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General Approach
- -Measure height, weight, BP, TPR, vision if applicable
- -Provide exam gown, leave when pt undressing
- -Wash hand's in front of pt
- -Explain each step
- -Give encouragement as you proceed
- -Organize exam for efficiency & pt comfort
- -Use systematic approach (top down, in sequence)
- -Give summary of findings
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General Appearance
(physical characteristics)
- -Age (look stated age?)
- -Sex (development appropriate to age?)
- -Skin (pale, red, flushed, cyanotic, lesions, sores?)
- -Facial features (symmetric?)
- -Signs of acute distress (SOB, in pain?)
- -Personal hygiene (clean, well groomed, oily, BO)
- -Involuntary movement (twitches, tics)
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General Appearance
(body structure)
- **WDWN: well developed well nurtured
- -Stature (height w/in standards)
- -Nutrition ( well nourished, overweight, obese, thin, cachetic [thin, wasted])
- -Symmetry (atrophy, hypertrophy, swelling)
- -Posture (erect, slumped-sign of depression)
- -Body build (lean muscular)
- -Physical deformities (limp, one leg shorter)
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General Appearance
(Mobility)
(& Mental status & behavior)
- -Gait (how they walk: steady, ataxic, ataxic gait [drunk walk])
- -ROM (FROM vs. limited ROM)
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Clinical Measurements
- -An essential part of initial data base
- -Analyzed in relation to normal ranges, client's recent values & serial readings, and dx
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Weight
- -Remove shoes & heavy clothing
- -Serial weights
- -Weight gain
- -Weight loss (intentional, unintentional)
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Weight gain
- -Rapid: liquid; slow: food
- -Overeating or decreased activity
- -Fluid vol. excess (2.2lb gain = 1L; > 2-3lbs/wk is significant); kidney dysfunction
- -Hypothyroidism (underactive = dec secretion of TH = hypometabolism)
- -Drug therapy (corticosteroids: inc apetite
- -Diabetes: II overweight b/c excess circulating insulin which alters fat distribution (accumulates)
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Height, weight & head circumference
(children)
- -Plot on graph, compare to norms
- -Check head circum. until age 2, & yearly til age 6
- -hydrocephalus, mental retardation
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Temperature
- -Regulated by hypothalamus
- -Febrile vs afebrile
- -febrile seizure: give tepid bath to bring fever down to prevent seizure
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Things that affect temperature
- -Diurnal cycle (1-1.5° change; peak: lowest late afternoon 4PM; trough: highest early am 4AM)
- -Menstrual cycle: temp inc 0.5-1.0°F midcycle ovulation through menses due to progesterone secretion
- -Moderate/heavy exercise
- -Age: Children under 8 may have high fevers w/ minor illness (103-105°); older adults inc risk of hypothermia
- illness: infection, inflammation
- -Prolonged exposure to cold
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Fever
Generally defines as temp > 101-101.5°F or > 38-38.5°C
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Temp Techniques:
-Oral
-Rectal
-Tympanic
- O: insert at base of tongue (sublingual pocket), wait 15 min after hot/cold fluids, 2 min after smoking
- R: insert 1 in using lubricant
- T: unreliable w/ ear infection or local inflammation (tooth, dental infection)
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Pulse:
-Regular
-Irregular
-Sinus arrythmia
- *Palpate radial pulse for rate and rhythm
- R: count 30 sec x 2
- I: count 60 sec
- SA: pulse inc w/ inspiration, dec with expiration (common in children, young adults)
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Pulse:
-Children
-Adults
- C: use apical pulse until 2 yo, then radial (1min)
- A: normal = 60-100bpm, bradycardia < 60, tachycardia >100
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Factors increasing pulse rate
- -Age (higher in children)
- -Female
- -Exercise
- -Anxiety
- -Pain
- -Fever
- -Dehydration
- -Anemia (heart works harder to circulate what's present)
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Pulse Deficit
- *Difference between apical pulse and radial pulse
- -Should both be the same. If not = may mean heart isn't strong enough to push apical pulse to radial pulse; maybe cardiac arrythmia
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Force
4+, 3+, 2+, 1+, 0
- *Strength of SV
- 4+ bounding
- 3+ full (normal during exercise)
- 2+ normal
- 1+ weak, thready
- 0 absent
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Elasticity
- *Artery feels straight, resilient, soft
- -how rubbery the artery feels, not stiff
- -atherosclerosis: hardened artery, plaque in vessels
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Respirations
(reg, irreg, children)
- R: count 30 sec x 2
- I: count 60 sec
- C: count 60 sec
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Rate of Respirations
- -Varies w/ age and fitness
- -Children: age specific
- -Adults: 10-20/min
- -bradypnea: < 10/min
- -tachypnea: > 20/min
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Respirations:
-Rhythm
-Depth
- R: eupnic (regular, even, quiet breathing)
- D: shallow, moderate, or deep
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Respirations:
-Type
-Abnormal patterns
- T: thoracic (women breathe through thorax); abdominal (men & infants)
- AP: hyperventilation, hypoventilation, apnea, dyspnea
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Blood pressure
- *Force exerted against walls of peripheral vessels during the cardiac cycle
- -Systolic, diastolic, pulse pressure
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Systolic Pressure
*Maximum pressure exerted on arterial walls during ventricular contraction
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Diastolic pressure
*Resting pressure b/t contractions
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Pulse Pressure
*Difference b/t systolic & diastolic BP
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Factors Determining BP
- -CO (sys higher when heart works more)
- -Vol. of circulating blood
- -Blood viscosity (inc pressure w/ thicker blood, takes more force to pump)
- -Peripheral Vascular Resistance (PVR): in pressure is generated to pump against constricted BV, heart works harder to pump
- -Elasticity of vessel walls: inc pressure w/ stiffer vessels
- -SNS may inc BP
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Hypertension levels
- *must be doc on 2 separate occasions
- -Medical dx, doc as elevated BP til dx is made; requires serial BP to dx
- -Take in both arms, take highest reading
- SBP > or = 140 or
- DBP > or = 90
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Factors Increasing BP
- -Age, male gender (female after menopause), race (african americans), alcohol, white coat syndrome, obesity
- -Diurnal rhythm: highest in late afternoon, lowest in early am
- -Exercise (inc 5 min after exercise)
- -Emotions, stress & pain (stimulation of SNS)
- -Smoking/caffeine (wait 30 min before taking BP)
- -Meds (NSAIDS, pseudoephedrine [decongestants])
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