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Physical Assessment as a Screening Tool

Terms in this set (121)

Contents of a screening examination toolkit
Stethoscope, sphygmomanometer, thermometer, pulse oximeter, reflex hammer, penlight, safety pin or sharp object, cotton tipped swab or cotton ball, Tuning fork (128 Hz), watch with ability to count seconds, gloves for palpation of skin lesions, ruler or plastic tape measure to measure wound dimension, skin lesion, leg length, goniometer
AMPLE
-what does it stand for
-when used
Allergies
Medications
Past medical hx
Last meal
Events of injury

Used when history taking in a trauma unit
ABCDE
Airway
Breathing
Circulation
Disability
Exposure

used when assessing/treating a critically ill or deteriorating patient
Vital Signs
HR
BP
Temp
RR
Pain
What is the general physical assessment outline?
Mental status
Nutritional status
Body and breath odors
Vital signs (HR, BP, Temp, RR, Pain)
Signs and symptoms of undernutrition or malnutrition
-Muscle wasting
-Alopecia
-Dermatitis
-Dry, flakying skin
-Chopped lips
-Lesions of the corners of the mouth
-Brittle nails
-Abdominal distension
-Decreased physical activity or energy level
-Fatigue
-Lethargy
-Peripheral edema
-Bruising
Factors affecting pulse
-Age
-Anemia
-Autonomic dysfunction (DM or SCI)
-Caffeine
-Cardiac muscle dysfunction
-Conditioned/deconditoned state
-Dehydraton (decreased BV and increase in HR)
-Exercise
-Fever
-Heat
-Hyperthyroidism
-Infection
-Medications
-Sleep disorders
-Sleep deprivation
-Stress (emotional/psychogenic)
Factors affecting BP
-Age
-Alcohol use
-BV size
-Blood viscosity
-Caffeine
-Cocaine & derivatives
-Diet
-Distended urinary bladder
-Force of heart contraction
-Living at higher altitude
-Medications
-Nicotine
-Pain
-Time of recent meal
Pulse readings
0= absent, not palpable
1+ = pulse diminished, barely palpable
2+ = easily palpable, normal
3+ =full pulse, increased strength
4+ =bounding pulse, too strong to obliterate
Pulse abnormalities
-Weak pulse beats alternating with strong beats
-Weak, thready pulse
-Bounding pulse
-Two quick beats followed by a pause (no pulse)
-Irregular rhythm (interval between beats is not equal)
-Pulse amplitude decreases with inspiration / increases with expiration (paradoxic) e.g. COPD, Pericarditis
-Pulse rate too fast > 100 bpm
-Pulse rate too slow < 60 bpm
What is a bounding pulse?
A throbbing pulse followed by sudden collapse or decrease in the force of the pulse
What are important tips on palpating pulse?

What may indicate heart disease?
-Assess each pulse for strength and quality
-HR expected to be between 60-90 bpm
-Normal: 2+ bilaterally
-Gentle pressure to avoid obliterating pulse
-Popliteal pulse requires deeper palpation
-Normal veins are flat: pulsation not visible
-Pulses should be the same bilaterally, and should not change with respiration or change in position
-with diminished or absent pulses, listen for a bruit to detect arterial narrowing
-with diminished or absent pulses, observe for trophic changes. Ask about pain in calf that comes on with walkng or goes away with rest
-Pedal pulses can be congenitally absent
-
-Flat veins in supine that become extended in sitting may indicate heart disease
When assessing pulse, HR should be expected to be between
60-90 bpm
Normal pulse when assessing pt
2+ bilaterally
How do you assess the popliteal pulse as opposed to other pulses
Popliteal pulse requires deeper palpation
Normally, veins are ______
Pulsation (is/is not) visisble
flat; is not
What might flat veins that become extended in sitting indicate?
Heart disease
When assessing a patient's pulse, what should you expect with respiration or position changes
no change
Pulse rate: too fast
>100 bpm
Pulse rate: too slow
<60 bpm
Will you always find a pedal pulse? Why/why not?
No; pedal pulse can be congenitally absent.
How does pulse change with age? How does this play out clinically?
Pulse tends to diminish with age

Clinically, distal pulses are not palpable in many older adults.
If pulse is diminished or absent, what else should you look out for? What should you ask and why?
Skin temp
Trophic changes (skin temp, texture, color, hair loss, change in toe nails

