session 1 general survey & vital signs biosciences …€¢ direct –the striking hand contacts...
TRANSCRIPT
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Session Objectives
o Identify the role of clinical examination and its relevance
to complementary medicine.
o Understand the professional and ethical conduct
required during clinical examination of a client.
o Describe the clinical examination environment -
equipment, set-up and safe practice.
o Describe the components of a complete physical
assessment.
o Describe the process for the subjective assessment of
pain.
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Session Objectives cont
o Describe the basic techniques of inspection, palpation,
percussion and auscultation.
o Describe the variations in clinical examination findings
that occur across the lifespan.
o Perform various physical examinations inclusive of
• General Survey
• Vital Signs (Temperature, Pulse, Respiration)
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So why do we need clinical
examination?• Develop and refine our differential diagnosis
• Assess whether we can manage the client within our
scope of practice
• Guides treatment planning
• Monitors treatment effectiveness
• Facilitates communication
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Conduct during Clinical Examination
o The Endeavour College Wellnation Clinics Handbook
states:
“Clinical observation and practice is a key feature of the
Endeavour courses of study. Students are expected to
show ethical and cultural awareness and behave
appropriately in all clinical settings when interacting with
clients, staff and fellow students and concerning issues of
confidentiality.”
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Conduct during Clinical Examination
o Respect & Dignity • As physical contact will be required in order to perform
examinations students need to demonstrate professional attitude and respect for fellow students
• Demonstrate a social and cultural respect for fellow students
• As a certain amount of clothing may need to be removed for some examination techniques draping and dignity of student client needs to be ensured
o Consent• Every examination will be described to obtain informed consent
o Confidentiality• Maintain confidentiality of measured results and personal
medical information
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The Clinical Exam Environment
o The examination room should be warm, quiet, private and have good lighting.
o The examination table should be easily accessible from both sides and at appropriate height for examiner
o Equipment should be accessible and organized
o Adjustable height stool - for examiner or client
o Clean linen on table/ for draping
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The Equipment
o Thermometer
o Stethoscope
o Sphygmomanometer
o Pen torch
o Reflex Hammer
o Otoscope & speculae
o Tape measure
o Draping
o Tongue depressors
o Scales and height
measuring apparatus
o Alcohol prep swabs/
mediwipes
o Handwash
o Gloves
o Waste bins
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WHS & Infection Control
Workplace Health & Safety (WHS) considerations include:
o Positioning of equipment and client’s personal belongings to prevent trips and falls.
o Manual handling, including assisting clients where needed.
o Use of Standard Precautions to ensure infection control
• Personal hygiene and hand washing
• Cleaning and disinfecting equipment between uses
• Use of personal protective equipment e.g. gloves
• Ensuring a clean environment
• Appropriate handling and disposal of waste products
Note:
Hand hygiene is also
performed after the
removal of gloves
(QLD Dept. of Health, 2013)
Routine Hand Hygiene
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Handwashing Procedure
(QLD Dept. of Health, 2013)
Use handwashing technique
with soap and water when
your hands are visibly soiled.
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Hand-rubbing Procedure
(QLD Dept. of Health, 2013)
Use alcohol based hand rub
for all general clinical contact
and procedures .
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Role of Clinical Examination
o Clinical examination is one component of the complete
health assessment of a client. It involves the skills of
observation and physical assessment.
The complete health assessment consists of:
The clients health history
Observation
Physical examination
Diagnostics
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The Health History
The clients health
history commonly
includes the following
information
o Biographic data
o Reason for seeking
care
o Present health state or
history of current illness
o Past health history
o Medications
o Family health history
o Systems review
o Functional assessment
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The General Survey
o The general survey is
a study of the whole
person, covering the
general health state
and obvious physical
characteristics
o It gives an overall
impression that forms
the baseline for
further assessment
4 Parts of the General
Survey
Physical appearance
Body structure
Mobility
Behaviour
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The General Survey
Physical Appearance
• Age, Gender
• Level of
Consciousness
• Skin colour
• Facial features
Body Structure
• Stature
• Weight, Height, BMI
• Waist/Hip ratio
• Posture
Mobility
• Gait
• Range of motion
Behaviour
• Facial Expression
• Mood and Emotion
• Speech
• Dress & Appearance
• Personal hygiene
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Complete Physical Assessment
o The examination and measurement of the characteristics
and features of the body and its systems.
