H.A Regional examination Unit#02,Chapter#04 full chapter

1. HEALTH ASSESSMENT
UNIT#02
Regional Examinations
C H A P T E R#04 (Part 1)
Beginning the Physical Examination:
General Survey, Vital Signs, and Pain
Prepared By:
Afza Malik (BScN ,CCRN)
Coordinator,
CON National Hospital & Medical Centre, Lahore.

2. The Health History
Common or Concerning Symptoms
• Fatigue and weakness
• Fever, chills, night sweats
• Weight change
• Pain

3. Health Promotion and
Counseling: Evidence and Recommendations
Important Topics for Health Promotion and Counseling
• Optimal weight, nutrition, and diet
• Blood pressure and dietary sodium
• Exercise

4. The General Survey
• Your goal is to describe the distinguishing features of the
patient so clearly that colleagues can spot the patient in a
crowd of strangers, avoiding clichés like “middle-aged
gentleman” and the uninformative “in no acute distress.”

5. General Appearance
• Apparent State of Health. Try to make a general judgment based on
observations throughout the encounter. Support it with the significant
details.
• Level of Consciousness. Is the patient awake, alert, and responsive to
you and others in the environment? If not, promptly assess the level
of consciousness.
• Signs of Distress. Does the patient show evidence of the problems
listed below?
• Cardiac or respiratory distress
• Pain
• Anxiety or depression

6. Conti….
• Skin Color and Obvious Lesions. Inspect for any changes in
skin color, scars, plaques, or nevi.
• Dress, Grooming, and Personal Hygiene. How is the
patient dressed? Is the clothing suitable for the temperature
and weather? Is it clean and appropriate to the setting?

7. Conti….
• Facial Expression. Observe the facial expression at rest,
during conversation and social interactions, and during the
physical examination. Watch closely for eye contact. Is it
natural? . . . sustained and unblinking?.....Averted quickly? . .
. absent?
• Odors of the Body and Breath. Odors can be important
diagnostic clues, like the fruity odor of diabetes or the scent
of alcohol.

8. Conti….
• Posture, Gait, and Motor Activity. What is the patient’s
preferred posture? Is the patient restless or quiet? How often does
the patient change position? Is there any involuntary motor
activity? Are some body parts immobile? Which ones? Does the
patient walk smoothly, with comfort, self-confidence, and
balance, or is there a limp, fear of falling, loss of balance, or any
movement disorder?
• Height and Weight. Measure the patient’s height and weight
with shoes removed to determine the BMI. Note any changes in
height or weight over time. Is the patient unusually short or tall?
Is the build slender, muscular, or stocky? Is the body symmetric?
Note the general body proportions.

9. Conti….
Calculating the BMI. Use your measurements of height and
weight to determine BMI. Body fat consists primarily of
adipose in the form of triglycerides and is stored in
subcutaneous, intra-abdominal, and intramuscular fat deposits
that are difficult to measure directly. The BMI incorporates
estimated but more accurate measures of body fat than weight
alone.

10. Conti….
• Waist Circumference. If the BMI is ≥35 kg/m2, measure the
patient’s waist circumference just above the hips. Risk for
diabetes, hypertension, and cardiovascular disease increases
significantly if the waist circumference is 35 inches or more
in women and 40 inches or more in men.

11. The Vital Signs
• The Vital Signs—blood pressure, heart rate, respiratory rate,
and temperature—provide critical initial information that
often influences the tempo and direction of your evaluation.
• Blood Pressure
The Complexities of Measuring Blood Pressure. The
accuracy of blood pressure measurements varies according to
how these measurements are taken.