Ask: is there pain in calf or leg with walking that goes away with rest? Screen for intermittent claudication.
How should you take distal pulses?
Bilaterally, and record it
When should you record and report a change in pulse?
If pulse increases >20bpm lasting >3 minutes after rest from physical activity should be recorded and reported.
Normal BP (min and max)
min: 100/60

max 120/80
Regarding blood pressure, who should you closely monitor?
Individuals with:
-High BP + risk factors
-BP variations (>10 mmHg) between UEs
-BP changes associated with warning signs
-Sudden drop in BP (>10mmHg) with rise in pulse (10-20%) = Postural hypotension
Postural hypotension
A sudden drop in BP >10 mmHg accompanied by a 10-20% rise in pulse
Yellow flags for BP
-SBP > 120 or DBP > 80 in the presence of risk factors (age, medications, personal and family history)
-DBP < 70 mmHg in adults > 75 y.o. (Alzheimer's)
-BP fluctuation in client taking NSAIDs, contraceptive pills
-Steady falls in BP over several years > 75 (Alzheimer's)
-DBP < 10 mmHg in adult > 65 with h/o falls
-Difference in pulse pressure > 40 mmHg
-More than 10 mmHg difference (SBP/DBP) from side to side (upper extremities)
-More than 40 mmHg difference (SBP/DBP) from side to side (lower extremities)
-BP in lower extremities lower than upper extremities
-DBP increases > 10 mmHg during activity or exercises
-SBP does not rise as workload increase, SBP falls as workload increases
-SBP > 200 mmHg or -DBP > 100 mmHg during exercise/physical activity
-BP changes in the presence of other warning signs such as angina, dizziness, nausea, pallor, extreme diaphoresis
-Sudden rise in BP SBP > 10, DBP > 10 mmHg with concomitant rise in pulse; watch for postural hypotension in hypertensive clients especially anyone taking diuretics
Why do we take patient's temperature
To help identify concomitant systems

To decide tx of the day (exercise and hydration guidelines)
Normal temps
Core: 98.6
Oral: 96.8 - 99.5
Rectal: 97.3-100.2
Tympanic: 97.2-100
Hypothermia <95
Normal respiratory rate
12-20 breaths/min
Signs of dehydration

What can it progress to?
Thirst, poor skin turgor, sunken eyes

Severe: reduced urine output, rapid pulse

Progresses to shock, late stage can cause cyanosis, dilated pupils, bowel and bladder dysfunction and LOC
Signs of mild dehydration
Thirst, dry mouth, dry lips
Signs of moderate dehydration
Very dry mouth, sunken eyes, cracked lips, sunken fontanelles in infants, poor skin turgor, postural hypotension, headache
Signs of severe dehydration:
Signs of moderate dehydration PLUS
Rapid weak pulse
Rapid breathing
Confusion
Lethargy
Irritability
Cold hands and feet
Inability to cry or urinate
Signs of stage 1 shock
restlessness, anxiety, hyperalertness, lack of interest in play (kids), tachycardia, increased respiratory rate, shallow breathing, frequent sighs, rapid bounding pulse (not weak), distended neck veins, skin warm and flushed, thirst, nausea, vomiting
Signs of stage 2 shock:
confusion, lack of focused eye contact (vacant look), abrupt changes in affect or behavior, no crying or excessive unexplained crying in infant, cold clammy skin, profuse sweating, chills, weak pulse, hypotension, dizziness, fainting, collapsed neck veins, weak or absent peripheral pulses, muscle tension
Signs of stage 3 shock
cyanosis (blue lips, gray skin), dull eyes, dilated pupils, loss of bowel or bladder control, change in LOC
Assessment of Skin and Nail bed changes ABCDE
Asymmetry
Border
Color
Diameter
Evolving
What is usually the first physical manifestation of rheumatic disease?
Skin lesions
What conditions would cause a skin lesion?
Rheumatic disease, STDs, cancer, psoriasis, fungal infections, incisions, incisions post-op, squamous cell carcinoma in a scar
When assessing nail beds, what are you looking for?
Clubbing, capillary refill, deformities
Surgical incisions
Supraclavicular lymphadenopathy at the R supraclavicular node might indicate
Cancer in the mediastinum, lungs, or esophagus
Supraclavicular lymphadenopathy at the L supraclavicular (AKA) node might indicate
AKA Virchow's node
may indicate pathology in thorax and abdomen
From where does Virchow's node receive lymphatic flow?
(Virchow's = L supraclavicular node)

receives lymphatic flow from thorax and abdomen
How should the physical examination be focused in patients with generalized lymphadenopathy?
Searching for S&S of systemic illness
Observation of lymph nodes. How does a normal lymph node present?
Observe for swelling and redness. Normal lymph nodes are not visible
Palpation of lymph nodes: what is abnormal size? Where to palpate?
>1 cm in adults or >2 cm in children is abnormal

