Beginning the physical examination: General survey, vital signs, pain and nutritional assessment

1. Beginning the physical examination: General survey, vital signs, pain and nutritional assessment AmaniKhalil, RN, PhD

2. II- General survey • Is an introduction of the PE • Gives an overall impression of the person • Consists of four main components : • Physical appearance • Body structure • Mobility • Behavior

3. General Survey • Physical appearance • Age • Sexual development • Level of consciousness: alert and oriented • Skin color: even tone, intact, no lesions • Facial features: symmetric with movement • Body fat: adipose tissue in the subcutaneous, intra-abdominal & intramuscular fat deposits (weight & height).

4. Body structure Stature: height appropriate to age Nutrition: weight approp. to height and age BMI & wait circumference. Symmetry: equal bilateral Posture: stand comfortably Position: sits comfortably, arms relaxed at sides, head turned to examiner. Body build, contour General Survey

5. BMI classification underweight is a BMI under 18.5, normal is 18.5-24.9, overweight is 25.0-29.9, obesity 1 is 30-34.9, obesity 2 is 35-39.9, and extreme obesity or obesity 3 is greater than or equal to 40

6. Assessing dietary intake Changes in weight (rapid changes in weight suggest changes in body fluids not tissues. Fatigue and weakness. Fever, chills & night sweats. Optimal weight & nutrition. Exercise. Blood pressure & diet.

7. General Survey • Mobility • Gait: the base as wide as the shoulder, smooth walk, even and well-balanced. With symmetric arm swing • Range of motion: full ROM for each joint. Accurate , smooth, and coordianted movement

8. Abnormal gaits Spastic Hemiparesis (upper motor neuron lesion). Cerebral ataxia (alcohol or barbiturate effect on cerebelum) Parkinsonian Scissors (multiple sclerosis) Steppageor foot drop (poliomyelitis)

9. Behavior Facial expression; maintains eye contact, expressions app to situation Mood and affect: comfortable and cooperative Speech: articulation -able to form ward - clear and understandable Dress: app to climate, clean, fits the body Personal hygiene; clean and groomed General Survey

10. Functional assessment Measure the ability to perform the activity of daily living eating, bathing. Difficulties in any of these warrant follow-up care, and consultation

11. Vital signs

12. Vital signs What are the vital signs? BP, HR, RR, Temp & pain assessment.

13. What are the optimal conditions to taking blood pressure avoid smoking or caffeine 30 min prior to, ensure room is quiet and comfy temp, pt should be seated quietly in chair w/ feet on floor for 5 min, pts arm should be free of clothing, palpate the brachial artery, position arm so that the brachial artery is at heart level, rest arm on table o little above the pts waist or support the patients arm with your own at his mid-chest level

14. BP How is the size cuff to be used determined? width: 40% of upper arm circumference, Length 80 of upper arm circumference

15. Blood pressure classifications • Normal <120 <80 • Prehypertensio n 120-139 80 to 90 • Hypertension • Stage 1 140-159 90-99 • Stage II ≥160 ≥100

16. Blood pressure abnormalities Hypertension (effects on eyes, heart, brain, kidney). Coartication of the aorta. Orthostatic (postural) hypotension.

17. Diagnostic Assessment for PVD Ankle-brachial index (ABI) • Using handheld Doppler • Calculated by deviding the ankle systolic BP (SBP)by the highest brachial SBP. • Normal ABI is 0.9-1.3 • ABI 0.41-0.89 indicates mild to mod PVD • ABI 0-40 indicates severe PVD • The same procedure used post operative bypass surgery

19. HR What is most commonly used to measure the HR? radial How do u measure the HR? use the pads of the index and middle fingers, if the rate seems normal and the rhythm is regular count the rate for 30 second and multiply by 2. if the rate is fast or slow and/or the rhythm is irregular count for a full 60 seconds

20. RR How do you take the respiratory rate? observe rate rhythm, depth and effort of breathing, normal rate is 14-20 breaths/min, count for 60 seconds

21. Temp What is the average oral temperature? 37C or 98.6F Hyperthermia hypothermia

22. Pain Assessment

23. PAIN • Pain is a highly complex & subjective experience that originates from the central (CNS) or peripheral nervous system (PNS) or both. • Pain is a highly unpleasant sensatory& emotional experience associated with acute or potential tissue damage.

24. Types of Pain. • Pain in term of origin: • Coetaneous pain originates in the skin surface & subcutaneous tissues. • Deep somatic pain originates from ligaments, tendons, bones, muscles, blood vessels, & nerves. • Visceral pain originates from the larger interior organs (E.g.: kidney, stomach).

25. Definition of Pain • Pain is a complex experience that is not measurable or observable by anyone other than the person experiencing the pain. • In 1968, McCaffery defined pain as “whatever the experiencing person says it is, existing whenever she/he says it does”. • pain is a subjective experience. • All pain is real, even if no physical cause or origin can be identified.

