Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2656_Библиотеки_им_академика_М_И_Перельмана
.pdf
146 PHYSICAL EXAMINATION
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-300
https://t.me/medicina_free
UNIT 2
A thin or frail appearance occurs when there are limited body fat stores. Severely
A
limited fat stores can be a life-threatening condition.
Energy expenditures that exceed caloric intake will result in decreased fat stores.
P
This may be caused by several conditions, including:
> anorexia nervosa, which results in inadequate intake of calories from food
and over-expenditure of energy by means of exercise
> hyperkinetic states, in which the body’s metabolic needs are greater than
the ability to ingest calories. Adolescent growth spurts result in tall, thin
teens because the increased metabolic demands for growing tissue exceed the
calories teens can consume
> chronic disease processes that may be due to hyperkinetic states or a result of
malabsorption diseases.
Body conformation and posture
N
Limbs and trunk should appear proportional to body height; posture should be
erect (see
approximately equal to their height, and body length (crown to pubis) should be
about equal to the length from the pubis to the feet.
A slumped or humpbacked appearance is abnormal.
A
Osteoporosis, especially in postmenopausal women, may cause a slumped or
P
humpbacked appearance.
P
Consumers experiencing depression may also present with a slumped posture.
Long limbs relative to trunk length are abnormal.
A
Marfan syndrome, an inherited disease, can result in the development of long
P
limbs; long, thin ngers; a tall, thin appearance; and poorly developed muscles
due to a defect in the elastic bres of connective tissues. The consumer’s arm
span is greater than their height.
Figure 6.2). A person’s arm span (ngertip to ngertip) should be
FIGURE 6.2 Example of good and poor posture
GETT Y IMAGES/WETCAK E
Motor activity
N
Gait as well as other body movements should be smooth and effortless. All body
parts should have controlled, purposeful movement.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
EXAMINATION REQUIREMENTS FOR EVERY CONSUMER 147
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-300
https://t.me/medicina_free
An unsteady gait or movements that are slow, absent or require great effort are
A
abnormal. Tremors or movements that seem uncontrollable by the consumer are
also abnormal.
Arthritis can result in slow and difcult movement because joint movement is
P
painful. See Chapter 16 for additional information.
Neurological disturbances can result in tics, paralysis or ataxia, and can cause
P
difculty with the smoothness of movement. See Chapter 7 for
additional information.
REFLECTION IN PRACTICE
Assessing the consumer with severe odours
You are examining a young person and about to take their oral temperature. At this
time, you note they have severe halitosis. Consider how you would progress with this
observation, and the approach you would take, including the questions you would pose to
discover the cause of the odour. In these situations it is imperative to maintain respect for
the consumer’s dignity.
Body and breath odours
N
Normally, there is no apparent odour from consumers. It is normal for some
people to have bad breath related to the types of foods ingested or due to
individual digestive processes and reux.
A
Severe body or breath odour is abnormal.
Poor hygiene can cause body odours due to perspiration and bacteria left on
P
the skin.
An alcohol smell on the breath can result from alcohol ingestion or from
P
ketoacidosis in a diabetic consumer.
Bad breath can result from poor oral hygiene, allergic rhinitis, or from infections
P
such as tonsillitis, rhinosinusitis or pneumonia.
Severe vaginal infections can result in an offensive body odour.
P
CHAPTER 6
Examination of psychological status
Observe the consumer’s:
E
1. mental status and cognitive function (level of consciousness)
2. facial expressions
3. dress, grooming and personal hygiene
4. mood and manner
5. speech and communication
6. distress.
Mental status and cognitive function
N
The consumer should appear awake and alert, and be generally oriented to
person, place and date/time. When using assessment tools such as AVPU or
Glasgow Coma Scale (GCS), normal function is ‘A’ in AVPU or a score of 15 for
GCS (see Figure 6.3). Mini Mental State Examination (see Figure 6.4) also should
show normal function for attention, memory, judgement, insight, spatial
perception, calculation, abstraction, thought processes and thought content.
The consumer with normal function has no plans to harm self or others.
A
Altered level of consciousness.
Confusion, lethargy, stupor, permanent vegetative state, locked-in syndrome,
P
coma or brain death (see Chapter 7 for detailed information) can alter a person’s
level of consciousness.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
148 PHYSICAL EXAMINATION
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-300
https://t.me/medicina_free
UNIT 2
FIGURE 6.3 Scales for assessing level of consciousness
SATS: Danish Student Society of Anesthesiology and Traumatology
A
Altered attention, memory, judgement, insight, spatial perception, calculation,
abstraction, thought processes and thought content.
