PHCL 326

Physical Assessment (Part I )

Vital Signs

Vital Signs

• Temperature (T)• Blood pressure (BP)• Pulse (P, HR, RRR)• Respiratory rate (R)Pain scale (“5th vital sign”)Smoking status, Nutritional status,spirometry

Vital signs

• VS are useful in detecting or monitoring medical problems.

• VS + Wt&Ht provide important screening and diagnostic information as well as monitoring data for assessment of short/long term response to medication therapy.

• VS can be measured in a medical setting, at home, at the site of a medical emergency, or elsewhere

Temperature

• Normal range depends on route▫ Rectal > Temporal artery > Ear > Oral > Axillary

• Where’s the best place to take a temperature?▫ <3 months old: rectally▫ 3 months – 5 yrs old: rectal, temporal, ear▫ >5 yrs old: oral, ear, temporal artery

• A normal temperature is 98.6 degrees Fahrenheit (37 degrees Centigrade)

• Hypothermia is defined as a drop in body temperature below 95° F

• Fever:▫ Oral temp of >=38°C (100.9°F)

WHAT IS A NORMAL TEMPERATURE?

How to take an oral temperature : Place thermometer under tongue; use probe cover Wait 3 minutes if mercury thermometer, 10 seconds if electronic Wait 10 minutes after eating or drinking hot or cold liquids

How to take a rectal temperature : Use lubrication and probe cover Rectal temperature is   0.4-0.5 degrees C (0.7 to 0.8 degrees F) higher than

oral

Use of axillary temperature : Axillary temperature correlates poorly with rectal temperature It may be OK to do axillary reading in neonates if can't do rectal thermometer

HOW TO TAKE TEMPERATURE

Blood Pressure

• Measures force of blood against artery walls

Systolic and diastolic blood pressure : Systolic blood pressure is the highest

pressure in the arteries, just after the heart beats

Diastolic blood pressure is the lowest pressure in the arteries, just before the heart beats

Blood pressure is measured indirectly by blood pressure cuff (sphygmomanometer)

Blood Pressure

Blood Pressure: Measurement

• Under external pressure, circulating blood hits the arterial wall which results in turbulence (Korotkoff’s sounds)

• Systolic BP: start of Korotkoff’s sounds• Diastolic BP: point at which sounds disappear

Korotkoff’s Sounds• Measurement of blood pressure by auscultation is based on the

sounds produced as a result of changes

1. Phase I The pressure level at which the first faint, clear tapping sounds are heard, which increase as the cuff is deflated (reference point for systolic BP).

2. Phase II During cuff deflation when a murmur or swishing sounds are heard.

3. Phase III The period during which sounds are crisper and increase in intensity.

4. Phase IV When a distinct, abrupt, muffling of sound is heard

5. Phase V The pressure level when the last sound is heard (reference point for diastolic BP).

Blood Pressure: Measurement

Recommended Blood Pressure Measurement Technique

• Patient should be seated and have rested for 5 minutes and have arm supported

at heart level.• Appropriate cuff size should be used, and the bladder should nearly (at least80%) or completely encircle arm.• Patients should not have smoked or ingested caffeine within 30 minutes beforemeasurements.• Measurements should be taken with a mercury sphygmomanometer, a recentlycalibrated aneroid manometer, or a calibrated electronic device.• Both systolic and diastolic blood pressure should be recorded.• Korotkoff’s phase V (disappearance of sound) should be used for the diastolicreading.• Two or more readings, separated by 2 minutes, should be averaged, and moretaken if they differ by more than 5mmHg.

Inflating cuff increases pressure until it cuts off arterial circulation to the arm

Deflating cuff, decrease pressure by 2 to 3 mm of mercury per second until blood first enters the artery, creating turbulence; this causes a sound with each heartbeat

Sounds continue with each heartbeat until pressure lowers to the lowest pressure in the artery; then turbulence stops, so the sound stops

Systolic blood pressure is the cuff pressure at the first sounds; diastolic is the cuff pressure just before the sounds stop

HOW A CUFF MEASURES BLOOD PRESSURE

– Normal: <120/<80 – Prehypertensive: 120-139/80-89 – Stage 1 hypertension: 140-159/90-99 – Stage 2 hypertension: >=160/>=100

• The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

DOES YOUR PATIENT HAVE HYPERTENSION (HIGH BLOOD PRESSURE) ?

http://www.nhlbi.nih.gov/guidelines/hypertension/

BLOOD PRESSURE

• Blood Pressure Checklist

What is the pulse rate?

