Health Assessment Unit 2

Developmental Competence (nutritional) Adolescents

After a period of slow growth in late childhood, adolescence presents rapid physical growth and endocrine and hormonal changes. Caloric and protein requirements increase to meet this demand, and because of bone growth and increasing muscle mass (and in girls the onset of menarche), calcium and iron requirements also increase. Typically these increased requirements cannot be met by three meals per day; therefore nutritious snacks play an important role. Consider the following factors when working with adolescents to select healthier food choices: skipped meals, excessive fast food and sweetened beverage consumption, limited fruit and vegetable intake, peer pressure, alternative dietary patterns, eating disorders, hectic schedules, and possible experimentation with drugs and alcohol. In general boys grow taller and have less body fat than girls. The percentage of body fat increases in females to about 25% and decreases in males (replaced by muscle mass) to about 12%. Typically girls double their body weight between the ages of 8 and 14 years; boys double their body weight between the ages of 10 and 17 years. The health-related outcomes of childhood and adolescent obesity include high blood pressure (BP), dyslipidemia, metabolic syndrome, type 2 diabetes, orthopedic problems, sleep apnea, asthma, and fatty liver disease.

Auscultation

Auscultation is listening to sounds produced by the body, such as the heart and blood vessels and the lungs and abdomen. Likely you already have heard certain body sounds with your ear alone (e.g., the harsh gurgling of very congested breathing). However, most body sounds are very soft and must be channeled through a stethoscope for you to evaluate them. Before you can evaluate body sounds, you must eliminate any confusing artifacts: • Any extra room noise can produce a "roaring" in your stethoscope; therefore the room must be quiet. • Keep the examination room warm. If the person starts shivering, the involuntary muscle contractions could drown out other sounds. • Clean the stethoscope endpiece with an alcohol wipe. Then warm it by rubbing it in your palm. This avoids the "chandelier sign" elicited when placing a cold endpiece on a warm chest! • The friction on the endpiece from a man's hairy chest causes a crackling sound that mimics an abnormal breath sound called crackles. To minimize this problem, wet the hair before auscultating the area. • Never listen through a gown. Even though you see this on television, listening through clothing creates artifactual sound and muffles any diagnostically valuable sound from the heart or lungs. Therefore reach under a gown to listen, and take care that no clothing rubs on the stethoscope. • Finally avoid your own "artifact," such as breathing on the tubing or the "thump" from bumping the tubing together.

Vital Signs blood pressure

Blood pressure (BP) is the force of the blood pushing against the side of its container, the vessel wall. The strength of the push changes with the event in the cardiac cycle. The systolic pressure is the maximum pressure felt on the artery during left ventricular contraction, or systole. The diastolic pressure is the elastic. recoil, or resting, pressure that the blood exerts constantly between each contraction. The pulse pressure is the difference between the systolic and diastolic pressures and reflects the stroke volume (Fig. 9-5). The mean arterial pressure (MAP) is the pressure forcing blood into the tissues averaged over the cardiac cycle. This is not an arithmetic average of systolic and diastolic pressures because diastole lasts longer. Rather it is a value closer to diastolic pressure plus one third the pulse pressure. The average BP in the young adult varies with many factors such as: Age sex race weight exercise stress emotions The level of BP is determined by five factors; 1. Cardiac output. If the heart pumps more blood into the container (i.e., the blood vessels), the pressure on the container walls increases. 2. Peripheral vascular resistance. Peripheral vascular resistance is the opposition to blood flow through the arteries. When the container becomes smaller (e.g., with constricted vessels), the pressure needed to push the contents becomes greater. Conversely, if the container becomes larger (e.g., vasodilation), less pressure is needed. 3. Volume of circulating blood. Volume of circulating blood refers to how tightly the blood is packed into the arteries. Increasing the contents in the container increases the pressure. 4. Viscosity. The "thickness" of blood is determined by its formed elements, the blood cells. When the contents are thicker, the pressure increases. 5. Elasticity of vessel walls. When the container walls are stiff and rigid, the pressure needed to push the contents increases. Many medications used in the treatment of critically ill people affect peripheral vascular resistance. Blood volume is increased via blood transfusions or volume expanders and decreased through hemorrhage