Dementia, delirium, neurological injury, infection or disease, intellectual
P
disability, effect of drugs and alcohol, psychosis, bipolar affective disorders,
schizophrenia, endogenous anxiety states or depressed states, brain lesions or
growths can cause altered cognitive function.
A
Expresses plans or intention to harm self or others.
Suicidal or homicidal ideation can occur when mental disorders, particularly
P
depression, substance abuse and schizophrenia, are present and active.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
EXAMINATION REQUIREMENTS FOR EVERY CONSUMER 149
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-300
https://t.me/medicina_free
CHAPTER 6
FIGURE 6.4 Mini Mental State Examination
https://Medworksmedia.Com/Product/Mini-Mental-State-Examination-Mmse/
Facial expressions
N
Facial expressions should be appropriate for what is happening in the
environment and should change naturally.
A
Unchanging or at facial expression/affect, inappropriate facial expression,
tremors or tics are abnormal.
Apathy or depression may cause lack of facial expression due to feelings of
P
lethargy or sadness.
Dementia may cause inappropriate facial expressions because the consumer’s
P
perception of reality is distorted.
Cranial nerve (CN) dysfunction or impingement of CN VII may show
P
asymmetry in muscle control in the face, which includes abnormal facial
movements. Bell’s palsy, a condition resulting in paralysis of the muscles in the
face, may cause the mouth to droop and the affected side of the face to appear
accid, with the inability to completely close the eye on the affected side.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
150 PHYSICAL EXAMINATION
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-300
https://t.me/medicina_free
UNIT 2
Dress, grooming and personal hygiene
N
Normally, consumers should appear clean and neatly dressed. Clothing choice
should be appropriate for the weather. Norms and standards for dress and
cleanliness may vary among cultures.
A
A dishevelled, unkempt appearance or clothing that is inappropriate for the
weather (such as a wool coat in hot weather) is abnormal.
Psychological or psychiatric disorders such as depression (characterised in part
P
by lethargy, mood swings, anhedonia [or lack of pleasure in activities], fatigue),
psychotic disorders (characterised by a distortion in thinking) and dementia
(processes that alter perceptions of reality) may be reected in inappropriate
appearance (hair, make-up) or through inappropriate clothing selection.
Poor self-esteem or a homeless lifestyle may be reected by general neglect of
P
personal hygiene, grooming and dress.
An unshaven, unclean appearance may reect abuse or neglect of the consumer
P
by the consumer’s caregiver.
FIGURE 6.5 Assessing a consumer’s
psychological presence, specically
dress, grooming and personal hygiene.
A dishevelled appearance is an
abnormal nding.
ALAMY STOCK PHOTO/SCOTT RYLANDER
Mood and manner
N
Generally, a consumer should be cooperative and pleasant.
A
An uncooperative, hostile or tearful adult or an adult who seems unusually
elated or who has a at affect needs further assessment.
Psychiatric conditions such as depression, manic disorders, paranoid disorders
P
and psychotic disorders produce a distortion in reality (distorted thinking and
perceptions), resulting in abnormal behaviours. Dementia or confusion in the
elderly can also result in disturbances of mood and manner. See Chapter 7 for a
more complete discussion.
Speech and communication
N
The consumer should respond to questions and commands easily. Speech should
be clear and understandable. Pitch, rate, content and volume should be
appropriate to the circumstances.
A
Speech that is slow, slurred, mumbled, very loud or rapid needs to be
assessed further.
Hyperthyroidism can cause rapid speech because of hormones that are
P
stimulatory in nature and result in hypermetabolism and hyperactivity.
Alcohol ingestion can cause slow, mumbled or slurred speech because alcohol
P
affects the central nervous system, causing transient brain dysfunction.
Hearing difculties may be associated with loud speech because individuals with
P
decreased ability to hear may not be able to hear themselves at normal
conversational decibels.
Strokes or brain injury can result in aphasia if the speech centre in the brain is
P
affected, or language dysfunction such as dysphasia. Lesions in the brain can
impact on communication with other dysfunctions such as dysphonia, aphonia,
dysarthria, apraxia, agraphia and alexia.
Damage to CN XII, the hypoglossal nerve, can cause inability to speak or
P
changed lingual sounds; speech changes may include lisps.