• Anthropometrics – height, weight, BMI, hip/waist ratio
• Vital signs – Temperature, pulse, BP, respiratory rate
• General survey – Appearance, structure, mobility, behaviour
• System analysis – Inspection, palpation, percussion, auscultation
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Physical (Clinical) Examination
o Physical examination focuses on observation and
physical assessment of a client
• The assessment techniques learned will be important tools for
the practitioner of any complementary medicine modality to add
to their assessment repertoire.
• The information obtained from observation and physical
assessment can be used to assist in client diagnosis and
management, which may include the need for referral.
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Order of Physical Examination
When approaching the process of performing a physical
examination of a client, you will most often use the
following order:
Inspection
Percussion
Palpation
Auscultation
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Inspection
ALWAYS COMES FIRST
o LOOK - Concentrated watching
• first of the individual as a whole and then of each of the body
systems
o Begins the moment you first meet the client and develop
a “general survey”
o Compare both sides of the body
o Needs good lighting, adequate exposure
o Used before any other technique / equipment is used
• e.g. otoscope, penlight, tongue depressor
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Percussion
Tapping the person’s body with short, sharp strokes to
assess underlying structures using characteristic sounds
indicative of tissue density.
Used to:
o Map out the location and size of an organ
o Determine the density (air, fluid or solid) of the structure
by the characteristic sound e.g. solid organ = dull
o Elicits pain if the underlying structure is inflamed e.g.
sinus or kidneys
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Percussion Techniques
o 2 percussion techniques:
• Direct – the striking hand contacts directly with the body wall
• Indirect – the striking hand contacts the stationary hand fixed to
the persons skin
Characteristics of percussion
Resonance Clear & Hollow Adult thorax
Hyper-resonant Booming Child Thorax
Tympany Drum like Abdomen
Dull Muffled thud Solid organs
Flat Absolute dullness Bone or tumour
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Palpation
o Palpation usually follows and often qualifies findings you
noted during inspection and percussion.
o Applies your sense of touch to assess:
• Texture, temperature, moisture
• Organ location and size
• Swelling, vibration, pulsation, rigidity or spasticity, crepitus
• Presence of lumps or masses
• Presence of pain or tenderness
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Palpation Techniques
1. Fingertips
• Feeling for skin texture,
swelling, pulses, presence of
lumps
2. Grasping action of the fingers
and thumb
• To detect the position, shape
and consistency of an organ
or mass
3. Dorsum of the hands and fingers
• For determining the
temperature
4. Base of fingers or ulnar surface
of hands
• For assessing vibration
Technique:
Slow and systematic
Light to deep
Intermittent pressure
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Auscultation
o Auscultation involves listening with a stethoscope to the
sounds produced by the body such as the breathing,
heart sounds or bowel sounds.
o Stethoscopes do not magnify sound so the fit and quality
of the stethoscope is important
• When fitted and worn correctly, they reduce outside noise to
allow the user to better hear the body’s sounds
• The slope of the earpieces should point forward towards your
nose
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The Stethoscopeo There are 2 sides to the stethoscope head
• The diaphragm is best for high pitched sounds
– e.g. breath, bowel, and normal heart sounds
• The bell is best for soft, low-pitched sounds
– e.g. extra heart sounds or murmurs
• Minimise extraneous noise
– E.g. noise in the room, body hair, clothes rubbing
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Variations in Physical Assessment
o Assessment techniques sometimes need to be adapted
to suit the individual client
• Disability restricting ideal positioning
• Extreme age of client – very young/ elderly
• During pregnancy
o Normal ranges of measurement vary with changes in the
life cycle
• Infancy/ early – middle childhood
• Adolescence / early adulthood
• Middle adulthood/ late adulthood
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Anthropometrics
Anthropometrics involves the measurement of the human
body. Basic measurements are included as part of the
complete health assessment of an individual, most often as
an integral part of the general survey.
