Week 1 PPT for PA PDF

Welcome to Physical Assessment Dr. Laura Graafland, DNP, MS, AGPCNP-BC, CBCN Communication Assigned TAs Name Uni Assigned Students by Last Name Kathleen McAuliffe kcm2202 A-D Akilah Tatyana Lovell...

Welcome to Physical Assessment Dr. Laura Graafland, DNP, MS, AGPCNP-BC, CBCN Communication Assigned TAs Name Uni Assigned Students by Last Name Kathleen McAuliffe kcm2202 A-D Akilah Tatyana Lovell atl2156 E-J Trevor Chang tjc2191 K-Me Lindsey Jameson lmj2156 Mi-R Thomas Nguyen tcn2117 R-Z 2 Academic Coaching Core academic course support for course content, time, organization, and study management skills Peer to peer support (Doctoral students provide coaching) Weekly small group tutoring and pre-exam review sessions Submit a request form to [email protected] 3 Grading Assignments/Assessments Grade Weight Anatomy Quizzes 25% Midterm Exam 30% Final Exam (cumulative) 35% Kaplan Focused Review and Integrated Test 5% Participation 5% 4 Health Assessment Health Assessment Health assessment is a systematic, deliberative and interactive process by which nurses use critical thinking to collect, validate, analyze and synthesize the collected information to make judgement about the health status and life processes of individuals, families and communities. FOUNDATION FOR QUALITY NURSING CARE AND INTERVENTION! 6 7 Why Learn Basic Clinical Skills? 70% of diagnoses can be made based on history alone. 90% of diagnoses can be made when the physical exam is added. Lab or radiologic tests often confirm what is found during the H&P. The skills necessary to perform the H&P are the foundation of clinical practice. 8 Assessment: The Nursing Approach (7 Facets) Physical Health: how the body works and adapts Emotional health: positive outlook and emotions channeled in a healthy manner Social well-being: supportive relationships with family and friends Cultural influences: favorable connections to promote health Spiritual influences: living peacefully, morally and ethically Environmental influences: favorable conditions to promote health Developmental level: how one thinks, solves problems and makes decisions 9 Critical Thinking We all start at the novice level Critical thinking is how we become experts Learn to assess and modify before acting Learn to think outside the box – multidimensional thinking processes Necessary for excellent clinical judgement 10 Components of Health Assessment and Types of Data Collection Components of Health Assessment 1. Health History (subjective data) 2. Physical Assessment (objective data) 3. Documentation/Communication of findings 12 4 Types of assessment 1. Comprehensive - Complete Assessment – Complete health history and full head to toe physical exam – Describes the patient’s current and past health state – Provides baseline for future assessments – Ex: annual well visit or a baseline assessment when a patient first enters the health care setting 13 4 Types of assessment 2. Problem Focused – Episodic Assessment – Assessing a specific system (or 2) due to a specific patient complaint – Ex: Sick visit, patient complains of sore throat à you will take a history and physical specific to ears, nose, throat, respiratory 3. Problem Focused - Follow-up Assessment – A repeated/follow up assessment focused on a known/existing problem to monitor effectiveness of an intervention. – Usually conducted at regular intervals (i.e., every 3 months) 4. Problem Focused – Emergency Assessment – Rapid focused assessment conducted when addressing life-threatening or unable clinical conditions. – Circulation, airway, breathing 14 Comprehensive vs Focused Assessment Comprehensive Focused New patients to office/hospital Used for established patients especially during follow-up, new problems or urgent visits Provides fundamental and personalized Addresses focused concerns or symptoms knowledge about the patient Provides baseline for future assessments Assess symptoms restricted to a specific body system Creates a platform for health promotion Applies exam methods relevant to assessing the concern or problem as thoroughly and carefully as possible Strengthens the clinician-patient Applies to Episodic, Follow up, or relationship Emergency visits Helps identify or rule out physical causes related to patient concerns 15 What type of assessment? Patient presenting with a cold for two weeks Patient previously diagnosed and treated