Distress
Observe the consumer for:
E
1. laboured breathing, wheezing or cough, or laboured speech
2. painful facial expression, sweating, or physical protection of painful area
3. serious or life-threatening occurrences such as seizure activity, active and
severe bleeding, gaping wounds and open fractures.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
EXAMINATION REQUIREMENTS FOR EVERY CONSUMER 151
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-300
https://t.me/medicina_free
4. signs of emotional distress or anxiety that may include, but are not limited
to, tearfulness, nervous tics or laughter, avoidance of eye contact, cold
clammy hands, excessive nail biting, inability to pay attention, autonomic
responses such as diaphoresis, or changes in breathing patterns.
N
Breathing should be effortless, without cough or wheezing. Speech should
not leave a consumer breathless. The face should be relaxed, and the
individual should be willing to move all body parts freely. There should be no
serious or life-threatening conditions. The consumer should not perspire
excessively or show signs of emotional distress such as nail biting or
avoidance of eye contact (Figure 6.6).
A
The presence of shortness of breath with laboured speech, wheezing or cough
is abnormal.
Pulmonary disease may be present. See Chapter 13 for additional information.
P
A
Pain, as evidenced by facial grimacing, crying, moaning, sweating or protection
of a body part, is an abnormal nding.
Tissue damage results in pain, and further investigation is needed into the
P
character, location, intensity and occurrence of the pain, as well as factors
associated with increased and decreased pain.
A
Excessive nail biting, avoidance of eye contact, nervous laughter, tearfulness or
FIGURE 6.6 The general survey includes
assessing every consumer for signs
of distress.
CHAPTER 6
Nervous habits are often displayed when a person is in an uncomfortable or new
P
situation. A tearful or sad affect can result from emotional pain related to
situations the consumer may be experiencing or has experienced. Often, there is
an attempt made to disguise emotional distress.
URGENT FINDING
Recognition of deterioration in a person’s mental state
Mental state deterioration can be due to internal factors, including exacerbation of mental
illness, psychological distress, physical conditions such as delirium, atypical responses to
prescribed treatments, or intoxication with licit or illicit substances. Deterioration in mental
state can also be attributed to factors arising from an individual’s social context or their
response to the environment. It is important to note that individuals experience and express
deterioration in mental state in different ways (ACSQHC, 2017).
Acute deterioration in a consumer’s mental state can occur in any healthcare setting,
and this in itself is an adverse outcome. However, this acute change can also be associated
with further adverse outcomes including attempted suicide, increased aggression and the
traumatic use of restrictive practices, if not managed in a timely manner.
The key for a nurse to identify deterioration in a person’s mental state is observing any
changes in current or usual behaviours, cognitive function, perception or emotional state
by using relevant screening processes at presentation, during physical examination and
health history taking.
Common signs of deterioration in mental state can include the following.
> Reported by the consumer/family:
· mood disturbance (elevated or irritable mood; depression)
· psychotic symptoms (paranoid ideas; hallucinations; delusions)
· situational crisis
· attempted self-harm
· risk of harm to others
· verbal commands to do harm to self or others
· suicidal ideation
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
>>
152 PHYSICAL EXAMINATION
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-300
https://t.me/medicina_free
UNIT 2
>>
> Observed behaviours:
· ambivalence about treatment
· restlessness
· confusion
· agitation
· physical/verbal aggression
· bizarre/disoriented behaviour
· withdrawn/uncommunicative
(Adapted from ACSQHC, 2017)
When a consumer’s mental state is observed to have changed, the nurse must determine
the immediate actions needed to prevent further deterioration by following the escalation
protocol in place in their healthcare facility.
For more information on standards and protocols related to the deteriorating mental
state of the consumer, visit ACSQHC (2017) – National Consensus Statement: Essential
elements for recognising and responding to deterioration in a person’s mental state,
https://www.safetyandquality.gov.au/publications-and-resources/resource-library/
national-consensus-statement-essential-elements-recognising-and-responding-deterioration-persons-mental-state.
EXAMINATION OF VITAL SIGNS
Vital sign measurements include respiration, pulse, temperature, blood pressure
and oxygen saturations (if indicated). Note that the vital sign measurements
adopted in this textbook are based on the current evidence-based literature.
You may note slight variations to these parameters published in other literature
sources. It is important that you check your health service for guidelines on what
the ‘normal ranges’ are to ensure you respond and act as appropriate in your work
environment.
General approach to vital signs assessment
1. Gather equipment.
2. Explain the procedure to the consumer.
3. Select equipment according to the consumer’s age, size and developmental
level, and the site selected for assessment. Specic decision-making criteria
are discussed under each section.