A Clean Field

Do not let your stethoscope become a staph-oscope! Stethoscopes and other equipment that are frequently used on many patients are common vehicles for transmission of infection. Clean your stethoscope endpiece with an alcohol wipe before and after every patient contact. The best routine is to combine stethoscope rubbing with every episode of hand hygiene. Designate a "clean" versus a "used" area for handling your equipment. In a hospital setting you may use the bedside stand for your clean surface and the over-bed table for the used equipment surface. Or in a clinic setting use two separate areas of the pull-up table. Distinguish the clean area by one or two disposable paper towels. On the towels place all the new or newly alcohol-swabbed equipment that you will use for this patient (e.g., your stethoscope endpieces, the reflex hammer, ruler).

Developmental Competence (nutritional) Adulthood

During adulthood growth and nutrient needs stabilize (Fig. 11-2). Most adults are in relatively good health. However, lifestyle factors such as cigarette smoking; stress; lack of exercise; excessive alcohol intake; and diets high in saturated fat, cholesterol, salt, and sugar and low in fiber can be factors in the development of hypertension, obesity, atherosclerosis, cancer, osteoporosis, and diabetes mellitus. Therefore the adult years are an important time for education to preserve health and prevent or delay the onset of chronic disease.

The Aging Adult

During later years the tasks are developing the meaning of life and one's own existence and adjusting to changes in physical strength and health. Position • The older adult should be sitting on the examination table; a frail older adult may need to be supine. • Arrange the sequence to allow as few position changes as possible. • Allow rest periods when needed. Preparation • Adjust examination pace to meet the possible slowed pace of the aging person. It is better to break the complete examination into a few visits than to rush through the examination and turn off the person. • Use physical touch (unless there is a cultural contraindication). This is especially important with the aging person because other senses such as vision and hearing may be diminished. • Do not mistake diminished vision or hearing for confusion. Confusion of sudden onset may signify a disease state. It is noted by short-term memory loss, diminished thought process, diminished attention span, and labile emotions. • Be aware that aging years contain more life stress. Loss is inevitable, including changes in physical appearance of the face and body, declining energy level, loss of job through retirement, loss of financial security, loss of longtime home, and death of friends or spouse. How the person adapts to these losses significantly affects health assessment. Sequence • Use the head-to-toe approach as in the younger adult.

The School-Age Child

During the school-age period the major task of the child is developing industry. The child is developing basic competency in school and social networks and desires the approval of parents and teachers. When successful, the child has a feeling of accomplishment. During the examination the child is cooperative and interested in learning about the body. Language is more sophisticated now, but do not overestimate and treat the school-age child as a small adult. The child's level of understanding does not match that of his or her speech. Position • The school-age child should be sitting or lying on the examination table. • A 5-year-old child has a sense of modesty. To maintain privacy, let the older child (an 11- or 12-year-old child) decide whether parents or siblings should be present. Preparation • Break the ice with small talk about family, school, friends, music, or sports. • The child should undress himself or herself, leave underpants on, and use a gown and drape. • Demonstrate equipment; a school-age child is curious to know how equipment works. • Comment on the body and how it works. An 8- or 9-year-old child has some understanding of the body and is interested to learn more. It is rewarding to see the child's eyes light up when he or she hears the heart sounds. Sequence • As with the adult, progress from head to toes.

Endogenous Obesity—Cushing Syndrome

Either administration of adrenocorticotropin (ACTH) or excessive production of ACTH by the pituitary stimulates the adrenal cortex to secrete excess cortisol. This causes Cushing syndrome, characterized by weight gain and edema with central trunk and cervical obesity (buffalo hump) and round, plethoric face (moon face). Excessive catabolism causes muscle wasting; weakness; thin arms and legs; reduced height; and thin, fragile skin with purple abdominal striae, bruising, and acne. Note that the obesity here is markedly different from exogenous obesity caused by excessive caloric intake, in which body fat is evenly distributed and muscle strength is intact.