Palpate: supraclavicular, infraclavicular, and axillary nodes
What should you ask the patient if you find an enlarged lymph node?
Ask about hx of cancer, infections, breast implants, allergic rhinitis, and food intolerance
How might a lymph node present that would make you suspect cancer?
Hard, immovable, non-tender lymph nodes
If you find an abnormal lymph node, what should you do?
All findings of abnormal lymph nodes should be reported to MD.
The 5 P's of arterial insufficiency
Pain
Pallor
Pulselessness
Paresthesia
Paralysis
Signs of arterial insufficiency
the 5 P's (pain, pallor, pulselessness, paresthesia, paralysis)

cool to touch, shiny skin

pale and painful on elevation

Rubor

Relieved by dependent position
Special test for arterial insufficiency. What is it measuring? How to perform it
Rubor on dependency: measures severe ischemia in LE in response to positional change

Supine: inspect foot color. Elevate leg to 60° for 1 min and reinspect. Place leg in dependent position (hanging off bed)

Normal = color returning to normal in 15 seconds
Abnormal: = color returns after 30 seconds, or the foot turns bright red.
Signs of Venous insufficiency
Normal pulses
Cyanotic
Warm to touch, edematous, scaly skin (eczema)
Painful in dependent positions, relieved w/ elevation
What is the Autar DVT scale?
Predictive index of DVT
According to the Autar DVT scale, what are the 7 reisk categories for DVT?
Age
BMI
Mobility
Special DVT Risk
Trauma Risk
Surgical Risk
High Risk Diseases
Autar DVT Scale scores
6: no risk
7-10 low risk
11-14: moderate risk
>15: high risk
Components of a routine physical assessment
Musculoskeletal (ROM, STTT, Joint palp, special tests)
Vital signs
Lymph nodes

As indicated:
-Neuro screening (UMN, LMN, brain)
-Cardiopulmonary screening (inspiration, palpation, auscultation)
-Vascular status screening
-Abominal screening (inspiraiton, auscultation, palpation)
Techniques of physical examination (broad)
Inspection
Palpation
Percussion
Auscultation
Inspection includes observation of
texture, size, position, alignment, color, tenderness, shape, contour, symmetry, mobility or movement, location
Palpation includes assessment of
Texture, size, shape, position, pulsation, consistency, temperature, moisture, turgor
Percussion includes assessment of
Size, shape, density of tissue created by vibration
Skin assessment in an integumentary screening exam
Pallor
Pigmentation changes
Yellow or red skin color
Cyanosis
Integumentary Screening Examination includes
Skin assessment
Nail bed assessment
Lymph node palpation
Vitiglio
A lack of pigmentation from melanocyte destruction (hereditary)
Cafe-au-lait spots
Light brown macules, flat lesions, different in color

(neurofbromatosis)
Hemorrhagic rash (petechiae)
Round spots that appear on the skin as the result of bleeding. appear red, brown, or purple. Commonly appear in clusters and may look like a rash. Usually flat to the touch, and don't lose color when you press on them.
Dermatitis (Eczema)
Skin that is red, brown, or gray, sore, itchy and sometimes swollen
Rosacea
A chronic facial skin disorder in adults 30-60 y/o
Thrombocytopenia
Abnormally low level of platelets
Xanthomas
Benign, fatty fibrous yellow plaques, nodules, or tumors that develop in the subcutaneous layer of the skin, often around the tendons
Xanthelasmas
Yellowish papules and plaques caused by localized accumulation of lipid deposits commonly seen on eyelids
Steroid skin
bruising or ecchymosis that occurs as a result of chornic use of topical or systemic corticosteroids
How can radiation affect skin appearance?
Hyperpigmentation or depigmentation
Kaposi's sarcoma
Cancer that causes patches of abnormal tissue to grow under the skin, lining of the mouth, nose and throat, in lymph nodes, or in other organs. Patches usually red or purple in color
Seborrheic keratosis
Common noncancerous skin growth that is common as one ages. Usually brown, black, or light tan and commonly appear on the head, neck, chest, or back (moles)
Purpura
Called blood spots or skin hemorrhages, refers to purple-colored spots that are recognizable on skin. Occurs when small blood vessels burst and cause blood to pool under the skn
Ecchymosis
Bruising
discoid lupus erythematosus
The most common type of chronic cutaneous lupus (CCLE)