4. Warm the stethoscope headpiece before touching the consumer with it.
5. Assess vital signs and record ndings.
CLINICAL REASONING
Practice tip: Frequency of assessing vital signs
Vital signs should be assessed as often as prescribed (as per the clinical pathway/policy/
protocol in the health service area) or as often as the consumer’s condition requires. Within
active plans of care, vital sign frequency is often ordered by a medical ofcer or nurse
practitioner (e.g. every 6 hours); however, this should be considered the minimum frequency
for vital signs to be taken. If the consumer’s condition changes, nurses can increase
frequency of vital signs as often as required by the change in their condition. For example,
for a consumer who has a drop in blood pressure, the nurse may re-evaluate the person’s
vital signs every half-hour. This may also trigger an escalation protocol, which should be
documented and revisited often.
EXAMINATION REQUIREMENTS FOR EVERY CONSUMER 153
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-300
https://t.me/medicina_free
Respiration
Respiration is the act of breathing. Breathing supplies oxygen to the body and occurs
in response to changes in the concentration of oxygen (O
+
hydrogen (H
) in the arterial blood. Inhalation, or inspiration, occurs when air is taken
into the lungs. Exhalation, or expiration, refers to the airow out of the lungs.
Inspiration occurs when the diaphragm and the intercostal muscles contract.
This can be observed by the movement of the abdomen outwards and the
movement of the chest upwards and outwards, resulting in the lungs lling with air.
Expiration occurs when the external intercostal muscles and the diaphragm relax.
The abdomen and the chest return to a resting position.
Respiratory rate is measured in breaths per minute. One respiratory cycle
consists of one inhalation and one expiration. A complete discussion of respiratory
assessment is found in Chapter 13.
To assess respiratory rate:
E
1. Stand in front of or to the side of the consumer.
2. Discreetly observe the consumer’s breathing (rise and fall of the chest).
These observations are best done with the consumer unaware of what you
are doing. If the consumer is aware that you are counting respirations, the
breathing pattern may be altered.
3. Count the number of respiratory cycles that occur in 1 minute.
N
Table 6.1 lists the normal respiratory rates for different ages. Respiratory rates
decrease with age and may vary with excitement, anxiety, fever, exercise,
medications and altitude.
), carbon dioxide (CO2) and
2
CHAPTER 6
TABLE 6.1 Respiratory rate
RESTING RESPIRATORY RATE
AGE
(BREATHS PER MINUTE) AVERAGE
Newborn 30–50 40
1 year 20–40 30
3 years 20–30 25
6 years 16–22 19
10 years 16–20 18
14 years 14–20 17
Adult 12–20 18
A
Tachypnoea is a respiratory rate greater than 20 breaths per minute in an adult.
Hypoxaemia and metabolic acidosis are common causes of tachypnoea. The increased
P
respiratory rate is a compensatory mechanism to provide the body with more oxygen
and eliminate excess hydrogen ions when the body’s metabolism is increased.
Stress and anxiety cause the release of catecholamines, which can elevate the
P
respiratory rate.
A
Bradypnoea is a respiratory rate less than 12 breaths per minute in an adult at rest.
Head injury resulting in increased intracranial pressure in the respiratory centre
P
of the brain can cause bradypnoea.
Medications or chemicals such as narcotics, barbiturates and alcohol depress the
P
respiratory centre of the brain and can cause bradypnoea.
A lower metabolic rate that occurs during normal sleep can result in bradypnoea.
P
A
Apnoea is the absence of spontaneous breathing for 10 or more seconds.
Many causes of apnoea are unknown.
P
Traumatic brain injury may lead to apnoea from injury of the brain stem.
P
Death ensues in the absence of respirations and pulse.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
154 PHYSICAL EXAMINATION
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-300
https://t.me/medicina_free
UNIT 2
CLINICAL REASONING
Practice tip: Assessing respiration
Respirations are the most sensitive vital signs for detecting deterioration. To assist
collection of accurate counts, respirations can be measured when assessing the radial or
apical pulse. Observe and count the consumer’s chest movements when they are unaware,
as this provides an accurate assessment of their respirations. Alternatively, if respirations
are shallow and difcult to observe, put the individual’s arm across the chest while taking a
radial pulse and feel the chest rise while observing respirations.
Pulse
As the heart contracts, blood is ejected from the left ventricle (stroke volume) into the
aorta. A pressure wave is created as the blood is carried to the peripheral vasculature.
