins → GI: appetite, food intolerance, dysphagia, heartburn, indigestion,, nausea, vomiting, flatulence, frequent bowel movement, history of abdominal disease, stool characteristics, constipation, diarrhea, black stool, rectal bleeding → Urinary: frequency, urgency, nutrinia, dysuria, polyuria, oliguria → Male genital system: penis or testicular pain → Female genital system: menstrual history start, end, duration, menorrrhagia, dysmenoorhea, baginal itching, discharge, postmenpaul bleeing) → Sexual Health: ask about sex life, are they currently having sex, what protection do they use, dyspareunia, erectile dysfunction STI transmission → Musculoskeletal system: history of arthritis or gout, pain stiffness in joints, muscle cramps, weakness, gait problems, coordination, limitation of motion → Neurologic system: history of seizures, blackouts, fainting, stroke, cognitive + memory function, mental status → Hematologic system: bleeding tendency, excessive bruising, lymph node swelling, blood transfusion reactions → Endocrine system: history of diabetes or symptoms, history of thyroid, intolerance to heat or cold, change in skin pigmentatio or texture, excessive sweating, appetite, hair distribution, nervousness, tremors c) Spiritual, cultural, nutritional assessment
- Assessment
- Spiritual: provide spiritual care, refer patients to spiritual support personnel
- Cultural: beliefs/customs, ways of living; assess how it affects their life experiences
- Nutritional: objective and subjective data related to food and nutrient intake, lifestyle, medical history; collect and asse the nutritional status of that person
- Cultural competence: acquire specific knowledge, skills, attitudes to ensure delivery of congruent care (care that fits a person’ life patterns/meaning/cultural values/beliefs)
- BMI Weight in pounds × 703 Height in inches 2 ( squared ) Weight: 150 Height: 5’5 (65’’) (1ft=12in) 150 x 703 → 65 (squared) = 24.96 BMI (Round to 25) BMI → BMI between 20 - 25 is associated with the least mortality, under 16 = eating disorders <18 → Underweight <18.5 → Thin for height 18.6-24.9 → Healthy weight 25 - 29.9 → Overweight
30 → Obesity
- Macronutrients and calories 1g Carbs = 4 calories (only calories that contribute to food) 1g Protein = 4 calories (only calories that contribute to food) 1g Fat = 9 calories Example: 25 gram of Carbs 4 calories 25x4=100 cal 3 gram of Proteins 4 calories 3x4=12 cal 12 gram of Fats 9 calories 12x9=108 cal Total = 220 cal d) Smoking, pack, years Formula: Divide the # of cigarettes smoked per day by 20 (# of cigarettes in a pack), then multiply by the number of years smoked 70 cigarettes / day ÷ 20 Cigarettes / P ack × 10 years = 35 pack years
quality (musical, crackling, raspy)
- Diaphragm best used to detect high pitched sounds (bowel, breath, heart sounds) *Bell best used for soft low pitched sounds (extra heart sounds, murmurs) b) Preparing the client → Uncover only what is necessary; maintain modesty c) Managing the environment: internal and external factors
- Internal: make room comfortable (temp and privacy)
- External: note what you inspect (color, pattern, size, location, consistency, movement, odors, sounds, compare symmetr d) Standard precautions
- Applies to blood, blood products, all body fluids, secretions, excretions (except sweat), non-intact skin and mucous membrane.
- Perform hand hygiene before, after and between direct contact with patients.
- Perform hand hygiene after contact with: blood, body fluids, mucous membranes, nonintact skin, secretions, excretions, wound dressing etc.
- When hands are visibly soiled-wash with soap (non-antimicrobial or antimicrobial) and water. - When hands are not visibly soiled or contaminated with blood or body fluids, use and alcohol-based, waterless antiseptic agent to perform hand hygiene.
- Do not wear artificial fingernails or extenders if duties include direct contact with patients at high risk for infection and associated adverse outcomes.
- Wear gloves when touching blood, body fluids, secretions etc.
- Wear personal protective equipment (PPE) when the anticipated patient interaction indicates that contact with blood or body fluids may occur.
