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What is the General Approach?
- - Measure 1. height; 2. weight; 3. blood pressure; 4. TPR (temperature, pulse, respiratory); 5. pain
- - Provide an exam gown; ask the patient if he / she needs assistance, otherwise respect privacy while changing into exam gown; tell him / her that the ties go in the back
- - Wash your hands before having contact with the patient (wash hands constantly, 20 second hand wash - Happy Bday twice, use hand sanitizer between the fingers)
- - Explain each step
- - Give encouragement as you proceed (Leave abnormality to the end & don't be judgmental)
- - Organize the exam for optimal efficiency & patient comfort
- - Use systematic approach so as not to forget anything (start at the head to the feet)
- - Give a summary of findings & given an opportunity for questions (not done with the exam, I'll give you a summary at the end)
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What is consisted in the General Survey?
- - Physical Appearance
- - Body Structure
- - Mobility
- - Mental Status & Behavior
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What is consisted in the Physical Appearance of the General Survey?
- Age: Appear stated age? Younger/older?
- Sex: Sexual development appropriate for age? Early development?
- Skin: Face is pale / red? Skin lesions? Burns?
- Facial Features: Symmetric?
- Signs of Acute Distress: Pain shown in face? Grasp Chest? SOB?
- Personal Hygiene: Body odor? Dirt on skin, disheveled appearance
- - Poor hygiene may be a sign of physical or mental illness (may not be properly groomed)
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What is consisted in the Body Structure of the General Survey?
- Stature (height w/in standards; under 5' or above 7')
- Nutrition (well nourished / adequate, overweight, obese, thin, cachectic - loss of body mass)
- Symmetry (atrophy, hypertrophy, swelling, etc.) - disuse of extremities can lead to dystrophy, swelling = excess fluid like edema (Ex. Congestive Heart Failure, Rheumatoid Arthritis , Heart & Kidney Failure, Pregnancy)
- Posture (erect, slumped) - erect in bed / sitting up in bed, slumped (can detect mental illness or depression)
- Position (relaxed, tense, fetal) - peritinitis (fetal position because stomach hurts)
- Body build & contour (lean, muscular)
- Physical deformities
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What is consisted in the Mobility of the General Survey?
- Gait - how do they walk?
- ROM - (FROM vs limited ROM)
- - FROM = Full Range of Motion
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What is the Clinical Measurements?
- Analyze data: patient's past & normal
- Analyze in relation to:
- - Normal Ranges (Ex. B/P, P, R) - look at change over time
- - Client's Recent Values & Serial Readings (Ex. Daily weights for fluid monitoring in heart failure)
- - Diagnosis (Ex. With cancer, you may expect the patient to be underweight)
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Weight
- Remove shoes (but doesn't happen b/c of athlete's foot) & heavy clothing
- Serial weights - patient w/ ineffective pump, accumulate fluid. Morning = lightest weight
- Weight Gain
- - Overeating or decreased activity
- - 2.2 pounds weight gain = 1L of water. Fluid volume excess to weight.
- - > 2-3 pounds per week is significant (may be related to decompensating heart failure)
- - Hypothyroidism (slows metabolism) - weight gain
- - Drug therapy - steroid = weight gain
- - Diabetes b/c of insulin, metabolism is effected
- Weight Loss (intentional vs unintentional)
- - Anorexia or decreased intake
- - Dehydration
- - Increased metabolic rate - hyperthyroidism
- - Diabetes (new onset or poor control)
- - Malignancy, cancer, etc.
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Apple Figure
Weight above waist
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Pear Figure
- Weight below waist
- Better figure
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Weight in the middle
Causes heart disease
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Vital Signs
- TPR
- B/P
- Pain is 5th Vital Sign
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Temperature
- Regulated by hypothalamus
- - Febrile: Fever
- - Afebrile: No fever
- Temperature affected by:
- - Diurinal cycle (1-1.5 degrees F change)
- - Peak: Late afternoon (4:00 p.m.)
- - Trough: early AM (4:00 a.m.)