12. Methods for Measuring Blood Pressure
• Auscultatory office blood pressure with aneroid or mercury blood pressure cuff
• Automated oscillometric office blood pressure
• Home blood pressure monitoring
• Ambulatory blood pressure monitoring

13. Types of Hypertension.
• White coat hypertension (isolated clinic hypertension)
• Masked hypertension
• Nocturnal hypertension

14. Choosing the Correct Blood Pressure Cuff
(Sphygmomanometer).
• Selecting the Correct Size Blood Pressure Cuff
• It is important for clinicians and patients to use a cuff that fits the patient’s arm.
• Follow the guidelines outlined here for selecting the correct size:
• Width of the inflatable bladder of the cuff should be about 40% of upper arm circumference (about 12
to 14 cm in the average adult).
• Length of the inflatable bladder should be about 80% of upper arm circumference (almost long enough
to encircle the arm).
• The standard cuff is 12 × 23 cm, appropriate for arm circumferences up to 28 cm.

15. Steps to Ensure Accurate Blood Pressure
Measurement
• 1. The patient should avoid smoking, caffeine, or exercise for 30 minutes prior to measurement.
• 2. The examining room should be quiet and comfortably warm.
• 3. The patient should sit quietly for 5 minutes in a chair with feet on the floor, rather than on the
examining table.
• 4. The arm selected should be free of clothing, fistulas for dialysis, scars from brachial artery
cutdowns, or lymphedema from axillary node dissection or radiation therapy.
• 5. Palpate the brachial artery to confirm a viable pulse and position the arm so that the brachial
artery, at the antecubital crease, is at heart level—roughly level with the fourth interspace at its
junction with the sternum.
• 6. If the patient is seated, rest the arm on a table a little above the patient’s waist; if standing, try to
support the patient’s arm at the midchest level.

16. Measuring Steps
• Position the Cuff and Arm.
• Estimate the Systolic Pressure and Add 30 mm Hg.
• Position the Stethoscope Bell Over the Brachial Artery.
• Identify the Systolic Blood Pressure.
• Average Two or More Readings.
• Measure Blood Pressure in Both Arms At Least Once.

17. Classification of Blood Pressure
• Normal
• Prehypertension
• Stage 1 hypertension
• Stage 2 hypertension
Low Blood Pressure
Orthostatic Hypotension

18. Special Situations
• Weak or Inaudible Korotkoff Sounds.
• White Coat Hypertension.
• The Obese or Very Thin Patient.
• Arrhythmias.
• The Hypertensive Patient with Systolic Blood Pressure Higher in the Arms
than in the Legs.

19. Heart Rate and Rhythm
• Heart Rate. The radial pulse is commonly used to assess the heart rate. With the pads of your
index and middle fingers, compress the radial artery until a maximal pulsation is detected. If the
rhythm is regular and the rate seems normal, count the rate for 30 seconds and multiply by 2. If the
rate is unusually fast or slow, count for 60 seconds. The usual range of normal is 60 to 90 to 100
beats per minute.51

20. Conti….
• Rhythm. Begin by palpating the radial pulse. If there are any irregularities, assess
the rhythm at the apex by listening with your stethoscope. Premature beats of low
amplitude may not be transmitted to the peripheral pulses, leading to
underestimates of the heart rate. Is the rhythm regular or irregular? If irregular, try
to identify a pattern: (1) Do early beats appear in a basically regular rhythm? (2)
Does the irregularity vary consistently with respiration? (3) Is the rhythm totally
irregular?

21. Pulse Sites
Systematic examination of pulses
Which and what order? Where and how? Why?
1. Radial artery Radial side of wrist.
With tips of index and middle
fingers.
To assess rate and rhythm.
Simultaneously with femoral to
detect delay.
Not good for pulse character.
2. Brachial artery Medial border of humerus at elbow
medial to biceps tendon.
Either with thumb of examiner's
right hand or index and middle of
left hand.
To assess pulse character.
To confirm rhythm.
3. Carotid artery Press examiner's left thumb against
patient's larynx.
Press back to feel carotid artery
against precervical muscles.
Alternatively from behind, curling
fingers around side of neck.
Best for pulse character and, to
some extent, left ventricular
function.
To detect carotid stenosis.
At resuscitation (CPR)