Culture And Genetics

General Appearance Genetic differences are found in the body proportions of individuals. In general, White males are 1.27 cm (0.5 in) taller than Black males, whereas White women and Black women are, on the average, the same height. Sitting-to-standing height ratios reveal that Blacks of both sexes have longer legs and shorter trunks than Whites.5 Because proportionately most of the weight is in the trunk, White men appear more obese than Black men. Asians are markedly shorter, weigh less, and have smaller body frames. However, genes are not destiny. In the 20th century people grew taller in developed countries than they did in developing countries, largely because of environmental influences. This is most apparent among children of immigrants. On average, Asians and American Indians have proportionately longer trunks and shorter limbs than Whites. Blacks tend to be wide shouldered and narrow hipped, whereas Asians tend to be wide hipped and narrow shouldered. Shoulder width is largely produced by the clavicle. Because the clavicle is a long bone, taller people have wide shoulders, whereas shorter people have narrower shoulders.

The Clinical Setting

General Approach Consider your emotional state and that of the person being examined. The patient may be anxious about being examined by a stranger and the unknown outcome of the examination. Try to reduce any anxiety so the data will more closely describe the person's natural state. Anxiety can be reduced by an examiner who is confident and self-assured, considerate, and unhurried. Hands On With this preparation it is possible to interact with your own patient in a confident manner. Begin by measuring the person's height, weight, blood pressure, temperature, pulse, and respirations (see Chapter 9). If needed, measure visual acuity at this time using the Snellen eye chart. All of these are familiar, relatively nonthreatening actions; they will gradually accustom the person to the examination. Sometimes an icebreaker about an irrelevant topic will help the person feel he or she is seen as an individual. You might say, "Interesting cap. Does that mean you are a baseball fan?" or "I see you are from Michigan. How was the winter there?" These irrelevant openers signal that you have shared experiences and also that you are willing to have a conversation—a good warm-up for the examination data and shared decision making that come next.8c Then ask the person to change into an examining gown, leaving his or her underpants on. This will feel more comfortable, and the underpants can easily be removed just before the genital examination. Unless your assistance is needed, leave the room as the person undresses. (Teens can remain in street clothes.)

STANDARD PRECAUTIONS

Hand hygiene. (1) Avoid unnecessary touching of surfaces in close proximity to the patient. (2) When hands are visibly dirty, contaminated with proteinaceous material, or visibly soiled with blood or body fluids, wash them with soap and water. (3) If not visibly soiled, decontaminate hands with an alcohol-based hand rub. Perform hand hygiene: (a) before having direct contact with patients; (b) after contact with blood, body fluids or excretions, mucous membranes, nonintact skin, or wound dressings; (c) after contact with a patient's intact skin (e.g., taking a pulse or blood pressure or lifting a patient); (d) after contact with medical equipment in the immediate vicinity of the patient; (e) after removing gloves. Use of gloves, gown, mask, eye protection, or face shield. (1) Wear gloves when you anticipate that contact with blood or other potentially infectious materials, mucous membranes, nonintact skin, or potentially contaminated intact skin (e.g., patient incontinent of stool or urine) could occur. (2) Wear a gown to protect skin and clothing when you anticipate contact with blood, body fluids, secretions, or excretions. (3) Use mouth, nose, and eye protection to protect the mucous membranes during procedures that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions. • Respiratory hygiene/cough etiquette is targeted at patients and accompanying persons with undiagnosed transmissible respiratory infections. Elements include: (1) education of staff, patients, and visitors; (2) posted signs in language(s) appropriate to the population; (3) source control measures (e.g., covering the mouth/nose with a tissue when coughing and promptly disposing of used tissues, using surgical masks on the coughing person); (4) hand hygiene after contact with respiratory secretions; and (5) spatial separation of >3 feet from people with respiratory infections in common waiting areas.