- A private room is unnecessary unless the patient’s hygiene is unacceptable (wound drainage, uncontained secretions/excretions).
- Discard all contaminated sharp instruments and needles in a puncture-resistant container. Respiratory hygiene/cough etiquette (sit at least 3 feet away from others if coughing etc.) Airborne → Disease spread by small droplets that remain in the air for longer periods of time *TB → Negative air flow (HEPA→ high efficiency particulate air) *Must wear N95 Mask → higher filtration rate for smaller particles Droplet → infections are spread through larger particles → can travel 3 to 6ft from the patient *Private room, surgical simple mask when 3ft from patient, hand sanitize *Patient must wear a mask for transport → mumps, rubella, pneumonia, influenza Contact → Infectious diseases
- For patients who are infected by microorganisms that spread by direct or indirect contact:
- MRSA, VRE, enteric pathogens (herpes zoster, shingles)
- Private room or cohort, Wear gloves, Wear gown if contact with wound drainage, feces, mucus, etc. is anticipated
- Remove PPE before exiting room and hand sanitize Respiratory System Anatomical landmarks for assessing the lungs and thorax Physical assessment techniques for assessing the lungs and thorax Normal and Abnormal Findings: Inspection, Palpation, Percussion, Auscultation Breath Sounds: Normal and Abnormal findings and clinical significance Voice Sounds: Normal and Abnormal findings and clinical significance
Anatomical Landmarks for Assessing the Lungs & Thorax Anterior
- Midsternal line: anterior chest, right down the middle over the sternum
- Midclavicular line: anterior chest, bisects the center of each clavicle
- Anterior axillary line Posterior
Lateral
Scapular line: extends through the inferior angle of the scapula when the arms at the sides of the body Vertebral line: posterior chest wall; also called midspinal line; goes right down the vertebra (middle of back) Inferior angle Anterior axillary line (AAL) - at anterior axillary fold Midaxillary line (MAL) - midway between AAL and PAL Posterior axillary line (PAL) - at posterior axillary fold ❖ For assessment, always compare BILATERALLY
- Right lung has 3 lobes: RUL (right upper lobe), RML (right middle lobe) and RLL (right lower lobe); divided by the right oblique fissure and the horizontal fissure
- Left lung has 2 lobes: LUL (left upper lobe) and LLL (left lower lobe); divided by the left oblique fissure Physical Assessment Techniques for Assessing the Lungs & Thorax Typical Physical Examination: INSPECTION
- Posterior thorax: (examined 1st) inspect the shape and configuration, slope of ribs, skeletal abnormalities (i.e. protrusio of bones → usually done through palpation unless pt. is extremely thin) Normal Findings:
- Spinal processes appear straight
- Thoracic symmetric with ribs sloping downward, approx. 45 degrees in relation to the spine
- Scapulae are symmetric and non-protruding
- Shoulders and scapula are at equal horizontal positions
- Ratio to anterior-posterior to transverse diameter is 1:2 → anterior posterior is less than the transverse diameter
- Sternal angle should be less than 90 degrees → should be a more vertical configuration to the ribs compared to someon with a barrel chest
- Barrel chest: ribs that are more horizontal, the sternal angle is greater than 90 degrees; barrel chest can be congenital, however it is common in those with long-standing COPD; barrel chest will have an anterior-posterio to transverse diameter of 1:1 (person is equally wide as they are thick/depth) Anterior-posterior: side view Transverse: frontal or back view Typical Physical Examination: RESPIRATORY PATTERNS
- Watch for 30 sec, multiply by 2, if irregularity is seen count breaths for one full min.