for osteoarthritis returning to evaluate the effectiveness of recent pain regimen changes Pediatric patient with h/o allergy to bee sting, reporting to counselor that he was just stung by a bee 16 Subjective vs Objective Data Subjective data (symptoms) – What the patient says about themself during the history taking. Objective data (signs) – What you as the healthcare professional observe by inspecting, percussing, palpating and auscultating during the physical exam (or review via laboratory studies) Both comprehensive AND focused assessments will always contain a combo of subjective and objective information 17 Subjective or Objective? Indigestion Blurred vision Unequal pupils Nontender Voice change Palpitations abdomen Absent R nasolabial Coarse hair Dizziness fold Intermittent cough Morning stiffness Epistaxis Intact gag reflex Cyanosis Nausea Sore shoulder Blood in urine Weight gain Deviated septum Orthopnea Edema 18 Disparities in Healthcare  Social Determinants of Health WHO: the conditions in which people are born, grow, work, live, and age, and are the wider set of forces and systems shaping the conditions of daily life. They are the social, economic, and political conditions that influence the health of both individuals and populations. 20 Implicit bias A set of unconscious beliefs or associations that lead to a negative evaluation of a person based on their perceived group identity – Race and Ethnicity bias – Gender bias – LGBTQIA + community bias – Age bias 21 Continuum of self evaluation Reflect on patterns of emotion and behavior Pause before starting and prepare for potential triggers of bias Generate alternative hypotheses for biases anchored in behavior Use universal communication and interpersonal skills Explore your patients’ identities Explore your patients’ experiences of bias 22 Cultural Humility “process that requires humility as individuals continually engage in self-reflection and self-critique as lifelong learners and reflective practitioners” in effort to address power imbalances and to advocate for others Three dimensions of cultural humility – Self-awareness – Respectful communication – Collaborative partnerships 23 Trauma informed care Trauma-informed care is defined as practices that promote a culture of safety, empowerment, and healing. The first step is to recognize how common trauma is, and to understand that every patient may have experienced serious trauma. Adopting trauma-informed practices can potentially improve patient engagement, treatment adherence, and health outcomes, as well as provider and staff wellness. 24 Therapeutic Communication  Listening and understanding the patient’s message Therapeutic Communication = Facilitating the patient’s verbalization and understanding their feelings Provide an atmosphere of acceptance and understanding 26 Things to remember: Always be aware of the patient’s nonverbal communication – Is their body language matching what they are saying? – Is the patient saying what they really mean? Your nonverbal communication is just as important Maintaining a physical environment that facilitates therapeutic communication is key – Room temp – Sufficient lighting – Quiet/no distractions – Maintain comfortable distance – Equal status seating – Patient should remain clothed for the history/interview 27 Nonverbal Communication Skills SOLER: Sit squarely or at an angle Open posture Lean forward Eye Contact Relax Be aware of gestures and facial expressions 28 Verbal Communication Techniques Facilitation Silence Reflection Empathy Clarification Confrontation Interpretation Examiner led techniques Explanation Summary 29 Ten Traps of Interviewing Providing false reassurance Giving unwanted advice Using authority Using avoidance language Engaging in “distancing” Using professional jargon Using leading or biased questions Talking too much Interrupting Using “why” questions 30 Conducting the Interview Introduction – Introduce yourself (formal title) – Ask the patient their preferred name – Ask about their pronouns – Ensure confidentiality/privacy The Working Phase – Open-ended questions What brings you here today? How can I help you today? Was there a specific health concern that made you schedule an appointment for today? – Closed or direct questions – Responses Components of Documentation  Identifying Information CC - Chief Complaint HPI - History of Present Illness PMH - Past Medical History Subjective Data Current Health Status/History collected during the Social, Occupational, Family History history/interview Functional Assessment ROS - Review of Systems PE - *Physical Examination* Objective Data Assessment Plan 33 History / Interview (subjective data) Identifying Information Name Age Gender/Identity Race/Ethnicity Place of birth Marital Status Occupation Source of history E. K. is a 54-year-old widowed female, presently employed in an office setting. Source: Self, seems reliable 35 Chief Complaint Represents the primary reason for the patient seeking medical attention By convention, it is stated in the patient’s own words and written in quotation marks. May include a short statement on duration. It is not a diagnostic statement. Chief Complaint: "I'm coming in for headaches." 36 History of Present Illness (HPI) For the well person, this is a short statement about their general state of health. For the ill person, this will be a detailed chronological account of their chief complaint. You will include eight key points of information referred to as an analysis of the symptom. 37 Analysis of a Symptom Mnemonic O : Onset P : Provocative or Palliative Q : Quality or Quantity R : Region or Radiation S : Severity Scale/Site T : Timing O : Onset L : Location D : Duration C : Character A : Associated/Aggravating Factors R : Radiation T : Timing 38 Sample HPI (I) Beginning three months ago, E. K. has been increasingly troubled by headaches described as frontal, usually aching, occasionally throbbing, mild to moderately severe. 7 on a 1-10 scale, with 10 being the worst. She has missed work only once because of headaches, due to associative nausea and 3 episodes of vomiting. Otherwise, nausea is rare. Headaches now average once a week, are present on waking and last all day. They are relieved by lying down in a dark, quiet room and using a cold wet towel on head. Little relief from acetaminophen … 39 Sample HPI (II) E.K. reports that these “sick headaches” with nausea and vomiting began at age 15, recurred through her mid-20’s, then diminished to one every 2-3 months and ultimately disappeared. E.K. reports recent increased pressure at work from a new and demanding boss. She thinks her headaches may be like those in the past but is concerned because her mother died of a stroke. She is concerned that the headaches make her irritable with her family. Currently eating regular meals, drinks 3 cups coffee per day, and cola at night. Denies head injury, dizziness, syncope, or vertigo. No other related symptoms, no local weakness, no numbness, no photophobia or phonophobia or visual symptoms 40 Past Medical History Past Medical History – Adult illnesses – Childhood illnesses – Prior hospitalizations Past Surgical History (include as much detail as possible) Obstetric/Contraceptive history (G P Ab) Psychiatric History Accidents or injuries Health Maintenance (vaccinations, cancer screenings) Allergies (include reaction and severity) Current Medications 41 Sample Past Medical Health (PMH) PMH: – Adult Medical Illnesses. Acute kidney infection, age 36. Denies glaucoma, thyroid disease, diabetes, tuberculosis, cancer, anemia, arthritis, cardiac, hepatitis, asthma – Childhood Illnesses. Chicken pox, age 6. Denies measles, mumps, croup, pertussis. Denies rheumatic fever, scarlet fever, or polio. – Prior Hospitalizations: Denies prior hospitalizations PSH: Age 12, Memorial Hospital, surgery to repair compound fracture right leg, Dr. M.J. Carlson, surgeon. Obstetric History/contraceptive history. G1 P1 Ab 0. Not currently sexually active Psychiatric History: Denies history of psychiatric illness Accidents. Stepped on glass at beach, 1991, laceration right foot, sutured, healed. 42 Sample PMH continued Health Maintenance: – Immunizations: Oral polio vaccine, year uncertain; Hep B x 3, 1984; TDAP, 2020 etc… – Cancer screening: Last pap, 2021, normal; Annual mammogram, last 2022, BIRADs 2; Colonoscopy, 2018, normal findings Allergies: – Ampicillin causes shortness of breath and rash. No other known allergies to other medications, food or environment. Current Medications: – Acetaminophen 625 mg q6hr prn for headaches, multivitamins 43 Family Medical History For positives, include relationship to the patient, age and health or age and cause of death of each immediate relative, including parents, grandparents, siblings, children, and grandchildren Conditions to ask about: hypertension, CAD, hyperlipidemia, CVA, diabetes, thyroid or renal disease, arthritis, TB, asthma or other lung disease, headache, seizure disorder, mental illness, suicide, substance abuse, and allergies, as well as symptoms reported by the patient. 