Equipment

Have all your equipment at easy reach and laid out in an organized fashion.The following items are usually needed for a screening physical examination: • Platform scale with height attachment • Sphygmomanometer • Stethoscope with bell and diaphragm endpieces • Thermometer • Pulse oximeter (in hospital setting) • Paper and pencil or pen • Flashlight or penlight • Otoscope/ophthalmoscope • Tuning fork • Nasal speculum (if a short, broad speculum is not included with the otoscope) • Tongue depressor • Pocket vision screener • Skin-marking pen • Flexible tape measure and ruler marked in centimeters • Reflex hammer • Sharp object (split tongue blade) • Cotton balls • Bivalve vaginal speculum • Clean gloves • Alcohol wipes • Hand sanitizer • Materials for cytologic study • Lubricant • Fecal occult blood test materials

Hypotension

In normotensive adults: <95/60 mm Hg In hypertensive adults: 95/60 mm Hg In children:less than the expected value. Occurs With Acute myocardial infarction- Decreased cardiac output Shock- Decreased cardiac output Hemorrhage- Decrease in total blood volume Vasodilation- Decrease in peripheral vascular resistance Addison disease (hypofunction of adrenal glands)- Decrease in circulating aldosterone Associated Symptoms and Signs In conditions of decreased cardiac output, a low BP is accompanied by an increased pulse, dizziness, diaphoresis, confusion, and blurred vision. The skin feels cool and clammy because the superficial blood vessels constrict to shunt blood to the vital organs. An individual having an acute MI may also complain of crushing substernal chest pain, high epigastric pain, and shoulder or jaw pain.

Vital signs rate

In the adult at physical and mental rest, recent clinical evidence shows the normal resting heart range of 95% of healthy persons at 50 to 95 beats/min.24 Traditional resting heart rate limits established in the 1950s are 60 to100 beats/min. This range is still used; however, no research evidence supports it. The rate normally varies with age, being more rapid in infancy and childhood and more moderate during adult and older years. The rate also varies with gender; after puberty females have a slightly faster rate than males. Many medications also affect heart rate, with nearly all heart disease patients taking at least one medication that slows the heart rate. In the adult a resting heart rate less than 50 beats/min is bradycardia. Heart rates in the 50s/min occur normally in the well-trained athlete whose heart muscle develops along with the skeletal muscles. The stronger, more efficient heart muscle pushes out a larger stroke volume with each beat, thus requiring fewer beats per minute to maintain a stable cardiac output. For descriptions of abnormal rates and rhythms, see Table 20-1, Variations in Pulse Contour on p. 530). A more rapid heart rate, variably defined as over 95 beats/min or over 100 beats/min, is tachycardia. Rapid rates occur normally with anxiety or with increased exercise to match the body's demand for increased metabolism.

Developmental Competence (nutritional) Infants

Infants and Children The time from birth to 4 months of age is the most rapid period of growth in the life cycle. Although infants lose weight during the first few days of life, they usually regain birth weight by the 7th to 10th day after birth. Thereafter infants double their birth weight by 4 months and triple it by 1 year of age. Breastfeeding is recommended for full-term infants for the first year of life because breast milk is ideally formulated to promote normal infant growth and development and natural immunity. Other advantages of breastfeeding are (1) fewer food allergies and intolerances, (2) reduced likelihood of overfeeding, (3) less cost than commercial infant formulas, and (4) increased mother-infant interaction time. Because cow's milk may cause gastrointestinal (GI) and kidney problems and is a poor source of iron and vitamins C and E, it is not recommended for infants until 1 year of age. Infants increase their length by 50% during the first year of life and double it by 4 years of age. Brain size also increases very rapidly during infancy and childhood. By 2 years of age the brain has reached 50% of its adult size; by age 4, 75%; and by age 8, 100%. For this reason infants and children younger than 2 years should not drink skim or low-fat milk or be placed on low-fat diets; fat is required for proper growth and central nervous system development.