- Normal range = 10 - 20 breaths/min
- Position: inspect posture, ability to support weight while breathing comfortably, inspect for use of accessory muscles while breathing Assessment: Lungs & Thorax Health History:
- History of disease → COPD (ratio of anterior-posterior diameter to transverse diameter is 1:1), asthma, emphysema (sternal angle greater than 90 degrees), chronic bronchitis, pneumonia, cancers, sinus infections/chronic sinusitis, allergi rhinitis, chest surgeries, cystic fibrosis
- Common respiratory symptoms → cough: productive vs nonproductive, SOB, pain in chest, wheezing, abnormal breath sounds, congestion, tachypnea
- Self-care behaviors → smoking, aerobic exercise, humidifier use, use of sinus flushing techniques
- Environmental exposure → workplace asbestos, mold, radiation, construction site dust/particulates, pollutants (urban areas)
Respiratory Patterns: Abnormal Findings & Clinical Significance RESPIRATORY PATTERNS → Abnormal Findings
- Tachypnea: fast
- Bradypnea: slow
- Apnea: cease/absence
- Cheyne-Strokes: starts shallow, and progressively gets deeper with each breath, cycle repeats
- Biot’s: clusters of fairly rapid respirations of close to equal depth followed by regular periods of apnea
- Kussmaul’s: labored hyperventilation characterized by a deep and rapid respiratory pattern (DKA) K=ketoacidosis U=uremia S=salicylate poisoning (aspirin poisoning) S=sepsis M=methanol poisoning A=aldehyde U=ureterenterostomy L=lactic acidosis Other abnormal diagnoses:
- Orthopnea: pt. needs 2 or more pillows in order to breathe effectively
- Paroxysmal nocturnal dyspnea: starts and stops abruptly without any treatment, sporadic difficult breathing/SOB at
night, NOT the same as sleep apnea, pt. may not know this is occurring…would need to do a sleep study
Tripod position: person cannot breath without having their hands on their knees seated, if pt. must be in this position to breath it indicates respiratory distress, leans forward and uses arms to support weight e.g. COPD Pursed lip: blowing against the lips extends the respiration allowing the alveoli to stay open for longer for more gas exchange, sign of respiratory distress if person breathes this way normally
- Stomal: person breathes through stoma/tracheostomy
- Clubbing: swelling of ends of fingers/fingernail area-fingernails look rounded and large→ Associate w/ heart disease,
- Tidal volume of lungs is often asymmetrical, surgical interventions are not taken before puberty/full development unless condition is life threatening or interfering with breathing
- Kyphosis: exaggerated curvature of the thoracic vertebrae (e.g. “hunchback”); no surgical interventions unless it affects respiration PALPATION → Abnormal Findings:
- Crepitus: sound the body creates that is abnormal; “cracking”
- When palpating the chest area if you feel a crackling sound-indicates that air is trapped in the subcutaneous tissue, AKA subcutaneous emphysema, caused by some sort of occlusion that forces air out of the respiratory tissues, most often occurs above and below the clavicles
- If trachea is deviated towards one side it is an indicator of:
- Pneumothorax: air in pleural space compressing lungs
- Hemothorax: blood in pleural space compressing lungs
- Trachea will be deviated towards the opposite direction of the problem
- Symmetric Expansion: unequal chest expansion occurs with marked atelectasis or pneumothoracic trauma, such as fractured ribs or pneumothoraxàPAIN is also an indication What happens if there are abnormal findings, e.g. vibrations/fremitus are stronger where they should be weaker?
- Indicates some sort of consolidation/solid (increased density), such as infection, inflammation, tumor, etc.
- Decreased fremitus is an indication of an occlusion of airflow, pleural effusion, and pneumothorax PERCUSSION → Abnormal Findings:
- 2 - 3 cm wide percussion note (this is literally the only abnormal finding listed on the powerpoint) Ok so the slides don’t really say what the abnormal findings are but I assume it is hearing dullness/resonance where you are not supposed to, and this is what these sounds could be indicative of: · Pleural effusion · Atelectasis · Diaphragmatic Paralysis
Abnormal/Adventitious Breath Sounds: Document → what you hear and where you hear it, indicates abnormal findings. Do you hear the sounds on inspiration or expiration? What are the types?