22. Conti….
4. Femoral artery Patient lying flat and undressed.
Place finger directly above pubic
ramus and midway between pubic
tubercle and anterior superior iliac
spine.
To assess cardiac output.
To detect radio-femoral delay.
To assess peripheral arterial
disease.
5. Popliteal artery Deep within the popliteal fossa.
Compress against posterior of distal
femur with knee slightly flexed.
Mainly to assess peripheral arterial
disease.
In people with diabetes.
6. Dorsalis pedis (DP) and tibialis
posterior (TP) arteries (foot)
Lateral to extensor hallucis longus
(DP).
Posterior to medial malleolus (TP).
As above.
7. The abdominal aorta With the flat of the hand per
abdomen, as body habitus allows.
In peripheral arterial disease.
To detect aneurysmal swelling.

23. How to Assess

24. Characteristics of Pulse
• Rate.
• Rhythm.
• Volume.
• Force.
• Tension.
• Form.
• Equality.
• Condition of arterial wall.

25. Pulse Types
• Pulselessness
• Bouncing
• Week
• Water Hammer Pulse

26. Pulse force is recorded using a four-point scale:
• 3+ Full, bounding
• 2+ Normal/strong
• 1+ Weak, diminished, thready
• 0 Absent/non-palpable

27. Trills and Bruits
After palpating the artery, auscultation for a bruit should be performed.
Bruits are detected by auscultation over the large and medium-sized
arteries (e.g., carotid, brachial, abdominal aorta, femoral) with the
diaphragm of the stethoscope using light to moderate pressure.
Frequently the examiner will detect a "thrill" or palpable vibratory
sensation over a vessel in which a loud bruit is audible.

28. Respiratory Rate and Rhythm
Observe the rate, rhythm, depth, and effort of breathing. Count the
number of respirations in 1 minute either by visual inspection or by
subtly listening over the patient’s trachea with your stethoscope during
your examination of the head and neck or chest. Normally, adults take
approximately 20 breaths per minute in a quiet, regular pattern. An
occasional sigh is normal. Check to see if expiration is prolonged.

29. Common terms
• Hyperventilation
• Dyspnea
• Shallow Breathing
• Apnoea
• Tychipnea

30. Temperature
• The core body temperature, measured internally, is approximately
37°C (98.6°F)and fluctuates approximately 1°C over the course of the
day. It is lowest in the early morning and highest in the afternoon and
evening. Women have a wider range of normal temperature than men.
• Surface
• Core

31. Methods
• Oral
• Axillary
• Rectal

32. Pain
• Assessing Acute and Chronic Pain
• The International Association for the Study of Pain defines pain as “an
unpleasant sensory and emotional experience” associated with tissue
damage. The experience of pain is complex and multifactorial. Pain
involves sensory, emotional, and cognitive processing, but may lack a
specific physical etiology.
• Acute
• Chronic

33. Technique
There are multiple acronyms used to obtain the history
of a patient's pain. Some of the most commonly used
abbreviations are “COLDERR” "COLDERAS" and
"OLDCARTS. Both of these acronyms summarize the
character, onset, location, duration exacerbating
symptoms, relieving symptoms, radiation of pain,
associated symptoms, and severity of illness.

34. COLDERR
• Character: description of sensation of the pain (dull, sharp, aching, burning,
tingling, etc.).
• Onset: when did it start? Were there any recipitants or triggers?
• Location: where does it hurt? Is the pain unilateral, bilateral, radiating?
• Duration: constant versus intermittent in nature, does it change during the
day?
• Exacerbation: which factors make it worse?
• Relief: what makes it better, including medications, mechanical
treatments, posture change?
• Relief: what makes it better, including medications, mechanical
treatments, posture change?
• Radiation: pattern of spread from its origin.

35. OLDCARTS
Onset
Location
Duration
Character
Alleviating
Radiation
Temporal Patterns
Symptoms

36. Subjective to Objective
Offer Patient to rank His or Her pian according to given
scale.

37. Pediatric Pain

38. Any Question ?

39. Thank You …..!