Developmental Competence Pain measurement

Infants have the same capacity for pain as adults. In fetal development ascending sensory fibers, neurotransmitters, and connections to the thalamus are developed by 20 weeks' gestation.24 However, the immaturity of the cortex and lack of conscious awareness may prevent the fetus from experiencing emotional "pain" until 30 weeks' gestation. The Aging Adult No evidence exists to suggest that older individuals perceive pain to a lesser degree or that sensitivity is diminished. Although pain is a common experience among individuals 65 years of age and older, it is not a normal process of aging. Pain indicates pathology or injury. It should never be considered something to tolerate or accept in one's later years. People with dementia do feel pain. The somatosensory cortex is generally unaffected by dementia of the Alzheimer type. Sensory discrimination is preserved in cognitively intact and impaired adults.1 Because the limbic system is affected by Alzheimer disease, current research focuses on how the person interprets and reports these pain messages. In patients with dementia we can assess body language instead of verbal communication (e.g., a clenched fist may indicate pain; agitation may mean hunger or cold). Other causes include fatigue, urinary tract or other infections, constipation, or medication side effects. Gender differences Hormonal changes have strong influences on pain sensitivity for women. Regarding migraine, the prevalence is equal in prepubertal girls and boys, but after puberty it increases to 18% for women and 6% for men.

Inspection

Inspection is concentrated watching. It is close, careful scrutiny, first of the individual as a whole and then of each body system. Inspection begins the moment you first meet the person and develop a "general survey." Learn to use each person as his or her own control and compare the right and left sides of the body. The two sides are nearly symmetric. Inspection requires good lighting, adequate exposure, and occasional use of certain instruments (otoscope, ophthalmoscope, penlight, nasal and vaginal specula) to enlarge your view.

Clinical Case Study (pain)

J.T. is an 18-year-old African-American male living with sickle cell anemia. Admitted to the ED by his parents following 4 hours of increasing pain at home. Subjective Within the past 48 hours J.T. reports increasing pain in upper- and lower-extremity joints and swelling of right knee. States having "stomach flu" 1 week before with periods of vomiting and diarrhea. Pain is aching and constant in nature. Rates pain as +10 on a 0-to-10 scale. Reports difficulty walking and climbing stairs. Taking acetaminophen, two tablets every 4 hours, and using ice packs with no relief. States, "I have had these before. I always need Dilaudid." Objective Temp 98.6° F (37° C) oral. BP 118/68 mm Hg. Pulse 112 bpm. Resp 24/min. Facial grimacing and moaning. Requiring assistance to sit on exam table. Unable to bear weight on right leg. Affect flat; clenches jaw during position changes. Tenderness localized in elbow, wrist, finger, and knee joints. Diminished ROM in wrists and knees (right knee 36 cm, left knee 30 cm circumference). Right knee warm and boggy to touch. Lungs: Clear to auscultation and percussion. Heart: S1 and S2 not diminished or accentuated; no murmur. Abdomen: Bowel sounds present, guarding with tenderness to palpation, RUQ pain with enlarged spleen at anterior axillary line. Lab: Hb 9 g/dL. Hct 30%. Indices show sickling with RBCs of varying shapes. Metabolic panel: Serum bilirubin 2 mg/dL, rest in normal limits. Assessment Acute pain Risk for venous or arterial thromboembolism Anemia R/T sickle cell crisis Fear R/T outcome of acute pain episode

Documentation and Critical Thinking Sample Charting

K.A. is a 56-year-old Hispanic male construction worker who appears healthy and stated age. Alert, oriented, cooperative, with no signs of distress. Ht 170 cm (5′7″). Wt 83 kg (182 lbs). BMI 28.5 (overweight). Temp 98.6° F (37° C). Pulse 84 bpm. Resp 14/min. BP 146/84 mm Hg right arm, sitting.