- Crackles/rales = air is moving through fluid
- Heard primarily during inspiration
- Popping open of previously closed airways
- Rhonchi = low pitched wheezing, air is moving through secretions, sound is more coarse e.g. mucus
- Continuous, heard on inspiration and expiration
- Wheezes = air is moving through narrow airways, e.g. bronchospasm
- Pleural friction rub=parietal and visceral pleural are rubbing together, will sound like a harsh grating sound with each respiration, e.g. pleuritis Breath Sounds: Normal & Abnormal Findings & Clinical Significance Normal Findings: Bronchial Breath Sounds
- Pitch = High
- Quality = Harsh/hollow
- Amplitude = Loud
- Duration = Short during inspiration, long on expiration
- Location = Trachea and larynx Broncho-Vesicular Breath Sounds
- Pitch = Moderate
- Quality = Mixed
- Amplitude = Moderate
- Duration = Equal on inspiration and expiration
- Location = POSTERIOR-over the main bronchi, between the scapulae, ANTERIOR-along the sternum in the 1 st^ and 2 nd intercostal spaces Vesicular Breath Sounds
- Pitch = Low
- Quality = Breezy
- Amplitude = Soft
- Duration = Long on inspiration, short on expiration
- Location = Peripheral lung fields lung disease, or malignancy
- Use of accessory muscles such as trapezius/shoulder muscles → indicative of acute or chronic airway obstruction or atelectasis
Physical assessment techniques for assessing the heart and neck vessels/Normal and Abnormal Findings
- Observation (Inspection)/Palpation: position client supine, head 30 - 45 angle, stand to right side,
- Inspect/Palpate assess precordium for pulsations.
- Aortic area pulsations could = aortic aneurysm, thrill could = aortic stenosis.
- Pulmonic area pulsations could = pulmonary HTN, thrill could = pulmonic stenosis.
- Erb’s Point pulsations similar to aortic/pulmonic.
- Tricuspid systolic lift could = RV enlargement. Tricuspid systolic thrill could = ventricular septal defect.
- Mitral pulsations: have pt hold breath, lean forward and note location, diameter, amplitude, duration and rate of PMI. Increased pulsations could= increased CO, anemia, anxiety, fear, pregnancy. Thrill could =mitral regurgitation or mitral stenosis
- Percussions: limited value to CV assessment- should be a dull sound in 3 - 5ICS
- Auscultations: assesses heart sounds and murmurs: S1/S2 normal sounds. S3/S4 or split S1/S2 are abnormal sounds/ Lo pitch (S3/S4)-use bell of steth. High (S1/S2)-diaphragm. Listen over several cycles for best practice Anatomical landmarks for assessing the heart and neck vessels
- APE To Man: Precordial Landmarks-- MUST KNOW THESE
- Angle of Louis (sternal angle- prominence of upper third of sternum- 2ICS)
- Aortic: second intercostal/right sternal border (base 2ICS-R)
- Pulmonic: second intercostal/left sternal border (base 2ICS-L)
- Erbs: S2 is best heard: 3 rd^ intercostal right along sternal border (3ICS-L)
- Tricuspid: 4 - 5 intercostal space (4/5ICS-L)
- Mitral: Apex: Apical pulse: PMI: Right below nipple: midclavicular/4- 5 intercostal space (4/5ICS-midclavicular line)
- Epigastric Area: area overlying xiphoid process 4 chambers: R/L atria, R/L ventricle 4 Valves:
- atrioventricular (means between atrium and ventricle): tricuspid (3 cusps) and mitral (2 cusps)
- semilunar valves (close between the vessels): pulmonic (valve between right ventricle and lungs- no oxygenated) and aortic (left ventricle to body- oxygenated)
- Neck Vessels: Carotid Artery: (located between the trachea/sternomastoid muscle-medial to/along side that muscle) Palpate both separately and compare: place pads of index/middle fingers medial to sternomastoid muscle. 2-3cm in height normally. (<2 dehydrated/hypervolemic. >3 fluid overload/hypovolemic/heart failure (usually right sided) Measuring is less invasive than central line, but not as accurate so not used much anymore. Harder to see w darker skin.
- Jugular Vein- (empty deoxygenated blood into the SVC) reflects right atrial pressure
- Internal jugular (deep and medial to sternomastoid muscle-only on left side)- usually not visible unless pt supine
- External Jugular (more superficial and lateral to sternomastoid muscle above clavicle-have a left and right)
- Orthopnea: The need to assume more upright position to be able to breathe. How many pillows needed when lying down?