This palpable pressure is the
rhythm, and the estimated volume (strength) of blood being pumped by the heart.
Rate
Pulse rate is the number of pulse beats counted in 1 minute. Several factors
inuence heart rate or pulse rate. These include:
> the S-A (sinoatrial) node, which res automatically at a rate of 60 to 100 times
per minute and is the primary controller of pulse rate and heart rate
> parasympathetic or vagal stimulation of the autonomic nervous system, which
can result in decreased heart rate
> sympathetic stimulation of the autonomic nervous system, which results in
increased heart rate
> baroreceptor sensors, which can detect changes in blood pressure and inuence
heart rate. Elevated blood pressure can decrease heart rate, whereas decreased
blood pressure can increase heart rate.
Other factors inuencing heart rate include:
> age. The heart rate generally decreases with age.
> sex. The average heart rate for females is higher than the average heart rate for males.
> activity. The heart rate increases with activity. Athletes will have a lower resting
heart rate than the average person because of their increased cardiac strength
and efciency.
> emotional status. Heart rate increases with anxiety.
> pain. Heart rate increases with pain.
> environmental factors. Temperature and noise level can alter the heart rate.
> stimulants. Caffeinated beverages and tobacco elevate the heart rate.
> medications. Drugs such as digoxin decrease the heart rate; drugs such as
amphetamines increase the heart rate.
> disease state. Abnormal clinical conditions can affect the heart rate (e.g.
increased heart rate in hyperthyroidism, fever and haemorrhage).
pulse. Pulse assessment can determine heart rate and
Rhythm
Pulse rhythm refers to the pattern of pulses and the intervals between pulses. Pulses
can be regular or irregular. A regular pulse occurs at regular intervals with even
intervals between each beat. Normal sinus rhythm is an example of a regular pulse.
An irregular pulse can be regularly irregular or irregularly irregular. A regular
irregular rhythm is one in which an abnormal conduction occurs in the heart,
but at regular intervals. Ventricular bigeminy is an example of a regularly irregular
rhythm. In ventricular bigeminy, the irregular conduction, called a premature
ventricular complex (PVC), occurs prior to the expected QRS complex. This PVC
occurs at a regular rhythm (every other beat).
EXAMINATION REQUIREMENTS FOR EVERY CONSUMER 155
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-300
https://t.me/medicina_free
An irregularly irregular rhythm has no predictable pattern. Atrial brillation is
an example of an irregularly irregular rhythm.
Volume
Pulse volume (also called pulse strength or amplitude) reects the stroke volume
and the
bounding.
systemic vascular resistance (SVR). It can range from absent to
Table 6.2 displays the most commonly used 4-point scale; however, your
clinical area may have other guidelines so it is important to refer to these. When
reporting pulse volume, 2+/4+ indicates a normal pulse (2+) on a 4-point scale. Refer
to the Clinical reasoning practice tip: Peripheral pulse documentation, for schematic
representations. If a pulse is not palpable, then attempt to ascertain its presence
with a Doppler ultrasonic stethoscope. The letter ‘D’ in a pulse chart or stick gure
represents the pulse that was detected by using this mechanical device.
CLINICAL REASONING
Practice tip: Peripheral pulse documentation
You can document the pulse volume (strength) of a consumer’s pulses by drawing a small
stick gure and labelling the pulses accordingly (
tabular format (
Figure 6.7B).
Figure 6.7A) or by recording the pulses in
CHAPTER 6
Carotid
+2 +2
+2+2 +2
+2
+2 +2
+2 +2
Posterior tibial
Scale = 4+
A. Stick gure peripheral pulse
documentation
+2
Dorsalis pedis
Brachial
Radial
Femoral
Popliteal
+2
+2+2
CAROTID BRACHIAL RADIAL FEMORAL POPLITEAL PT DP
R
2+ 2+ 2+ 1+ 1+
L
2+ 2+ 2+ 2+ 1+ 1+ 1+
Scale = 4+
D = Doppler ultrasonic stethoscope
B. Tabular peripheral pulse documentation
FIGURE 6.7 Methods for charting peripheral pulses
D D
TABLE 6.2 The 4-point scale for measuring pulse volume (strength)
SCALE DESCRIPTION OF PULSE
0 Absent
1+
2+
3+
4+
Thready/weak
Normal
Increased
Bounding
Соседние файлы в папке Библиотека им академика М.И. Перельмана