Basic Head to Toe Assessment Part 4 Including: Edema Skin Turgor Respiratory Assessment Oximeters Stethoscope Placement

GLOSSARY Edema Skin turgor The swelling of soft tissues as a result of excess fluid accumulation. Edema is often most prominent in the lower legs and feet toward the end of the day because fluid pools while people maintain an upright position. Skin turgor The degree of elasticity of skin.

GLOSSARY Respiratory assessment Assessing respiration Oximeters test performed on a sample of arterial blood (referred to as an arterial blood gas measurement) or by an instrument known as a pulse oximeter , which is clipped onto the finger Stethoscope placement An instrument that is used to transmit low-volume sounds such as a heartbeat (or intestinal, venous, or fetal sounds) to the ear of the listener.

Edema Generalized Edema = puffy (swollen) Pitting Edema =

How do we check for pitting edema? By applying pressure to the swollen area, by depressing the skin with a finger. If the pressing causes an indentation that persists for some time after the release of the pressure, the edema is referred to as pitting edema. EDEMA SCALE: Every 2 millimeters = +1 A +4 Edema is significant and could mean a pump problem, usually right-sided heart failure where the fluid is backing up into the tissues.

What is generalized edema? In generalized edema (non-pitting), which usually affects the legs or arms, pressure that is applied to the skin does not result in a persistent indentation. 

Skin Turgor What is skin turgor? Skin turgor is the skin's ability to change shape and return to normal (elasticity). Skin turgor is a sign commonly used by health care workers to assess the degree of fluid loss or dehydration. Fluid loss can occur from common conditions, such as diarrhea or vomiting. Infants and young children with vomiting, diarrhea, and decreased or no fluid intake can rapidly lose a significant amount of fluid. Fever speeds up this process. Older people have less subcutaneous tissue, therefore the skin takes longer to return to normal.

Checking Skin Turgor

How is skin turgor determined? To determine skin turgor, the health care provider grasps the skin on the back of the hand, lower arm, or abdomen between two fingers so that it is tented up. The skin is held for a few seconds then released. Skin with normal turgor snaps rapidly back to its normal position. Skin with decreased turgor remains elevated and returns slowly to its normal position. Decreased skin turgor is a late sign in dehydration. It occurs with moderate to severe dehydration. Fluid loss of 5% of the body weight is considered mild dehydration, 10% is moderate, and 15% or more is severe dehydration.

Checking Skin Turgor

How is skin turgor determined? Fluid loss of 5% of the body weight is considered…? Fluid loss of 10% of the body weight is considered…? Fluid loss of 15% of the body weight is considered…?

Respiratory Assessment How do you count respirations? Respiratory rate: The number of breaths per minute or, more formally, the number of movements indicative of inspiration and expiration per unit time. In practice, the respiratory rate is usually determined by counting the number of times the chest rises or falls per minute. The aim of measuring respiratory rate is to determine whether the respirations are  normal, abnormally fast (tachypnea), abnormally slow (bradypnea), or nonexistent (apnea).

When measuring respiration, abnormally fast means…? slow means…? When measuring respiration, non-existent means…?

Assessing Respiration Ask patient to breathe normally while you listen to his/her heart, count respiration. It is sufficient to count for 15 seconds if respiration is regular. If respiration is irregular, count for 1 full minute. You can also count respiration while taking radial pulse by placing the arm over the abdomen and counting.

During respiration assessment, in which case do you count for 15 seconds? During respiration assessment, in which case do you count for 1 full minute? Can you count respiration while performing another test, if so, which one?

Other factors to look for during respiration assessment: Chest looks equal and moves equally Good quality of respiratory effort Patient is not distressed How must the chest appear during respiratory assessment?

What is oximetry? Oximetry is a procedure for measuring the concentration of oxygen in the blood. The test is used in the evaluation of various medical conditions that affect the function of the heart and lungs.

How is oximetry done? This is done using an oximeter, a photoelectric device specially designed for this purpose. A reusable probe can be placed on the finger or a single use tape probe is placed on the earlobe or finger.

What are pulse oximeters? The oximeters most commonly used today are called pulse oximeters because they respond only to pulsations, such as those in pulsating capillaries of the area tested.

What is oxygen saturation? oxygen saturation (SO2), commonly referred to as "sats", measures the percentage of hemoglobin binding sites in the bloodstream occupied by oxygen. Oxygen saturation is a term referring to the concentration of oxygen in the blood. The human body requires and regulates a very precise and specific balance of oxygen in the blood. Normal blood oxygen levels in humans are considered 95-100 percent. If the level is below 90 percent, it is considered low resulting in hypoxemia. Blood oxygen levels below 80 percent may compromise organ function, such as the brain and heart, and should be promptly addressed. Continued low oxygen levels may lead to respiratory or cardiac arrest. 

Visual signs indicating respiratory distress Ruddy red in the face Dusky (not very bright; dark or soft in colour) Blue in the face What are some visual signs in the patient’s face which indicate respiratory distress?

Ascultation of the chest Front (anterior) Procedure Ask the patient to breathe in and out normally through his/her mouth. Use the diaphragm of stethoscope. Anterior chest: auscultate from side to side and top to bottom. Auscultate over equivalent areas and compare the volume and character of the sounds and note any additional sounds. Compare sounds during inspiration and expiration and note location and quality. Breath sounds should be clear and equal. Posterior chest: repeat procedure. Assess vocal resonance. Ask the patient to say ‘ninety-nine, ninety-nine’ and compare the sounds at equivalent positions on each side of the chest .  

Auscultation of the chest - Areas

How should a patient breathe during auscultation? How should the health provider auscultate the chest area? What type of breathe sounds are considered positive? Auscultaion should never be done over Bone What is also checked during posterior chest auscultation?

Ascultation of the chest Back (posterior) Posterior chest: repeat anterior procedure. Lungs must sound clear and equal. During this assessment skin is also checked (no breakdown) and the sacral area (Coccyx bone area is not red).