- Cough: Dry or productive? LHF goes into lungs, creating a productive cough. Color of sputum OLDCARTS
- Fatigue: from decreased cardiac output
- Cyanosis/Pallor: blue/gray coloring- occurs with MI/low cardiac output due to decreased tissue perfusion.
- Edema: cardiac edema is bilateral, worse @ PM/better in AM. SOB? Before/after swelling?
- Nocturia: how often? Onset? Any recent changes?
- Past Cardiac Hx: HTN (more prevalent in african american men), Hyperlipidemia, murmurs, CHD, rheumatic fever/joint pain when younger? Anemia? Tonsillitis? Last EEG, and other heart tests?
- Family Cardiac Hx: HTN, obesity, DM, CAD, sudden death at young age?
- Cardiac risk factors: Diet, smoking, alcohol, exercise, drugs? R-sided HF: if pump not working, it will back up into body: JVD (jugular vein distention)-distended jugular vein: direct indication of R-sided heart failure, edema, splenomegaly, hepatomegaly
- L-sided HF: if pump not working, it will back up into lungs (L-Lungs): SOB, hear crackling, coughing up pink frothy sputum
- Can be a mixture of symptoms if it affects both sides
- Heart Failure → S3 sound
Normal and Abnormal Findings: Inspection, Palpation, Percussion, Auscultation
- NORMAL Neck Vein Findings- NO SOUNDS HEARD
- Carotid Artery: Inspection- No visible pulsations unless patient is lying down. Palpations-equally strong pulses, no variation in strength of beats, usually smooth, fast upstroke, slower downstroke, both sides should be equal no thrills present.
- Auscultations: DO THIS FIRST IF: person is older (middle age+ around 65), suspected cardiac/peripheral condition, head/neck trauma. - Use bell on artery, have client hold breath/breathe via nose (so breathing doesn cover any vascular sounds). Do not palpate if there is a bruit
- Jugular Vein: Inspection- when lying down jugular fills and can be distended but should dissipate when patient sits or stands up. Look distended, not bulging from clavicle to jaw angle.
- Heart: see/feel apical impulse ABNORMAL Neck Vein Findings
- Carotid Artery: Bruit (turbulent sound due to narrowing artery)- blowing/swishing
- Thrill (palpable vibration- turbulent blood flow)
- Jugular Vein Findings: Inspection: unusual distention when person sits or stands up ABNORMAL Heart Findings:
- Bradycardia, Tachycardia, Arrhythmia (check for pulse deficit), A. Fib., Atrial flutter, wandering pacemaker, heart blocks V. fib. Asystole (flat line) Chest lift/heave-movements of sternum and ribs from forceful cardiac contractions, Thrills. NORMAL Heart Findings: Dull sounds at 3 - 5ICS Heart Sounds and Murmurs: Normal and Abnormal findings and clinical significance CARDIAC CYCLE
- S3 (protodiastole): “Rapid filling/protodiastolic” - “kentucky” - P wave- sign of LV failure- normal for under 30 years of age- have person lie left lateral horizontal and listen w/ bell- ventricle gallop- associated with CHF
- S4 (presystole): “After slow filling” - “tennessee” lub dub dub- Q wave - sign of R bundle branch block/ischemia- left later horizontal with bell- atrial gallop
- Isometric contraction= S1 (systole): “Ejection” - “lub” - R wave (closure of AV valves-mitral/tricuspid)- happens at same time of carotid artery pulse
- Isometric relaxation= S2 (diastole): “Rapid Filling” - ”dub” - S wave (closure of semilunar valves-aortic/pulmonic)
- Heart Murmurs: forward blood flow across a stenotic heart valve (mitral stenosis)/backflow (retrograde) across insufficient valve (aortic insufficiency)/ Turbulent blood flow/shunting/increased blood flow via narrowed vessel. Monitor: timing, location, radiation, intensity, quality and pitch. Graded 1-6 (4-6: severe) (1-3: less severe) avg is 3. Level 6= loudest, greatest level of dysfunction= increasing amount of pathology, can hear with steth without even touching it to the pt. Note: timing, loudness, pitch, pattern, quality, location, radiation and posture. Change position if needed. Jugular Venous Pressure: Normal and Abnormal findings and clinical significance
- NORMAL- Reflects right atrial pressure: Normal to be distended when lying down/30 degrees. Should go away as pt sits up/stands up.