44 Family History Heart attack, Stroke, age 72 age 68 Lung cancer, Uterine cancer, age 57 age 62 Male Female Deceased Male Deceased Female 45 Social History (I) Place of birth/residencies Sexual orientation and gender identity Occupation/Education Significant relationships (and safety in those relationships) Home environment (family and household composition) Religious beliefs Life experiences (military service, job history, retirement) Finances Transportation issues Baseline level of functioning (ADLs/IADLs) 46 Social History (II) Sexual history (5 Ps) Tobacco use Drug use ETOH use Sleep patterns Exercise/Leisure activities Diet Caffeine intake Environmental hazards Use of safety measures See Bates, Chapter 3 for good questions/flow 47 Social History Sample E.K. was born in Chicago, Illinois. Graduated from high school, married age 19. Worked as clerk in store for 2 year then moved with husband to NY, has one child. Describes family life growing up as chaotic. Father physically abusive toward mother. Went back to work 15 years ago in office setting to help with family income. Husband died after 5-month course of treatment for lung cancer, leaving little savings and no insurance. Finances now tight. Moved to small apartment to be near daughter. Daughter’s husband physically abusive. Ellen feels responsible for helping daughter and grandchildren (2). She has a few good friends. No religious affiliation or other organizational support. Typical day: arises 8:00 AM, light chore, commutes to work, stops at fast food on way home, watches TV, bedtime at 11:00 PM. No sustained physical exercise. Believes self able to perform all ADLs , no mobility aids. Raised as Presbyterian, believes in God, does not attend church. Believes self to be "honest, dependable.” Believes limitations are "smoking, weight" 48 Social History Sample (List format) Habits: Coffee, 3 cups per day, one cola at night. Denies use of recreational drugs. Cigarettes, smokes 2 PPD X 2 years, prior use I PPD x 4 years. Never tried to quit. Nutrition: 24-hour recall: breakfast, none; lunch, bologna sandwich, chips, coffee; dinner, hamburger, french fries, diet soda; snacks, peanuts, pretzels, potato chips, "bar food.” This menu is typical of most days. Brings lunch to work. Most dinners at fast-food restaurants, eats alone. No food intolerances. Sleep-Rest: Bedtime 11:00 PM. Sleeps 8 to 9 hours. No sleep aids. Exercise/Leisure Activities: Fishing, boating, snowmobiling, although currently has no finances to engage in most of these. Environmental Hazards: Lives near bus station and airport – noise and air pollution Use of Safety measures: Always uses seat belts, has working smoke detectors. No carbon monoxide detectors 49 Functional Assessment ADL’s IADL’s Transfer Using telephone Toileting Traveling Continence Shopping Bathing Preparing meal Dressing Doing housework Feeding Manage medications Manage money 50 Spiritual History: Questions to Ask Are you a member of a faith community? Is your faith an important part of your life Are there any religious / spiritual concerns you have related to your health that you would like me to know about? Do you have any religious beliefs / practices that would impact your daily activities while you are here at the hospital 51 Review of Systems Review of Systems (ROS) Complete history ends with a review of systems. The ROS summarizes all the symptoms that the patient reports, organized by body system. By reviewing in an orderly manner, you can specifically check each system and possibly uncover additional illnesses not previously discussed. 