Clinical Examination PDF
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Uploaded by GlimmeringAgate1495
Badr University in Cairo
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Summary
This document provides an overview of clinical examination, focusing on vital signs, including body temperature, pulse, and respiratory rate. It also covers different sites for measuring these vital signs and when to take them. The document also discusses various factors affecting vital sign measurements.
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CLINICAL EXAMINATION 1- VITAL SIGNS Vital Signs Because of the importance of Examination of body temperature, heart (pulse) rate (HR), respiratory rate (RR), blood pressure(BP) provides the physical therapist with important data about the status of the cardiovascular/...
CLINICAL EXAMINATION 1- VITAL SIGNS Vital Signs Because of the importance of Examination of body temperature, heart (pulse) rate (HR), respiratory rate (RR), blood pressure(BP) provides the physical therapist with important data about the status of the cardiovascular/ pulmonary system. These measurements are referred to as Vital Signs. They are important indicators of the body’s response to physical, environmental, and psychological stressors. Vital Signs VS may reveal sudden changes in a client’s condition in addition to changes that occur progressively over time. A baseline set of VS are important to identify changes in the patient’s condition. VS are part of a routine physical assessment and are not assessed in isolation. Other factors such as physical signs & symptoms are also considered. (pain, difficult breathing, cyanosis, cough ,various sound of respiration (wheezing) ) When to take vital signs 1. On a client’s admission 2. According to the physician’s order or the institution’s policy or standard of practice 3. When assessing the client during home health visit 4. Before & after a surgical or invasive diagnostic procedure 5. Before & after the administration of meds or therapy that affect cardiovascular, respiratory & temperature control functions. 6. When the client’s general physical condition changes i.e pain 7. Before, after & during nursing interventions influencing vital signs 8. When client reports symptoms of physical distress Body Temperature Core temperature – temperature of the body tissues, is controlled by the hypothalamus– maintained within a narrow range. Skin temperature rises & falls in response to environmental conditions & depends on blood flow to skin & amount of heat lost to external environment The body’s tissues & cells function best between the range from 36.5 deg C to 37.5 deg C Temperature is lowest in the morning, highest during the evening. Sites Oral No hot or cold drinks or smoking Leave in place 3 min Posterior sublingual pocket – 20 min prior to temp. Must be under tongue (close to carotid awake & alert. artery) Not for small children (bite down) Axillary Non invasive – good for children. Leave in place 5-10 min. Bulb in center of axilla Less accurate (no major bld Measures 0.5 C lower than oral Lower arm position across chest vessels nearby) temp. Rectal When unsafe or inaccurate by Leave in place 2-3 min. Side lying with upper leg flexed, mouth (unconscious, disoriented Measures 0.5 C higher than oral insert lubricated bulb or irrational) Side lying position – leg flexed Ear Rapid measurement 2-3 seconds Close to hypothalmus – sensitive Easy assessibility to core temp. changes Cerumen impaction distorts Adult - Pull pinna up & back reading Child – pull pinna down & back Otitis media can distort reading Assessing Arterial Pulse Left ventricle contracts causing a wave of blood to surge through arteries – called a pulse. Felt by palpating artery lightly against underlying bone or muscle. Carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis Assess: rate, rhythm, strength – can assess by using palpation & auscultation. Pulse deficit – the difference between the radial pulse and the apical pulse – indicates a decrease in peripheral perfusion from some heart conditions ie. Atrial fibrillation. Procedure for Assessing Pulses Peripheral – place 2nd, 3rd & 4th fingers lightly on skin where an artery passes over an underlying bone. Do not use your thumb (feel pulsations of your own radial artery). Count 30 seconds X 2, if irregular – count radial for 1 min. and then apically for full minute. Apical – beat of the heart at it’s apex or PMI (point of maximum impulse) – 5th intercostal space, midclavicular line, just below lt. nipple – listen for a full minute “Lub-Dub” Lub – close of atrioventricular (AV) valves – tricuspid & mitral valves Dub – close of semilunar valves – aortic & pulmonic valves Assess: rate, rhythm, strength & tension Rate – N – 60-100, average 80 bpm Tachycardia – greater than 100 bpm Bradycardia – less than 60 bpm Rhythm – the pattern of the beats (regular or irregular) Strength or size – or amplitude, the volume of blood pushed against the wall of an artery during the ventricular contraction weak or thready (lacks fullness) Full, bounding (volume higher than normal) Imperceptible (cannot be felt or heard) Normal Heart Rate Age Heart Rate (Beats/min) Infants 120-160 Toddlers 90-140 Preschoolers 80-110 School agers 75-100 Adolescent 60-90 Adult 60-100 Respirations Assess by observing rate, rhythm & depth Inspiration – inhalation (breathing in) Expiration – exhalation (breathing out) I&E is automatic & controlled by the medulla oblongata (respiratory center of brain) Normal breathing is active & passive Women breathe thoracically, while men & young children breathe diaphragmatically ***usually Asses after taking pulse, while still holding hand, so pt is unaware you are counting respirations Assessing Respiration Rate # of breathing cycles/minute (inhale/exhale-1cycle) N – 12-20 breaths/min – adult - Abnormal increase – tachypnea Abnormal decrease – bradypnea Absence of breathing – apnea Depth Amount of air inhaled/exhaled normal (deep & even movements of chest) shallow (rise & fall of chest is minimal) SOB shortness of breath (shallow & rapid) Rhythm Regularity of inhalation/exhalation Normal (very little variation in length of pauses between I&E Blood Pressure Force exerted by the blood against vessel walls. Pressure of blood within the arteries of the body – left ventricle contracts – blood is forced out into the aorta to the large arteries, smaller arteries & capillaries Systolic- force exerted against the arterial wall as left ventricle contracts & pumps blood into the aorta – max. pressure exerted on vessel wall. Diastolic – arterial pressure during ventricular relaxation, when the heart is filling, minimum pressure in arteries. Factors affecting B/P lower during sleep Lower with blood loss Position changes B/P Anything causing vessels to dilate or constrict - medications B/P (cont.) Measured in mmHg – millimeters of mercury Normal range syst 110-140 dias 60-90 Hypertensive - >160, >90 Hypotensive