26. Structure and Function

27. Neuroanatomic pathway Nociceptors detect painful stimuli from the site injury gives rise to a release of prostaglandin → the peripheral nervous system to the spinal cord where Substance P (a neurotransmitter) is released → facilitating the impulse through the spinal cord to the cerebral cortex.

29. Physiology of Acute Pain • Nociception: the process by which information about tissue damage is conveyed to the CNS. • Transduction: the conversion of the energy from a noxious stimulus into electrical energy (nerve impulses) by sensory receptors called nociceptors • Transmission: the transmission of these neural signals from the site of transduction (periphery) to the spinal cord and brain • Perception: the appreciation of signals arriving in higher structures as pain • Modulation: descending inhibitory and facilitory input from the brain that influences (modulates) nociceptive transmission at the level of the spinal cord.

30. What Happens During Transduction? • Nociceptor activationSignals from these nociceptors (the free endings of nerve fibers in the periphery) travel along two fiber types: • slowly conducting unmyelinatedC-fibers • small, myelinated, and more rapidly conducting A-delta fibers.

31. What Happens During Transduction? • cells release mediators of inflammation (prostaglandins, substance P, bradykinin, histamine, …) activate nociceptors generate nerve impulses

32. What Happens During Transmission? • Nerve impulses are transmitted to the spinal cord and brain in several phases: • Periphery to the spinal cord: sensory nerve impulses travel to the dorsal horn (DH) of the spinal cord. • Spinal cord to the brainThe nerve processes of DH projection neurons project to the brain in bundles called ascending tracts. transmit signals to the thalamus via the spinothalamic tract or to the reticular formation, and hypothalamus via the other tracts.

33. What Happens During Perception? • information from DH projection neurons travels via the thalamus to the somatosensory cortex,  conscious awareness of pain : location, intensity, and quality of the pain. • Immediate social and environmental context influences the perception of pain, as do past experience and culture. Consequently, a standard cause of pain (e.g., surgery) can generate enormous individual differences in pain perception.

34. What Happens During Modulation? • Descending pathwaysNerve fibers release inhibitory substances (endogenous opioids, norepinephrine) that bind to receptors inhibit transmission.

35. Subjective Data: Initial Assessment • Where is your pain? • When did your pain start? • What does your pain feel like? • How much pain do you have now? • What makes it better or worse? • How does pain limit your function or activities? • How you usually behave when you are in pain? How would others know you are in pain? • What does this pain mean to you? Why do you think you are having pain?

36. Initial Assessment • Location • Intensity • Quality, character • Onset • Duration • Improving and provoking factors • Effects of pain

37. Brief Pain Inventory • ask the client to rate the pain within the past 24 hours using graduated scales (0-10) with respect to its impact on mood, walking, and sleep.

38. Pain in terms of experience • Radiating pain: is perceived at the source of pain & extends to the near by tissues (cardiac pain). • Referred pain: is felt in a part of the body that is considered removed from the tissue causing of pain (abdominal visceral pain may be perceived in an area of the skin remote from the organ causing the pain).

39. Pain in terms of experience • Intractable pain: is highly resistant to relieve: (advanced malignancy). • Neuropathic pain: results from current or past damage to peripheral or CNS, & may haven’t a stimulus. • Phantom pain: is a painful pain sensation perceived in a body part that is missing. (E.g. amputated leg).

40. Pain in term of duration • Acute Pain is a sudden or slow onset regardless of the intensity& self-limiting. • Chronic Pain is a prolonged usually recurring or persisting over 6 mos. Or longer, interferers with function. • Malignant pain (E.g. Intractable pain). • Non- Malignant pain ( joints pain).

41. Brief Pain Inventory

42. McGill Pain Questionnaire Asks the client to rank a list of descriptors in terms of their intensity and to give an overall intensity rating the his pain

43. Pain Rating Scales

44. Pain Scales مقياس الألم المرئي|__________________________________________________________________| مقياس الألم الرقمي|---------|---------|----------|---------|---------|---------|---------|---------|---------|---------| Figure 7: Arabic version of pain rating scale

45. Pain Scales

46. Table 4: FLACC Scale

47. The World Health Organization (WHO) approach.

48. Objective Data: Initial Assessment • The joints: normally; no tenderness or pain • Muscles and skin • Abdomen Ta assess: • ask the person to close his eyes • Test his ability to perceive sensation by tongue blade • Test sharp and dull identification

49. Physiological measures • Physiological parameters; HR, RR, BP, palmer sweating, cortisone levels, transcutaneous oxygen, vagal tone • Physiologic parameters provide useful information about general distress levels of children who are experiencing pain.

50. Faces pain rating scale