Autoimmune skin condition on the lupus erythematosus spectrum

Presents with red, inflamed, coin-shaped patches of skin with scaling and crusty appearance, most often on the scalp, cheeks, and ears
Acne
inflammatory disease of the skin involving the sebaceous glands and hair follicles
What can occur on the hands as a result of HPV?
Warts
Primary syphilis can cause what on the skin?
Small, painless sores in or around the genitals, anus, or mouth
Secondary syphilis skin lesions
Maculopapular rash: flat and raised skin lesions that are red
Herpes Zoster
Viral infection that is painful but self-limited dermatomal rash
Mongolian spots (congenital dermal melanocytosis)
Birthmarks that appear flat blue or grey with an irregular shape that commonly appears at birth or soon after
Metastatic carcinoma
May present as a cellulitic skin rash
A purson with multiple myeloma may present with (skin lesion)
Pinch purpura
Metastatic renal carcinoma
Onycholysis
Painless loosening of the nail plate that occurs from the distal edge inward
Koilonychia (spoon nails)
Thin, depressed nails with lateral edges tilted upwards, forming a concave profile

Occurs in with anemia or iron deficiency
Beau's lines
Transverse grooves or ridges across the nail plates as a result of a decrease dor interrupted production of the nail by the matrix

Occurs in MI, cirrhosis, cancer chemotherapy
Splinter hemorrhages
Red brown linear streaks

Occurs in MI, endocarditis, renal failure
Leukonychia (white nail syndrome)
Dots or lines of white that progress to the free edge of the nail as the nail grows

Occurs due to hypocalcemia, anemia, hodgkin's disease, MI, cirrhosis
Paronychia
Infection of the fold of the skn at the margin of the nail

Red, swollen, tender, painful
Clubbing
Chronic oxygen deprivation of the nail beds

Occurs with lung cancer
Nail Patella Syndrome (NPS)
Abnormalities of the nails, knees, elbows, and pelvis

Nails present as missing, underdeveloped, discolored, split, ridged or pitted

Occurs with NPS, Fong's disease, Onycho-osteodysplasia, Turner-Kessler syndrome
White nails may indicate
Liver disease such as hepatitis
Yellowish, thickened, slow growing nails may indicate
Lung disease such as emphysema
Clubbing nails may indicate
Lung disease
Yellowish nails with a slight blush at the base indicate
Diabates
Half white half pink nails indicate
Kidney disease
Red nail beds indicate
Heart disease
Pale or white nail beds indicate
anemia
Pitting or ripping of the nail surface indicates
Psoriasis or inflammatory arthritis
Irregular red lines at the base of the nail fold indicate
Lupus or connective tissue disease
Dark lines beneath the nail indicate
Melanoma
Myxoid cysts
Small, benign lump that occurs on fingers or toes near a nail. Usually symptom free
Nail fold erythema or telangiectasis (widened venules causing threadline red lines or patterns on skin) indicate
SLE
Diffuse hair loss can be due to
systemic disease, hypothyroidism, anorexia nervosa, iron deficiency, SLE, cirrhosis of the liver, internal cancers
Patchy hairloss with a "mot eaten apperance" occurs in
secondary syphilis
Premature generalized thinning and graying of hair can occur in
AIDS
Ludwig type II pathology
classification for hair loss
(1 = mild, 3= severe)
Alopecia areata
autoimmune disorder that usually results in unpredictable patchy hair loss or complete loss of hair on scalp and body
What conditions can cause hair loss?
LUdwig type II or III
Alopecia areata
HIV
Chemotherapy
SLE
Herpes
Aids
Unexplained itching can be due to
Severe kidney disease (dry skin, severe itching)
Chronic liver disease
Internal malignancies like lymphomas with a generalized itch
AIDS
When to refer?
Skin and nail bed changes
Palpable liver, gallbladder, spleen
Headaches
Yellow warning signs
BP and Pulse irregularies
Fluid changes, night sweats
Weak but rapid pulse accompanied by fall in BP (pneumothorax)
Unexplained fever without systemic sx
Always take BP in patients with
Neck pain, upper quadrant symptoms, TOS
Immediate referral
Anyone with DM, immunocompromised, history of steroid and retroviral use with red, inflamed, swollen nail beds or skin lesions involving feet

Suspicious breast changes

Detection of palpable, fixed, irriegular mass in breat, axilla, or elsewhere suspicious of lymph node enlargement

Unusual finding with chest/abdomen exam

Recurrent cancer (a single lump, pale or red nodule, swelling, dimpling of skin, red rash)

New onset of SOB with tachypnea, diaphoretic/cyanotic
Abrupt change in mental status, confusion, new onset of delirium
OUtbreak of vesicular rash associated w/ Herpes zoster
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