53 Symptoms by Body System System Symptoms to ask about General Weight status/changes, generalized weakness, fatigue, fever Skin Rashes, lumps, sores, itching, dryness, color changes, changes in shape/size/color of moles; changes in appearance of hair or nails. HEENT Head: headache, head injury, dizziness, lightheadedness. Eyes: Glasses/contacts, pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma, cataracts. Ears: Hearing decreased/use of hearing aids, tinnitus, vertigo, earaches, infection, discharge, pain. Nose and Sinuses: nasal congestions, discharge, itching, hay fever, nose bleeds, sinus trouble. Throat: Conditions of teeth and gums, bleeding gums, dentures, sore tongue, dry mouth, frequent sore throats, hoarseness. Neck ”swollen glands,” goiter, lumps, pain, stiffness. Breasts Lumps, pain, discomfort, nipple discharge 54 Symptoms by Body System System Symptoms to ask about Respiratory Cough sputum (color, quantity), shortness of breath, wheezing, pain with deep breath. Cardiovascular “heart trouble” high blood pressure, rheumatic fever, heart murmurs, chest pain/discomfort, palpitations, shortness of breath, need to use pillows at night to ease breathing, need to sit up at night to ease breathing, swelling in the hands, ankles, or feet. Gastrointestinal Trouble swallowing, heartburn, appetite, nausea. Bowel movements, stool color/size, changes in bowel habits, pain with defecation, rectal bleeding or black or tarry stools, hemorrhoids, constipation, diarrhea. Abdominal pain, food intolerance, excessive belching/passing of gas. Jaundice, liver, or gallbladder trouble. Peripheral Intermittent leg pain with exertion, leg cramps, varicose veins, past Vascular clots in the veins, past clots in the veins, swelling in calves/legs/feet, color change in fingertips or toes in cold weather, swelling with redness or tenderness. 55 Symptoms by Body System System Symptoms to ask about Urinary Frequency of urination, polyuria, nighttime urination, urgency, burning or pain during urination, blood in the urine, urinary infections, kidney or flank pain, kidney stones, ureteral colic, suprapubic pain, incontinence; in male patients – reduced caliber or force of urinary stream, hesitancy, dribbling. Genital: Male: Hernias, discharge from or sores on penis, testicular pain or masses, scrotal pain/swelling, history of STIs and treatments, sexual interest/satisfaction. Female: Menstrual regularity/frequency/duration of periods and amounts of bleeding. Bleeding between periods or after intercourse, dysmenorrhea, premenstrual tension. Menopausal symptoms, post-menopausal bleeding. Vaginal discharge, itching sores, lumps, STIs and treatments, sexual interest/satisfaction, including pain during intercourse. 56 Symptoms by Body System System Symptoms to ask about Musculoskeletal Muscle/joint pain, stiffness, arthritis, gout, backache. If positives, give detailed descriptions. Psychiatric Nervousness, tension, mood, depression, memory change, suicidal ideation, suicide plans or attempts. Neurologic Changes in mood/attention/speech, changes in orientation, memory, insight or judgement; headache, dizziness, vertigo, fainting, blackouts, weakness, paralysis, numbness or loss of sensation, tingling, tremors or other involuntary movements, seizures. Hematologic Anemia, easy bruising or bleeding. Endocrine Heat or cold intolerance, excessive sweating, excessive thirst/hunger, excessive urine output. 57 Example General: Denies recent weight gain or loss. Denies weakness, fatigue or fevers. Gastrointestinal: Reports nausea and 3 episodes of vomiting, concomitant with her most recent headache. Otherwise denies acid reflux, changes in appetite, abdominal pain, changes in BMs, etc….. Neurologic: Reports aching, sometimes throbbing headaches felt at the front of her head approximately once weekly for 2 months. Average pain level of 7/10, lasting all day. Relieved by dark room with cold compress. Denies relief from OTC acetaminophen. Denies focal weakness, dizziness, vertigo, syncope, changes in mood, attention, speech or orientation. Denies h/o seizures, CVA, or head injury. 58 Ending the Health History Graceful ending – anything more to discuss that wasn’t covered? End of the subjective data Ease patient into the next phase At this point you would begin the physical examination (objective data - the signs) 59 Focused Visits Will Include Fewer Sections Identifying Data Chief Complaint or reason for hospitalization History of Present Illness Pertinent Past Medical/Surgical History Allergies Medications Pertinent Social/Family History Pertinent ROS 60 Problem-Oriented Records S – Subjective - What the patient (or family) tells you – Identifying data, CC, HPI, PMH, ROS (everything before PE) O – Objective - What you observe – Physical Exam & Labs A – Assessment - What you think is going on – A summary, usually organized by problem, of what you think is going on based on all data P – Plan - What you intend to do – Interventions, usually organized by problem. 