- ABNORMAL- Bulging, distended when sitting completely upright/standing (right sided HF)
Positioning: Left lateral/Sitting Pulse Deficit: When detecting irregularity: radial pulse - apical pulse = pulse deficit … happens with premature
- beats/irregular beats (A.fib) and CHF CLINICAL PORTRAIT OF CHF: dilated pupils, pallor/cyanotic skin, anxiety, decrease O2 sat, confusion, JVD, infarct, fatigue S3/gallop/tachycardia, splenomegaly, hepatomegaly, decreased urine output, weak pulse/moist skin/cold, ascites, pittin edema, N/V, hypotension, Dyspnea, orthopnea, crackles/wheezing.
- Checklist for Neck/Heart exam:
- Neck
- Carotid pulse: observe/palpate
- Jugular pulse: observe/estimate jugular venous pressure
- Precordium
- Inspection/palpation: describe location of PMI/apical pulse, note heaves/lifts/thrills
- Auscultation: Identify APE To Man landmarks, note rate/rhythm of HR, identify and listen for S1/S2 and any S3/S4 (extra sounds), murmurs, repeat w bell of steth, listen to apex w/person in left lateral position, listen at base in sitting position
Lymphatic System The vessels drain into two main ducts. The Right Lymphatic Duct drains the right side of the head, neck and arm. The Thoracic Duct drains the rest of the body. ● Cervical Nodes: drain the head and neck ● Axillary nodes: drain the breast and upper arm ● Epitrochlear nodes: in the antecubital fossa and drains the hand and lower arm ● Inguinal nodes: in the groin drain most of the lymph in the lower extremity, external genitalia, and anterior abdominal wall. Techniques for assessing the Lymphatic System
- Palpate the inguinal lymph nodes ● Normal findings is small, palpable nodes less than or equal to 1 cm that are movable and nontender.
- Palpate the peripheral arteries in both legs (femoral, popliteal, dorsalis pedis, posterior tibial) and grade the force on a 3 point scale.
- Locate the femoral arteries below the inguinal ligament halfway between the pubis and anterior superior iliac spines. ● Abnormal: Weak pulses or diminished pulse. Auscultate for a bruit.
- Popliteal pulse: Difficult to localize. With the leg extended but relaxed, anchor your thumbs on the knee and curl your fingers around into the popliteal fossa. Press your fingers forward to compress artery against the bone.
- Posterior Tibial Pulse: Curve your fingers around the medial malleolus. Feel the tapping right behind it in the groove between the malleolus and Achilles tendon.
