1. PHCL 326 Physical Assessment (Part I )

2. Vital Signs

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

4. 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

5. 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

6. 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?

7. 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

8. Blood Pressure Measures force of blood against artery walls

9. 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

10. 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

11. 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).

12. Blood Pressure: Measurement

13. 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 least 80%) or completely encircle arm. Patients should not have smoked or ingested caffeine within 30 minutes before measurements. Measurements should be taken with a mercury sphygmomanometer, a recently calibrated 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 diastolic reading. Two or more readings, separated by 2 minutes, should be averaged, and more taken if they differ by more than 5mmHg.

14.  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

15. – 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/

16. BLOOD PRESSURE Blood Pressure Checklist

17. 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.

18. 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

19. 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.

20.  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

21. 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?

22. 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?

23. 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.)

24. What is the Respiration Rate? The respiration rate is the number of breaths a person takes per minute ( breath/min, BPM)

25. 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 16-2 2 RESPIRATION

26. 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

27. 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)

28. 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)

29. 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

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

31. http://medinfo.ufl.edu/other/opeta/vital/VS _main.html Video