61 Remember…. Others will refer to your documentation – especially the initial history. Be complete, accurate, and clear in your recording of the history. 62 Physical Exam (objective data) Enhancing Your Powers of Observation Learning physical examination techniques is all about becoming a better observer. A skilled clinician has enhanced powers of observation and the knowledge to use these observations in the care of patients. You will use your senses – sight, smell, touch, and hearing, to gather this data 64 Considerations Prior to Starting the Exam Get Consent Empty Bladder Ensure Privacy Drape and Compare Side to Provide for Side for Warmth Symmetry Patient Education Consider Exam Sequence Explain Your Process 65 Assessment Techniques Inspection Palpation Percussion Auscultation Same order for ALL systems EXCEPT for the abdominal exam Not every system requires all of the above techniques 66 Inspection Visual assessment – Concentrated and active looking Provides an enormous amount of information Least mechanical but yields the most physical signs Always your first step in every system 67 Palpation Using sense of touch to examine the body- – Texture, moisture, temperature, organ location and size, masses, vibrations or pulsations, crepitus, presence of tenderness, swelling, tissue condition Use different parts of the hands for assessing different factors – Tips of fingers –fine tactile discrimination (texture, swelling, lumps) – Dorsa of hands - temperature – Palmar aspect of metacarpophalangeal (MCP) joints or ulnar surface- vibration Light vs. deep palpation 68  Percussion Tapping with short sharp strokes to create sound and vibrations that assess underlying structures The tapping strokes elicit a sound/vibration that will yield information about the structures below Location and size or organs and masses Density of underlying structures (ie air filled vs fluid filled vs solid underlying structure) Tenderness (ie CVA) Deep Tendon Reflexes Vibrations only penetrate about 5cms deep Direct vs indirect percussion 69 70  Types of Percussion Sounds Dull Moderate to high pitched, Over dense organ like liver, soft or muffled thud like spleen, heart sound, short duration Flat High pitched, soft, short Over extremely dense duration tissue: bone, solid tumor Tympany High pitched, drum Over fluid filled organs like like/musical sound, stomach and bladder moderate duration Resonance Low pitched, hollow Normal air-filled lungs sounds, moderate duration Hyperresonance Low pitched Booming Overinflated lungs sound – slightly longer (emphysema) than resonance 71  Auscultation Never to be used as a sole technique Earpieces positioned forward to seal ear canal Diaphragm and bell endpieces Eliminate confusing artifacts (use on bare skin) Diaphragm: High pitched sounds lung, bowel, normal heart sounds Place firmly on the skin Bell: low pitched sounds abnormal heart sounds, vascular sounds like bruits or while taking BP Place lightly on skin with enough pressure to form and air seal 72 Vital Signs Vital Signs 1. Temperature 2. Pulse 3. Respirations 4. Blood Pressure 5. Pain *Oxygen Saturation 74 Temperature Influences on temperature – Diurnal cycle Variation: 35.8°C (96.4°F) to 37.3°C (99.1°F) – Menstrual cycle – Stress – Exercise – Age – External Temperature Routes of temperature measurement – Oral – Temporal artery – Rectal - 0.5°C (1°F) > oral temperature – Axillary - 0.5°C (1°F) < oral temperature – Tympanic membrane - 0.8°C (1.4°F) > than oral temperature 75 Temperature Hypothermia Normal Hyperthermia < 96.8°F (36°C) 96.8°F to 100.4°F (36°C to 38°C) >100.4°F (38°C) Average Oral or Tympanic Rectal Axillary 98.6°F (37°C) 99.5°F (37.5°C) 97.7°F (36.5°C) 76 Assessing Pulse 1. Rate Auscultate Apical PMI Palpate Peripheral Use pads of first 2 fingers to compress artery until maximal pulsation is detected. If rhythm is regular, count for 30sec and multiply by 2 – if irregular, count a full 60sec. If 2 nurses assess together, one auscultates the other palpates – Difference in rate = pulse deficit, usually caused by an irregular rhythm 77  Normal Pulse Rate By Age Group Newborns 120 - 160bpm (up to 180 with crying) Toddler 90 - 140bpm 4-5 years old 80 - 110bpm 5-12 years old 75 - 100bpm Adult 60 – 100bpm Adult Bradycardia Adult Tachycardia 100bpm 78 Assessing Pulse 2. Rhythm (regular or irregular) – If palpably irregular, then listen apically 3. Force – Normal = Full and strong – Bounding (increased force) – Weak/Thready (decreased force) – Absent 4. Equality – Always compare sites bilaterally except for ???? 