Neuropathic Pain

Neuropathic pain is pain that does not adhere to the typical and rather predictable phases in nociceptive pain. It is "pain caused by a lesion or disease of the somatosensory nervous system."19 Neuropathic pain implies an abnormal processing of the pain message from an injury to the nerve fibers. This type of pain is the most difficult to assess and treat. Pain is often perceived long after the site of injury heals, and it evolves into a chronic condition. Nociceptive pain can change into a neuropathic pain pattern over time when pain has been poorly controlled. This is because of the constant irritation and inflammation caused by a pain stimulus, which alters nerve cells, making them more sensitive to any future stimulus. The constant irritation 163from uncontrolled pain also decreases the number of opioid receptors in the spinal cord.4 Neurons in the spinal cord dorsal horn may experience excitotoxic and apoptotic cell death. There is significant depletion of GABAergic interneurons; because GABA is an inhibitory neurotransmitter, this may cause hyperalgesia and allodynia. Conditions that may cause neuropathic pain include diabetes mellitus, herpes zoster (shingles), HIV/AIDS, sciatica, trigeminal neuralgia, phantom limb pain, and chemotherapy. Further examples include CNS lesions such as stroke, multiple sclerosis, and tumor. Pain sustained on a neurochemical level cannot be identified by x-ray image, computerized axial tomography (CAT) scan, or traditional magnetic resonance imaging (MRI). Recent advances in noninvasive neuroimaging techniques allow us to study the structural, functional, and neurochemical changes on the brain caused by nociception.

Nociceptive Pain

Nociceptive pain develops when functioning and intact nerve fibers in the periphery and the CNS are stimulated. It is triggered by events outside the nervous system from actual or potential tissue damage. Nociception can be divided into four phases: (1) transduction, (2) transmission, (3) perception, and (4) modulation Initially the first phase of transduction occurs when a noxious stimulus in the form of traumatic or chemical injury, burn, incision, or tumor takes place in the periphery. The periphery includes the skin and the somatic and visceral structures. In the second phase, known as transmission, the pain impulse moves from the level of the spinal cord to the brain. Within the spinal cord, at the site of the synaptic cleft, are opioid receptors that can block this pain signaling with our own endogenous opioids or with exogenous opioids if they are administered. However, if not stopped, the pain impulse moves to the brain via various ascending fibers within the spinothalamic tract to the thalamus. The third phase, perception, signifies the conscious awareness of a painful sensation. Cortical structures such as the limbic system account for the emotional response to pain, and somatosensory areas can characterize the sensation. Only when the noxious stimuli are interpreted in these higher cortical structures can this sensation be identified as "pain." Last, the pain message is inhibited through the phase of modulation. Fortunately our bodies have a built-in mechanism that will eventually slow down and stop the processing of a painful stimulus. If not for pain modulation, the experience of pain would continue from childhood injuries to adulthood.

Mobility

Normal - Gait—Feet approximately shoulder width apart; foot placement is accurate; walk is smooth and even, and person can maintain balance without assistance. Associated movements such as symmetric arm swing are present. Abnormal- Exceptionally wide base. Staggering, stumbling. Shuffling, dragging, nonfunctional leg. Limping with injury. Propulsion—Difficulty stopping Normal- Range of motion—Note full mobility for each joint and that movement is deliberate, accurate, smooth, and coordinated. (See Chapter 22 for information on more detailed testing of joint range of motion.) Abnormal- Limited joint range of motion. Paralysis—Absent movement. Jerky, uncoordinated movement. Normal- No involuntary movement. Abnormal- Tics, tremors, seizures (see Table 23-5, Abnormalities in Muscle Movement