o Common measurements include
• Height
• Weight
• Waist circumference
• Waist:hip ratio
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Height and Weight
o Height is measured using a standard height measure
device known as a stadiometer. The patient should have
bare feet, be standing flat footed with back comfortably
straight, and eyes looking straight ahead. Take the
measurement from the highest point of the head in this
position. Document the height in centimetres (cm)
o Weight is measured using a standard balance or
electronic scale. The patient should remove their shoes
and all excess clothing before stepping onto the scale.
Document the weight in kilograms (kg) to one decimal
place e.g. 85.5kg
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Waist Circumference
Waist circumference is measured
using a standard tape measure
located at the highest point of the
iliac crest (approximates to the
navel). Ensure the patient is
standing upright, with the abdomen
exposed and relaxed to its natural
position.
Increased risk of cardiovascular
disease is determined when the
waist circumference is:
Women: 80-88cm or above
Men: 94-102cm or above
(NHMRC, 2013)
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Anthropometric Calculations
o Waist:Hip Ratio
• Take a second measurement around the widest part of the hips
and buttocks:
Waist (cm) / Hips (cm) = Waist:Hip Ratio
A result >0.85 (F) and >0.90 (M) indicates central abdominal
obesity in adults only.
o Body Mass Index (BMI)
• To calculate the BMI:
Weight (kg) / Height (m2) = BMI kg/m2
<18.5 underweight 18.5-24.9 normal weight
25-29.9 overweight >30 obese
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Observing Behaviour
Observing behaviour is an important component
of the general survey and should be undertaken
from the first moment you meet the client.
o Abnormal behaviours may indicate
• Anxiety, depression or grief
• Distrust or potential hostility
• Psychological disorders
• Neurological disorders
• Pronounced illness or pain
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Observing Behaviour
o Facial Expression
• Maintains eye contact with appropriate expressions or the
situation
o Mood and Affect
• The person is comfortable and cooperative and interacts
pleasantly
o Speech
• The speech is clear, understandable and appropriate
o Dress
• Clothing is clean, culturally and age appropriate, and
appropriate for the climate
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Assessing Pain
“Pain is defined as an unpleasant sensory and emotional
experience associated with actual or potential tissue
damage…Pain is always subjective” (Jarvis, 2016, p.166)
o A subjective assessment of pain has been shown to be
clinically reliable. Pain assessment should include:
• An initial assessment of pain
– (PQRST Method)
• The patients subjective report of the pain intensity
– (0-10 numeric pain scale or Faces Pain Scale)
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PQRST Method
Provocation/palliation What caused/s the pain?
What makes it better or worse?
Quality/Quantity What does it feel like?
Is it sharp, dull, stabbing, burning, crushing,
throbbing, shooting?
Region/Radiation Where is the pain?
Does the pain radiate/refer somewhere else?
Severity Scale Use a validated pain scale such as the 0-10
Numerical Pain Scale.
For children use the Faces Pain Scale
Timing When did the pain start?
How long did the pain last for?
How often does the pain occur?
(Jarvis, 2016, p. 167)
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Pain Scales
o Numeric Pain Intensity Scale (Adults)
o Faces Pain Scale (Children)
(Jarvis, 2016, p.170)
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Vital Signs
There are 4 vital signs (T,P,R,BP)
Temperature
Pulse
Respiration
Blood Pressure
Baseline observation of vital signs should be performed on
all patients. Changes to the vital signs in terms of the
reference ranges or qualities may indicate disease or
disorder.
