Chapter 8-11: Initial Assessments Flashcards
Inspection
A concentrated watching that begins at the moment you meet, a close scrutiny first of the individual as a whole and then of each body system
What are you looking for while you inspect?
Consciousness, Skin color, Hygiene, Bruises, Redness, Injuries
Palpation
applies your sense of touch to assess (texture, temp, moisture, organ location and size, any swelling, vibration or pulsation, rigidity or spasticity, crepitation (sounds like hair rubbing together), presence of lumps or masses and presence of tenderness or pain.
Different methods when palpating
- Fingertips: best for fine, tactile discrimination, as of the skin texture, swelling, pulsation and determining presence of lumps
- A grasping action of the fingertips and thumb – to detect the position, shape, and consistency of an organ or mass
- The dorsa (backs) or hands and fingers: best for determining temp because the skin here is thinner than on the palms
- Base of fingers or ulnar surface of the hand —best for vibration
- Bimanual palpation = using two hands
Percussion purpose
Mapping out location and size or organ, Signaling the density (air, fluid or solid), Detecting an abnormal mass and eliciting a deep tendon reflex using percussion hammer
Direct palpation
Using your fingers on one hand to directly tap the patient to feel vibration
Indirect Palpation
Using two hands and tapping your own finger, not tapping directly the patient
Amplitude
Intensity of sound
Pitch
Frequency or number of vibrations per second
Quality
A subjective difference by overtones of sounds
Duration
Length of time the note lingers
What has resonant sounds?
Lungs
What has hyper-resonant sounds?
Childs lung or lung with emphysema
What has Tympany sounds?
Stomach, Intestine
What makes a Dull Sound?
Liver or Spleen
What makes a Flat sound?
Thigh muscles or bone or tumor
Auscultation
Listening to sounds produced by the body like the heart, blood vessels, abdomen and lungs
DO NOT listen through gown
Diaphragm of stethoscope: purpose
used for high pitched sounds like breath, bowel, and normal heart sounds (press down firmly with this one)
Bell of a stethoscope: purpose
used for soft, low pitched sounds like murmurs and extra heart sounds (press lightly with this one)
Physical exam on Infant
Child should be on an exam table or parents lap, parent should be in view to the toddler, plan exam 1-2 hrs after feeding
Physical exam on the toddler
Toddler should be on parents lap sitting and nurse on a seat as well, child should have a security object
Physical exam with preschool child
Child can go on the exam table if comfortable, verbal communication with child is important at this point, do most invasion things at the end
Physical exam of the school aged child
The child should e sitting on the exam table, decide if they want parents in the office, make small talk and teach them what you’re doing and why, head to toe evaluation
Physical exam on the adolescent child
Have the child sitting on the exam table and communicate with care, treat adolescent not as a child and promote positive practices and attitude
Physical exam on the aging adult
On exam table, give feedback, dont rush, break up the exam into parts if needed, use physical touch, don’t mistake diminished vision and hearing for confusion
The ill person
Alter positions during exam based on patient and their distresses if present , just do what you need to do
What general observations should you make when the patient walks in?
Physical appearance, Body structure, Mobility, Behavior
Normal BMI
Between 19 - 25
BMI between 25 - 29.9
Overweight
BMI between 30 - 34.5
Obese
BMI between 35 +
Extremely obese
BMI below 18.9
Underweight
Normal Temperature
97F - 99.8F (Average is 98.6F or 37C)
What should you keep in mind when taking rectal temp?
it is usually .1 or 1 greater
Stroke volume
Every beat the heart pumps an amount of blood into aorta
Pulse
the force flares of the arterial walls and generates a pressure wave that is felt in the periphery
What is considered a normal rate for an adult
60 - 100 bpm
Bradycardia
abnormally slow heart rate below 50
Tachycardia
Abnormally high heart rate higher than 100
Sinus Arrhythmias
the heart rate varies with the respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration
3 pt scale for pulse
3+ - Full, bounding
2+ - Normal (most common)
1+ - weak, thready
0 - absent
Respirations normal value for neonate
30 - 60
Respirations normal for 1 yr old
20 - 40
Respirations normal for 2 yr old
25 - 32
Respirations normal for 8 - 10 yrs
20 - 26
Respirations normal for 12 - 14 ys old
18 - 22
Respirations normal for 16 yrs old
12 - 20
Normal respirations for Adult
10 - 20
What are you assessing when taking respirations
Rate, rhythm, force
Blood Pressure normal value
Below 120/80
Systolic over Diastolic
What is systole?
Ventricular contraction
What is Diastole?
Ventricular relaxation
What is MAP?
Mean Arterial Pressure: pressure forcing blood into the tissue averages over the cardiac cycle
What can vary your BP?
Weight, age, Sex, Race, Exercise, Emotions, Stress
What 5 factors determine your BP?
Cardiac Output, Peripheral Vascular Resistance, Volume of Circulating Blood, Viscosity, Elasticity of Vessel Walls
Why would you check thigh BP in an adult or adolescent if their brachial artery is high?
Because if you check thigh pressure and its lower than the arm (which is not normal) then it means coarctation of the aorta
What happens if you use a BP cuff that is too small?
BP will be higher than usual
What happens if you use a BP cuff that is too big?
BP will be lower than usual
What is the normal BP range?
Lower than 120/80
What is considered stage 1 hypertension?
140-159/90-99
What is considered stage 2 hypertension?
> 160/ >100
When would you take a tympanic temperature?
You would use with a toddler that squirms
When would you take an axillary temp?
With an infant
When would you take an oral temp?
When the child is old enough to keep his or her mouth closed with thermometer under their tongue
When would you take a rectal temp?