- Dorsalis Pedis Pulse: Requires a light touch. ● Normal findings: Either dorsalis pedis or posterior tibial pulse. ● Abnormal findings: Absence of both dorsalis pedis and posterior tibial pulse on same foot. Arterial vs. Venous Insufficiency Arterial Insufficiency:
- Deep muscle pain
- Claudication-muscle pain on exertion, often interpreted as calf pain
- Rest pain-muscle pain continues at rest when activity has ceased
- Dependent rubor-distinction between client’s regular skin tone and a darker skin tone, will often see a “line” where skin is lighter on one side and darker on the other
- Diminished pulses ● release and note time for color return ● Normal findings: <3 seconds What can skew findings? Cold room, decreased body temp, cigarette smoking, peripheral edema, anemia findings should be equal BILATERALLY ● Palpate the radial pulses and note rate, rhythm, elasticity, force and grade it 0, +1, +2, or +3. ● Ulnar Pulses: Palpate the brachial and ulnar pulses. Normal findings should be +2 and regular bilaterally. ● Epitrochlear Lymph Node: In depression above and behind medial condyle of the humerus. Shake hands with a person. Reach your hand under a person’s elbow to the groove between the biceps and triceps just above the medial epicondyle Normal findings should be that it's not palpable. Allen Test: Depress radial artery, person opens and closes fist ● Normal→ blood returns via ulnar artery ● Occluded ulnar artery→ no blood return If DVT suspected ● Measure calf circumference with non-stretchable tape measure ● Signs: calf pain, edema, redness, skin discoloration, skin ulcers, gangrene Homan’s Sign → only about 35% accurate, if present it is likely that there is a DVT ● Ask client to raise their leg so femur is 90 degrees and calf is facing the bed, press the foot backwards (flex)-pain indicate POSITIVE homan’s sign Color changes: If you suspect an arterial deficit, raise the legs about 30 cm (1 foot) off the table and ask person to wag their feet for 30 seconds to drain off venous blood. The skin color now reflects only contribution of arterial blood. Then have person sit up and dangle legs, compare color of both feet and note time of color return ● Normal findings→ less than or equal to 10 secs for color return
Edema Pitting Edema Scales: 1+=2mm depression, barely detectable, immediate rebound 2+=4mm deep pit, a few seconds to rebound 3+=6mm deep pit, 10 - 12 seconds to rebound 4+=8mm very deep pit, >20 sec to rebound
- brawny edema: doesn’t pit, skin looks tight and shiny, painful What to do? Treat the cause, often w/ diuretics Ask the person to stand so that you can assess the venous system. Note any visible, dilated and tortuous veins. Manual Compression Test: While the person is still standing, test length of varicose vein to determine whether its valves are competent. Place one hand on lower part of the vein, and compress the vein with your other hand about 15 - 20 cm higher. ● Normal findings: Competent valves prevent a wave transmission and your lower (distal) fingers will feel no change. ● Abnormal findings: Wave felt. I. Abdomen a. Health Assessment: Abdomen i. Order of Assessment: Inspect → Auscultate → Percuss → Palpate *Note: Order is different because percussion/palpation alter the motility/sounds of the bowel
- Inspection a. Contour → should be flat or rounded (describes nutritional status) i. Stand on R-side, looking down abdomen ii. Observe from rib to margin of pubic bone iii. Abnormal: Scaphoid (sunken) or Protuberant (protrudes) b. Symmetry i. Abdomen should stay smooth and symmetric bilaterally as patient takes deep breath Abdomen Anatomical landmarks for assessing the abdomen Techniques for assessing the abdomen Normal and Abnormal Findings: Clinical Significance Bowel Sounds: Normal and Abnormal findings and clinical significance Abdominal pain: Assessment and Clinical Significance
- Skin changes
- Pain
- Pallor
- Pulselessness
- Paresthesia-numbing or tingling sensation
- Poikilothermia-inability to regulate body temperature, areas of affected limb may have some warm areas and some cooler areas
- Paralysis-complete loss of sensation and/or movement Risk factors: age, smoking, diabetes mellitus, hypertension, increased lipid levels, being male, obesity, high fat diet, heavy alcoho use, coagulation abnormalities and physical inactivity. Venous Insufficiency
- Aching
- Worsens with prolonged standing, sitting
- Brawny edema (greater than 4+)
- Coarse thickened skin-in light skin the tone may take on a brownish discoloration
- Dermatitis
- Pruritis-itching Risk factors: Pregnancy, prolonged sitting and standing, limited physical activity, age, obesity, and use of constrictive clothing.