- - Menstrual cycle (temperature increase by 0.5-1 degrees Fahrenheit starting at midcycle ovulation through menses due to progesterone secretion)
- - Moderate / heavy exercise
- - Age
- - Children under 8 years old may have high fevers w/ minor illness (Ex. 103-105 degrees F) - minor illness may equal to high temperature
- - Older Adults (increased risk for hypothermia) - unreliable in elderly
- - Illness
- - Prolonged exposure to cold - can cause hyperthermia
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Normal Temperatures
- Oral (benchmark) / Normal Body Temperature: 98.6 degrees F (range = 96.4 - 99.1); 37 degrees C (range = 35.8 - 37.3)
- - Blue probe
- - Insert at base of tongue (sublingual pocket)
- - Wait 15 minutes after drinking hot or cold drinks
- - Wait 2 minutes after smoking
- Rectal: 1 degree F or 0.5 degree C higher than oral
- - Red probe
- - Insert 1 inch (use lubricant)
- Tympanic (ear): 1 degree F or 0.5 degree C higher than oral
- - Unreliable with ear infection or local inflammation (tooth)
- Axillary (underarm): 1 degree F or 0.5 degree C lower than oral
- - Red probe
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Fever
- Generally defined as temperature > 101-101.5 degrees F or > 38-38.5 degrees C
- Afebrile = no fever
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What is consisted of the Pulse?
- Palpate radial pulse for rate & rhythm
- Factors Increasing Pulse Rate
- Pulse Deficit (difference between apical & radial pulse)
- Pulse Strength (force created in the artery by the stroke volume)
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Radial pulse for rate & rhythm
- If rate is regular: count for 30 seconds & multiply by 2
- If rate is irregular: count for 60 seconds
- Sinus arrhythmia: pulse increases with inspiration & decreases with expiration (common in children & young adults)
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Children's pulse
Use apical pulse until 2 years old, then radial (count x 1 min.)
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Where is the apical rate located?
Under the apex of the heart
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Does artery or vein have a pulse?
Artery
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Adult's pulse
- Normal Rate: 60-100 beats per minute - SA node fires
- Bradycardia < 60 bpm (slow)
- Tachycardia > 100 bpm (fast)
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What are the factors increasing pulse rate?
- Age (higher in children) - as person ages, it slows down
- Female - higher
- Exercise
- Anxiety
- Pain
- Fever - higher fever, higher heart rate
- Dehydration
- Anemia - decrease in RBC, heart rate increase
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What is the Pulse Deficit?
- Difference between apical & radial pulse
- In healthy heart, apical rate should be the same as the radial rate, then this indicates cardia arrhythmia
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What does it mean when radial rate is slower than apical rate?
Weak heart
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What is the Pulse Strength?
Force created in artery by the stroke volume
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What is the Pulse Strength Scale?
- 4+ bounding (exercise, heart disease if normal)
- 3+ full (norm during exercise)
- 2+ normal
- 1+ weak, thready
- 0 absent. no circulation to extremity
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Respirations
- Count breaths up to 30 seconds & multiply it by 2
- Children = count the full 60 seconds
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When assessing rhythm for respiration,
- If rhythm is irregular, count for 60 seconds
- Children - count for 60 seconds
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What is the respiration rate?
- Varies with age & fitness
- Children - age specific variations
- Adult Norms - 10 - 20 breaths per minute
- - Bradypnea < 10 breaths per minute (not adequate breaths, slow respiration)
- - Tachypnea > 20 breaths per minute
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What is the respiration depth?
Shallow, moderate or deep
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What is the respiration character?
- Thoracic (women) - chest breathers (watch chest)
- Abdominal (men & infants) - (watch abdomen)
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What is the abnormal respiration patterns?
- Hyperventilation
- Hypoventilation
- Apnea
- Dyspnea
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What is the "force exerted against walls of peripheral vessels during cardiac cycle?"
Blood Pressure
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What is the maximum pressure exerted on arterial walls during ventricular contraction?
Systolic Pressure
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What is the resting pressure between contractions / lower pressure?
Diastolic Pressure
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What is the difference between systolic & diastolic blood pressure / record for stroke pressure?
Pulse pressure
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What is the pressure forcing blood into the tissues averaged over the cardiac cycle?
Mean Arterial Pressure
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What is the equation for Mean Arterial Pressure?
MAP = DPB + 1/3 pulse pressure
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What are the factors determining blood pressure?
- Cardiac Output
- Volume of Circulating Blood (Ex. hemmorhage - decreased)
- Blood Viscosity (increased pressure w/ thicker blood)
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