Hypertension

Normal <120 mmHg and <80 mmHg Prehypertension 120-139 or 80-89 Stage 1 hypertension 140-159 or 90-99 Without compelling indication Thiazide-type diuretics for non-Blacks; may consider ACEI, ARB, CCB, or combination. Thiazide-type diuretic or CCB for Blacks. With compelling indication Drug(s) for the compelling indications; other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. Stage 2 hypertension ≥160 or ≥100 Without compelling indication Two-drug combination for most‡; usually thiazide-type diuretic and ACEI, ARB, or CCB With compelling indication Drug(s) for the compelling indications; other antihypertensive drugs (diuretics, ACEI, ARB, CCB) as needed§. Cardiovascular Risk Stratification in Patients With Hypertension Major risk factors Smoking Dyslipidemia Diabetes mellitus Age > 60 yr Gender (men and postmenopausal women) Family history of cardiovascular disease: women < 65 yr or men < 55 yr Target organ damage Heart diseases Left ventricular atrophy Angina or prior myocardial infarction Prior coronary revascularization Heart failure Stroke or transient ischemic attack Nephropathy Peripheral arterial disease Retinopathy Lifestyle Modifications for Hypertension Prevention and Management • Lose weight if overweight • Limit alcohol intake to no more than 1 oz (30 mL) of ethanol (e.g., 24 oz [720 mL] of beer, 10 oz [300 mL] of wine, or 2 oz [60 mL] of 100-proof whiskey) per day or 0.5 oz (15 mL) of ethanol per day for women and lighter-weight people. • Increase aerobic physical activity (30-45 min most days of the week). • Reduce sodium intake to no more than 100 mmol/day (2.4 g of sodium or 6 g of sodium chloride). • Maintain adequate intake of dietary potassium (approximately 90 mmol/day). • Maintain adequate intake of dietary calcium and magnesium for general health. • Stop smoking and reduce intake of dietary saturated fat and cholesterol for overall cardiovascular health.

Physical Appearance

Normal Age—The person appears his or her stated age. Abnormal- Appears older than stated age, as with chronic illness or chronic alcoholism. Normal -Sex—Sexual development is appropriate for sex and age. If the individual is transgender, note the stage of transformation. Abnormal- Delayed or precocious puberty. Normal- Level of consciousness—The person is alert and oriented to person, place, time, and situation. Attends to and responds appropriately to your questions. Abnormal- Confused, drowsy, lethargic (see Table 5-1, Levels of Consciousness, p. 79). Normal Skin color—Color tone is even, pigmentation varying with genetic background; skin is intact with no obvious lesions. Make note of tattoos and piercings and stage of healing. Abnormal- Pallor, cyanosis, jaundice, erythema, any lesions (see Chapter 12, p. 208). Normal- Facial features—Facial features are symmetric with movement. Abnormal Immobile, masklike, asymmetric, drooping (see Table 13-5, Abnormal Facies with Chronic Illness, p. 278). Normal -Overall appearance—No signs of acute distress are present. Abnormal -Cardiac or respiratory signs— Diaphoresis, clutching the chest, shortness of breath, wheezing. Pain, indicated by facial grimace, holding body part.

Behavior

Normal Facial expression—The person maintains eye contact (if culturally appropriate); expressions are appropriate to the situation (e.g., thoughtful, serious, or smiling). (Note expressions both while the face is at rest and while the person is talking.) Abnormal- Flat, depressed, angry, sad, anxious. However, note that anxiety is common in ill people. Also, some people smile when they are anxious. Normal Mood and affect—The person is comfortable and cooperative with the examiner and interacts pleasantly. Abnormal- Hostile, distrustful, suspicious, crying. Normal Speech—Articulation (the ability to form words) is clear and understandable. Abnormal- Dysarthria and dysphagia (see Table 5-2, Speech Disorders, p. 80). Speech defect, monotone, garbled speech. Normal Speech pattern—The stream of talking is fluent, with an even pace. The person conveys ideas clearly. Word choice is appropriate for culture and education. Communicates in prevailing language easily by himself or herself or with an interpreter. Abnormal- Extremes of few words or constant talking. Normal Dress—Clothing is appropriate to the climate, looks clean and fits the body, and is appropriate to the person's culture and age-group (e.g., normally Amish women wear clothing from the 19th century; Indian women may wear saris). Culturally determined dress should not be labeled as inappropriate by Western standards or adult expectations. Abnormal- Clothing too large and held up by belt suggests weight loss, as does the addition of new holes in belt. Clothing too tight may indicate obesity or ascites. Consistent wear of certain clothing may provide clues: long sleeves may conceal needle marks of drug abuse or thin arms of anorexia; Velcro fasteners instead of buttons may indicate chronic motor dysfunction. Normal Personal hygiene—The person appears clean and groomed appropriately for his or her age, occupation, and socioeconomic group. (Note that a wide variation of dress and hygiene is "normal." Many cultures do not include use of deodorant or women shaving legs.). Hair is groomed, brushed. Makeup is appropriate for age and culture. Abnormal- Body odor, scent of alcohol. Unkempt appearance in an individual who previously had good hygiene may indicate depression, malaise, or illness.