79 Assessing Respirations 1. Rate – Count the number of respirations either by visual inspection or auscultation over trachea – Count for 1 full minute if rate is irregular – Assess when the patient is unaware Normal Respiratory Rate by Age Group Newborns 30 - 60/min Infant (< 6months) 30 – 50/min Toddler 20 – 40/min Child 15 – 25/min Adolescent 16 – 20/min Adult 12 – 20/min All these normal ranges can vary slightly between individuals… what is the MOST important is if the patient is oxygenating well and doesn’t seem SOB or distressed 80 Assessing Respirations 2. Depth – Normal vs Shallow vs Deep – Inspiration vs expiration Ratio of 1:2 is normal May be reduced to 1:4 or 1:5 in obstructive airway disease 3. Rhythm - Regular vs Irregular 4. Effort - Diaphragmatic vs thoracic - Accessory muscle use? 81 Oxygen Saturation (SpO2) Measurement of arterial oxygenation by means of pulse oximeter. Apply pulse oximeter sensor to finger, forehead, or earlobe. Pulse oximeter compares the ratio of light emitted with light absorbed and converts this ratio into the % of oxygen saturation. Normal measurement in healthy person is SpO2 of 95-100% 82 Blood Pressure Force of blood pushing against the arterial walls Systolic pressure (SBP) – Max pressure on the artery during left ventricular contraction, (systole) Diastolic pressure (DBP) – Minimum pressure on the artery that is exerted constantly between left ventricular contractions, when the heart is at rest (diastole) Pulse Pressure – The difference between SBP and DBP (SBP – DBP) Mean Arterial Pressure (MAP) – Pressure forcing blood into the tissues averaged over the cardiac cycle – Map of ≥ 60mmHg is needed to maintain adequate tissue perfusion – This is NOT an average of the SBP and DBP 83 What influences blood pressure? Cardiac output – If heart pumps more blood, more pressure Vascular resistance – narrow vessels, more pressure Volume – increased blood volume, more pressure Elasticity of vessel walls – stiff vessel walls, more pressure 84 Blood Pressure – Optimal Conditions Avoid smoking or drinking caffeinated beverages 30 minutes prior to measurement Ensure that the room is quiet and comfortably warm Patient seated quietly in a chair with BOTH feet on the floor at least 5 minutes Arm should be FREE of clothing Use the CORRECT size cuff for the patient Palpate the brachial artery (rather than radial) Position the arm so that the brachial artery is at heart level Rest the arm on a table a little above the patient’s waist, or support the patient’s arm with your own at their mid-chest level 85 Measurement of BP (Part I) Determine your max inflation pressure – Palpate the brachial artery – Center cuff over brachial artery with lower border 2.5cm above antecubital crease and secure – snug, not tight – Palpate brachial artery while inflating the cuff and note mmHg once the pulse disappears. – Deflate the cuff and wait 15-30 seconds before re-inflating. – Add 20-30mmHg to the number you noted → MAX INFLATION PRESSURE 86 Auscultatory gap A period of silence between SBP and DBP which may be present. Occurs in ~5% of people, most often in hypertension caused by a non-compliant arterial system 87 Measurement of BP (Part II) Listen for Korotkoff sounds – Place the bell of the stethoscope over the brachial artery. – Rapidly inflate the cuff to your MAX INFLATION level. – Deflate the cuff at a rate of 2-3mmHg/second – Note the first sound you hear = Systolic BP – Node when sounds disappear= Diastolic BP 88 Measurement of BP Korotkoff Sounds Cuff Correctly Inflated No Sound N/A Phase I Tapping Systolic Pressure Auscultatory Gap No Sound Silence for 30-40mm Hg during deflation – ABNORMAL finding Phase II Swooshing Turbulent flow through partially occluded artery Phase III Knocking Crisp, high-pitched sounds Phase IV Abrupt muffling Low pitched/muted Phase V Silence Diastolic Pressure BP reading is Phase I/Phase V, unless there is a >10mm Hg difference between IV and V 89 Normal Blood Pressure Findings Normal BP Values by Age Group Newborn 65/41 mmHg 1 – 4 years 90-99/60-65 mmHg 5 – 12 years 100-110/55-60 mmHg Adolescent 119/75 mmHg Adult