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Temperature
Heat Production
o Metabolism
o Exercise
o Food digestion
o External factors
Heat loss
o Radiation
o Evaporation / sweat
o Convection
o Conduction
Body temperature is regulated by the hypothalamus. A
stable core temperature of 37.2oC is optimal for metabolism
and is achieved by balancing heat production and loss
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Sites for Taking a Temperature
The temperature can be taken via the oral, axilla, rectal or tympanic routes. In clinical routine clinical practice the most commonly used routes are”
o Oral – mercury in glass or digital thermometer (35.8-37.3oC)
– Accurate and convenient – 2 minutes
– Not after hot/cold drinks or smoking
o Ear – tympanic membrane thermometer
– Measures infra-red emissions from tympanic membrane
– 2-5 seconds
– Safe/ quick/ good for all ages
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Changes in Temperature Hyperthermia (fever) - >37.4oC
o Pyrogens secreted by
• Toxic bacteria - infection
• Tissue breakdown e.g. from trauma, surgery, heart attack,
cancer
o Neurological conditions that can “reset” the thermostat higher
• e.g. stroke, cerebral oedema, brain trauma/ tumour/ surgery
o Over– exposure to heat
• Heat exhaustion/ heat stroke
Hypothermia - <35.5oC
o Usually due to accidental prolonged exposure to cold
• 30 -32°C → loss of consciousness
• 28°C → heart failure / death
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Pulse Rate
o As the heart contracts it pumps blood into the Aorta. This bolus of blood is known as the stroke volume, and is about 70mls in the average adult.
o The force of the stroke volume against the arterial walls creates a pulse wave, which can be felt as the pulse by palpating peripheral arteries.
o Pulse is strongest in the arteries closest to the heart, weaker in the arterioles, and disappears in the capillaries.
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Pulse Ranges & Interpretation
AGE RATE
Neonates 0 – 1 month 70 – 190 bpm
Infants 1 – 11 months 80 – 160 bpm
Children 1 – 2 years 80 – 130 bpm
Children 3 – 4 years 80 – 120 bpm
Children 5 – 6 years 75 – 115 bpm
Children 7 – 9 years 70 – 110 bpm
Children >10yrs – Adults 60 – 100 bpm
Well-trained athletes 40 – 60 bpm
Tachycardia (in adults) >100 bpm
Bradycardia (in adults) <60 bpm
http://www.nlm.nih.gov/medlineplus/ency/article/003399.htm
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Variables of a Pulseo Rate (beats per min) – Count for 30 secs x 2 if regular
o Rhythm (regular or irregular)
o Force (stroke volume)
• 0 = absent
• 1+ = weak or thready
• 2+ = normal
• 3+ = full or bounding
o Elasticity (of the arterial wall)
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Radial Pulse(Jarvis 2004)
The radial pulse lies medial to the radius and lateral to the palmaris longus
tendon, a the wrist.
• Locate the palmaris longus tendon which is aligned to the 3rd phalanx.
• Place the pads of 2 or 3 fingers in the groove between the radius and the
palmaris longus tendon. Count the beats for 15 secs x 4 if regular, or for a
full minute if irregular.
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Respiration Rate
o Normal respiration is relaxed, regular, automatic and
silent
o When counting respirations, do so unobtrusively as rate
may change once the patient becomes aware that your
counting. Observe the rise and fall of the chest.
o Count for 30 seconds (x2) or 60 seconds
o Record as respirations per minute
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Respiration Rate
o 3 variables need to be observed:
• Rate (breath /minute)
• Rhythm (regular or irregular)
• Effort (relaxed or forced)
o Normal range:
• Adults: 10-20 BPM
• Teens: 12-22 BPM
• Neonate: 30-40 BPM
46
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References
o Jarvis, C. (2016) Physical Examination and Health Assessment (7th ed.). Missouri: Elsevier.
o Tortora, G., & Derrickson, B. (2014). Principles of Anatomy and Physiology (14th edn). Hoboken, NJ: John Wiley.
o Queensland Dept. of Health (2016). Guidelines: Hand Hygiene, Brisbane: Queensland Government.
o National Health & Medical Research Council (2013). Clinical Practice Guidelines for Management of Overweight and Obesity in Adults, Adolescents and Children in Australia. Melbourne: NHMRC.
© Endeavour College of Natural Health www.endeavour.edu.au 48
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