NRSG139 Lecture Notes - Lecture 4: Bradycardia, Radial Artery, Pulse Oximetry
Physical Assessment Techniques
IPPA
Inspection
Palpation
Percussion
Auscultation
Order may change - abdominal examination
IAPP
Auscultation
● Listening
○ By ear
○ By amplification
Lungs, heart, bowels, blood vessels
Pain Assessment
● Where is the pain?
● What does the pain feel like?
● How much pain do you have now?
● How much pain do you have when you move?
● How much does your pain affect your movement?
● What makes the pain better/worse?
● How do you act when you are in pain?
● What does this pain mean to you?
● What are your expectations or preferences for pain treatment?
Temperature
● Assessed via routes:
○ Oral
○ Axillary
○ Tympanic
○ Rectal
○ Temporal
● Normal ranges vary according to the assessment site
● Equipment: Thermometer
● Correct technique is important
● Hand Hygiene
What affects temperature assessment?
● Hypothalamic function - illness or central nervous system disorders
● Environment
● Medications
● Hot/cold drinks (oral)
● Assessor error
● Lifespan considerations
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Document Summary
Normal ranges vary according to the assessment site. Hypothalamic function - illness or central nervous system disorders. The heart is located in the thoracic cavity between the lungs and above the diagram. Pumps 4-5 litres of blood per minute. Is about the size of a clenched fist. Apex - lower portion also referred to as apical. Represents amount of pressure (or force) exerted on the arterial walls. Peripheral vascular resistance - vascular resistance to the flow of blood in peripheral arterial vessels. Palpation (radial artery with cuff, 30mmhg beyond when pulse stops) Auscultation (brachial artery, korotkoff sounds 1 + 5 primarily) Cuff size (e. g small cuff = artificially = increased bp) Represents conduction, and pump mechanism of heart. Normal resting adult heart rate (hr) 60-100 bpm. Feedback loop from carbon dioxide levels in blood. Chest expands with inspiration, relaxes with expiration. Normal awake resting adult respiatory rate (rr) 10-20bpm. Oxygen binds to haemoglobin in the blood.