When no other routes are feasible, last resort
When should you palpate a radial pulse?
When the child is older than 2
Where should you take a pulse for infants and toddlers?
Auscultate and Palpate Apical pulse
How long should you count respirations for an infant and how should you count?
You should count for a full minute. Keep in mind that infants breather more diaphragmatically than thoracic so you can watch their abdomen for movement
Is BP the same, higher or lower in infants and children compared to adults?
Lower
Why would you use an electric BP device that uses oscillometry or a doppler on children younger than 3?
Because it is hard to hear the Korotkoff sounds since it is very light and cant be heard with a stethescope
Vital signs that change in the aging adult
Rhythm of their pulse may be slightly irregular, decreased in vital capacity and decreased inspiratory reserve volume, Aorta and major arteries stiffen, (systolic BP slightly higher), lower temp (greater risk for hypothermia)
Electric vital signs monitor should not be used in people with a low systolic BP of _______ or lower
90
What is considered hypotension?
<95/60 mm Hg in a normotensive adult, or below the normal BP for a hypertensive individual
Reasons for hypotension
Acute M.I, shock, hemorrhage, vasodilation, Addison’s disease
Is pain a vital sign?
Yes
4 phases of nociception
Transduction, Transmission, Perception, Modulation
What is neuropathic pain?
(Pain from direct damage to the nerve) The type of pain that does not adhere to typical phases inherent in nociceptive pain. Constant dull pain (Neuropathic back pain, Herpes Zoser, Diabetes or HIV, Central post stroke pain)
What is Nociceptive pain
(Nociceptors is tissue send messages to CNS) Activity of nociceptors in cutaneous and deep musculoskeletal tissue in response to tissue damaging stimuli inflammation (postoperative pain, bone metastases, arthritis, sports injury, mechanical back pain, liver metastases, pancreatic cancer)
What does OLDCARTS stand for?
Onset, Location, Duration, Character, Aggravation factors, Relieving factors, Timing and Severity (OBJECTIVE)
What is PQRST for pain assessment
Provocation/Palliation, Quality/Quantity, Region/Radiation, Severity scale, Timing
Visceral vs Somatic Pain
Visceral: Originates from larger organs
Somatic: originates from musculoskeletal tissue or body tissue
Cutaneous vs Referred pain
Cutaneous: is derived from the skin surface and subcutaneous tissue “sharp pain”
Referred: Pain that is felt in a particular site but originates from another location
Acute pain behaviors
Guarding, Grimacing, Vocalizations like moaning, Agitation, Restlessness, Stillness, Diaphoresis, Change in vital signs
Chronic Pain behaviors
Lasts longer than 6 months
Bracing, Rubbing, Diminished activity, Signing, Change in appetite
Pain assessment toold
Numeric rating, Verbal descriptor scales, Visual analog scale
Wong Baker Scale
Faces pain rating scale for infants and children
Oucher scale
1 - 10 scale using real faces of infants
NIPS
Neonatal infant pain scale
CRIES
Postoperative pain for preterm and term neonates
FLACC
infants and young children under 3
PIPS
premature infant pain profile
PAINAD
Pain Assessment In Advanced Dementia
Focuses on breathing, vocalization, facial expressions, body language, consolability
(Agitation, Pacing, Repetitive yelling indicates pain
Objective vs Subjective
Objective: what you observe
Subjective: What patient tells you
CRPS
Complex Regional Pain Syndrome
(Chronic progressive nerve condition, characterized by burning pain, swelling, stiffness and discoloration of the affected extremity. Occurs weekks to months after a nerve injury [causes neuropathic “short circuit”])
Results of overnutrition
Type 2 diabetes, heart disease, hypertension, stroke, gallbladder disease, sleep apnea, certain cancers, osteoarthritis
BMI for overweight
25 or greater
BMI for Obese
BMI of 30 and up
Types of nutritional assessments
Nutrition screening (first step), Comprehensive nutritional assessment (dietary info, clinical info, physical exam, lab tests) , 24 hr recall, Food diary ( can be inaccurate and atypical, could be altered deliberately)
Should children drink skim or low fat milk under the age of 2?
No because they need fat
Normal weight gains for pregnant women
25 - 35 lbs for normal weight women
28 - 40 lbs for underweight women
11 - 20 lbs for overweight women
Most commonly anthropometric measures
Heigh and weigh, tricep skin fold test, elbow breadth, arm and head circumference
3 derived weight measure
Body weight as a percentage of ideal body weight, Percent usual body weight, BMI
Android obesity
Person with greater proportion of fat in upper body, especially abdomen
Gynecoid obesity
Person with most fat in the hips and thighs
Waist circumference
Measured in inches at larges circumference below ribcage and above umbilicus
Hip circumference
Measured in inches at largest circumference of buttocks (can indicate greater health risk alone)
Skinfold thickness, location mainly done
Triceps
What does low hemoglobin and Hematocrit mean?
Low iron
Serum Albumin
Protein, patient with renal problems have low protein
Adolescent nutrition
Shoudl increase caloric and protein intake to meet demands of bone growth and increasing muscle mass
Difference between boys and girls during growth
Boys are taller around 10 -17
Girls have more body fat and double their weight between 8 - 14
Metabolic syndrome and the 5 biomarkers
Syndrome carries increased cardiac risk and is diagnosed when a person has 3 of the following 5 biomarkers -Elevated BP -Increased fasting plasma glucose -Elevated triglycerides -Increased waist circumference Low high-density LipoproteinS (HDL)
Sarcopenic obesity
Sarcopenia (loss of muscle mass) combines with an increase in body fat