• The pulse rate is a measurement of the heart rate, or the number of times the heart beats per minute.(beats/min,BPM)

• The normal pulse for healthy adults ranges

from 60 to 100 beats per minute.

• Rate– Number of beats in 30 seconds x 2

• Strength

-The strength of the pulse is described as “normal,” “weak,” or “bounding”

• Regularity

–Regular or irregular

Pulse

How to check your pulse:• Using the first and second fingertips, press firmly but

gently on the arteries until you feel a pulse. • Begin counting the pulse when the clock's second

hand is on the 12. • Count your pulse for 60 seconds (or for 15 seconds

and then multiply by four to calculate beats per minute).

• When counting, do not watch the clock continuously, but concentrate on the beats of the pulse.

• If unsure about your results, ask another person to count for you.

Carotid: in neck, medial to and below angle of jaw Radial: ventral wrist proximal to base of thumb Brachial: antecubital fossa, medial to biceps tendon Femoral: in groin, just medial to quadriceps Popliteal: middle of popliteal fossa; knee flexed 30

degrees Posterior tibial (PT): posterior to medial malleolus, in

ankle Dorsalis pedis (DP): dorsal foot, lateral to extensor

hallucis longus

WHERE TO FIND PULSES

• Peripheral vascular disease : absent or diminished DP and PT pulses - carries risk of ulcers, infection, amputation and other vascular disease.

• Obtaining arterial blood for blood gas measurement

• Finding femoral vein for emergency access (IV line)

WHY FIND PULSES?

• Adult: 60 to 100 • Newborn: 120-170 • 1 year: 80-160 • 3 years: 80-120 • 6 years: 75-115 • 10 years: 70-110

WHAT IS A NORMAL PULSE?

Arterial pulse checklist

Locate the radial pulse. Palpate with the fingers (not thumb). Report/record the per-minute rate.

(Example: The heart rate is 80 beats per minute.)

Report/record the strength. (Example: The pulse is normal strength.)

Report/record the regularity. (Example: The pulse is regular.)

What is the Respiration Rate?

• The respiration rate is the number of breaths a person takes per minute

( breath/min, BPM)

• How to measure: observe rise and fall of chest • In infants, count for 60 seconds; in adults, 15 or

30 seconds • Normal respiration: •      Adults: 12 to 20 •      Children:

• newborn 30-80 • 1 year 20-40 • 3 years 20-30 • 6 years 16-22

RESPIRATION

26

Respirations

• Rate– Number of breaths in

30 seconds x 2

• Quality– Character of

breathing

• Rhythm– Regular or irregular

• Effort– Normal or labored

• Noisy respiration– Normal, stridor,

wheezing, snoring, gurgling

• Depth– Shallow or deep

Respiration checklist

Unobtrusively observe the patient’s breathing. Report/record the rate. (Example: The respiratory

rate is 12 breaths per minute.) Report/record the pattern. (Example: The

respiratory pattern is normal.) Report/record the use of accessory muscles.

(Example: No accessory muscles used.) Tachypnea, a fast respiratory rate (>20) Bradypnea, a slow respiratory rate (<12

breaths/min)

Height and Body Weight

• The patient’s height and body weight are not considered vital signs but are useful screening and monitoring parameters and are components of the body mass index (BMI)

• equation:BMI(metric)=weight in kilograms÷ (height in meters)

Classification BMI

• Underweight <18.5• Normal weight 18.5-24.9• Overweight 25-29.9• Class I obesity 30-34.9• Class II obesity 35-39.9• Class III obesity =40

Vital Signs

• PHYSICAL EXAMINATION FINDINGS

General: WDWN AAM in NAD sitting comfortably on examination table; Wt: 75 kg; Ht: 150 cmVital signs: BP 154/93 mm Hg, HR 78 beats/min (regular, normal strength), RR 16 breaths/min , T 98.6° (37°C).

• http://medinfo.ufl.edu/other/opeta/vital/VS_main.html

Video