Diagnostic Procedures, Nuclear Medicine and Complementary Medicine

Observation

• The first step in a physical assessment involves observing the patient’s appearance, emotional affect, and ambulation.
• Overall appearance encompasses factors like appropriateness of dress, body odor, and signs of self-care difficulties.
• Emotional affect refers to the patient’s expression, tone of voice, mood, and emotions.
• Affect means the outward expression of emotion.
• Ambulation refers to the way the patient walks, assessing gait, steadiness, and any potential difficulty.

Basic Examination Procedures

• Basic examination procedures are performed during the assessment of a patient’s condition.
• In medicine, assessment means evaluating or appraising the patient’s condition.
• This information is used to reach a diagnosis and formulate a care plan.

Diagnostic Procedures

• A range of diagnostic tools are utilized to determine a patient’s general health and to identify specific medical conditions.

Vital Signs

• Vital signs indicate how well the body systems are functioning and are recorded for most patient visits; they include temperature, pulse, respiration, and blood pressure.
• VSS is the abbreviation for vital signs stable.

Temperature

• Normal body temperature averages around 98.6°F (Fahrenheit) or 37.0°C (Celsius).
• An oral body temperature exceeding 100°F indicates a fever.
• Fever is most often caused by an infection, injury, or medication.
• Temperature readings are named for the location in which they are taken: oral (mouth), aural (ear), axillary (armpit), and rectal.
• A temporal artery (forehead) scanner can also be used.
• Oral and aural readings sound alike.
• Different thermometers are required and are taken in different locations.
• Temperature readings vary slightly depending on the location in which they are taken.
• Hyperthermia is an extremely high body temperature.
• Hyperthermia is usually caused by prolonged exposure to environmental heat.
• Hyper- means excessive, therm means heat, and -ia means pertaining to.

Pulse

• Hypothermia is an abnormally low body temperature.
• Hypo- means deficient, therm means heat, and -ia means pertaining to.
• Pulse is the rhythmic pressure against the walls of an artery caused by the heart's beating.
• Heart rate reflects the number of times the heart beats per minute, recorded as bpm.
• Pulse can be measured at different pulse points on the body.
• Normal resting heart rate varies by age group; adults: 60-100 bpm, newborns: 100-160 bpm, athletes: 40-60 bpm.
• Heart rates are generally higher in children.
• Four main pulse points are: carotid (on either side of the front of the neck), radial (at the wrist), femoral (at the inner thigh), and dorsalis pedis (on the top of the foot, in line with the second toe).
• Palpate for at least 15 seconds and avoid palpating with your thumb when assessing a person’s pulse.

Respiration

• Respiration, also known as the respiratory rate (RR), measures complete breaths per minute.
• A single respiration consists of one inhalation and one exhalation.
• A normal respiratory rate for adults is 12 to 20 respirations per minute.

Blood Pressure

• Blood pressure (BP) is the force of blood against artery walls.
• BP is measured using a sphygmomanometer.
• Using a manual sphygmomanometer requires a stethoscope to listen to blood sounds.
• Digital sphygmomanometers are automated and do not require a stethoscope.
• Blood pressure is recorded as a ratio of systolic over diastolic readings.
• Systolic pressure indicates the first heartbeat.
• Diastolic pressure indicates the last heartbeat.
• Memory aid: SSSS-systolic as in going up to the sky; DDDD-diastolic as in going down.
• Using a stethoscope, the systolic pressure is the first sound heard, and the diastolic pressure is the last beat heard.

Pain

• A pediatric pain scale uses facial expressions instead of numbers.
• Acute pain comes on quickly, is severe, lasts briefly, and subsides when the cause is diagnosed and treated.
• Acute pain can be caused by disease, inflammation, or injury.
• Chronic pain, which can be mild to severe, lasts for a longer time compared to acute pain and resists most medical treatments.

Auscultation

• Auscultation means listening for sounds within the body.
• Auscultation is usually performed through a stethoscope.

Respiratory Sounds

• Respiratory sounds heard through a stethoscope can provide data about the condition of the lungs and pleura.
• Rales, also known as crackles, are abnormal crackle-like lung sounds heard during inspiration (breathing in).
• Rhonchi are coarse rattling sounds, somewhat like snoring, usually caused by secretions in the bronchial airways.
• Stridor is an abnormal, high-pitched, musical breathing sound caused by a blockage in the throat or larynx.

Heart Sounds

• Heartbeat sounds heard through a stethoscope have two distinct sounds: LUBB dupp, or LUB dubb.
• The "lubb" sound is heard first, caused by the tricuspid and mitral valves closing between the atria and the ventricles.
• The "dupp" sound is shorter and higher pitched, and it is heard next, caused by the valves in the aorta and pulmonary arteries closing as blood is pumped out of the heart.