4. Left lower quadrant: bladder, descending colon, ovary/uterus/fallopian tube OR prostate and spermatic cord, small intestine, sigmoid colon, left ureter ii. 9 regions: 2 longitudinal lines (at right and left midclavicular line) and 2 transverse planes (at subcostal and intertubercular lines) c. Techniques for assessing the abdomen i. Use strong overhead light ii. Have person empty bladder in order to relax abdominal wall iii. Patient supine, head on pillow, knees bent, arms at sides/across chest iv. Warm room, warm hands, warm stethoscope, short nails v. Assess painful areas LAST and use distraction d. Normal and Abnormal Findings: Clinical Significance i. Normal: Flat/round abdomen with no lesions/masses, with bowel sounds present in all quadrants (high pitched gurgles) ii. Abnormal
- Ascites = sound waves transmitted through the body tissue, with the character of the sound depending on density of underlying tissue a. Tympany - over air b. Dullness - over more solid tissue a. Bowel Sounds: Normal and Abnormal findings and clinical significance i. Normal: high-pitched gurgles are present ii. Abnormal:
- Hypoactive → constipation, post-op, side effect of certain medications
- Hyperactive → after eating, with diarrhea
- Hyperperistalsis (stomach growling) = Borborygmus (rumbling/gurgling from movement of fluid or gases in the intestines)
- Vascular sounds → can be normal (in 4-20% of patients, i.e. may auscultate aorta)
- Bruits → examine aorta, renal arteries, and iliac arteries for bruits (swishing)
- Friction rub (auscultate over liver and spleen to check → may indicate inflammation of peritoneal layer of organ/infection b. Abdominal Pain: Assessment and Clinical Significance
i. Rebound tenderness (Blumberg’s sign) - press deeply/firmly with hand at 90 degrees, and then rapidly withdra hand
- Normal to feel NO pain ii. Iliopsoas Sign (muscle test) - patient supine, lift R leg, flex at hip
- Push down over thigh as patient resists
- Normal to feel NO pain
- Abnormal to feel pain, means acute appendicitis iii. Obturator sign - patient supine, right leg lifted, flex hip and knee at 90 degree angle
- Hold the patient’s ankle and rotate leg internally/externally
- Normal is NO pain
- Abnormal if pain (means ruptured appendix/pelvic abscess) iv. Murphy’s Sign (inspiratory arrest) - Place fingers perpendicular under liver while patient takes deep breath
- Normal is no pain on inspiration
- Abnormal is pain (indicates Cholecystitis) v. McBurney’s point - point located above anterior superior spine of ilium (joins it to the umbilicus)
- Pressure with finger will elicit tenderness if acute appendicitis c. Referred pain → Pain that "shifts" from the original site of onset to another location in the abdomen is most often associated with acute appendicitis where periumbilical or epigastric pain (visceral) that is present early in the course of the disease is replaced with right lower quadrant (somatic) pain later in the illness d. Possible indications of pain in abdomen → appendicitis, cholecystitis, cirrhosis (ascites), gastric/duodenal ulcer (perforation!), intestinal obstruction, leaking abdominal aneurysm, ectopic pregnancy, PID, abdominal mass/lesion ❏ Objective data: Inspect → Auscultate bowel sounds → percuss all quadrants and organs (liver span/splenic dullness) → palpate abdomen → do final assessment ❏ Subjective data: “Patient states… .” Document if patient reports: ❏ (Nutritional assessment): Diet (“tell me about the food you ate yesterday?”), appetite changes, change in weight, dysphagia (difficulty swallowing), food intolerance/allergies (what is the reaction? Any alleviating/relieving factors?) ❏ N/V, bowel habits (frequency/color/diarrhea/constipation → How long? How often? Precipitating factors? Recent changes? Use of laxatives?) ❏ (Abdominal history): GI problems (ulcer, gallbladder disease, jaundice, appendicitis, colitis, hernia, carcinoma = cancer), injury/surgery (When? Reason? Post-op complications?, i.e. C-section), Abdominal studies (i.e. x-ray, MRI, CT; results? reason?) ❏ (Medications): “How would you treat a stomach ache?”, OTCs/remedies, Alcohol consumed (how much? Last drink? Define what is a drink), Smoking? (Packs per day?, How long?, Pack years?) ❏ (Abdominal pain - absent or present?): Point to location of pain and pain scale (0 to 10), PQRST/COLDSPA/OLDCARTS, Type of pain (Cramping = colicky, burning in pit of stomach, dull stabbing/aching, relieved by food/worse after eating?) Cultural Considerations: A. Native Americans a. Higher incidence of gallbladder disease, alcoholism, liver disease, pancreatitis, diabetes