Body Structure

Normal Stature—The height appears within normal range for age, genetic heritage (see Measurement, p. 130). Abnormal- Excessively short or tall (see Table 9-5, Abnormalities in Body Height and Proportion, p. 156). Normal Nutrition—The weight appears within normal range for height and body build; body fat distribution is even. Abnormal - Cachectic, emaciated. Simple obesity, with even fat distribution. Centripetal (truncal) obesity—Fat concentrated in face, neck, trunk, with thin extremities, as in Cushing syndrome. Normal Symmetry—Body parts look equal bilaterally and are in relative proportion to each other. Abnormal Unilateral atrophy or hypertrophy. Asymmetric location of a body part. Normal Posture—The person stands comfortably erect as appropriate for age. Note the normal "plumb line" through anterior ear, shoulder, hip, patella, ankle. Exceptions are the standing toddler, who has a normally protuberant abdomen ("toddler lordosis"), and the aging person, who may be stooped with kyphosis. Abnormal- Rigid spine and neck; moves as one unit (e.g., arthritis). Stiff and tense, ready to spring from chair, fidgety movements. Shoulders slumped; looks deflated (e.g., depression). Normal- Position—The person sits comfortably with arms relaxed at sides and head turned to examiner. Abnormal- Tripod—Leaning forward with arms braced on chair arms; occurs with chronic pulmonary disease. Sits straight up and resists lying down (e.g., heart failure). Curled up in fetal position (e.g., acute abdominal pain). Normal- Body build, contour—Proportions are: 1. Arm span (fingertip to fingertip) equals height. 2. Body length from crown to pubis roughly equal to length from pubis to sole. Abnormal- Elongated arm span (e.g., Marfan syndrome, hypogonadism) Obvious physical deformities—Note any congenital or acquired defects. Missing extremities or digits; webbed digits; shortened limb.

Vital signs Respiration

Normally a person's breathing is relaxed, regular, automatic, and silent. Because most people are unaware of their breathing, do not mention that you will be counting the respirations, because sudden awareness may alter the normal pattern. Maintain your position of counting the radial pulse and unobtrusively count the respirations. Count for 30 seconds, but count for a full minute if you suspect an abnormality. Avoid the 15-second interval. The result can vary by a factor of +4 or −4, which is significant with such a small number. If you are having difficulty seeing the chest rise, which can be especially difficult in obese individuals and children, you can place a hand on the upper chest or abdomen to help you "feel" the respiratory rate. Report the number of breaths per minute. Note that respiratory rates presented in Table 9-2 normally are more rapid in infants and children. Also, a fairly constant ratio of pulse rate to respiratory rate exists, which is about 4 : 1. Normally both pulse and respiratory rates rise as a response to exercise or anxiety. More detailed assessment on respiratory status is presented in Chapter 18.

Types of Nutritional Assessment

Nutrition screening is the first step in assessing nutritional status. Based on easily obtained data, nutrition screening is a quick and easy way to identify individuals at nutrition risk such as those with weight loss, inadequate food intake, or recent illness. Parameters used for nutrition screening typically include weight and weight history, conditions associated with increased nutritional risk, diet information, and routine laboratory data. a comprehensive nutritional assessment, which includes dietary history and clinical information, physical examination for clinical signs, anthropometric measures, and laboratory tests. Food diaries or records ask the individual or family member to write down everything consumed for a certain period of time. Three days (i.e., two weekdays and one weekend day) are customarily used. A food diary is most complete and accurate if you teach the individual to record information immediately after eating. Potential problems with the food diary include (1) noncompliance, (2) inaccurate recording, (3) atypical intake on the recording days, and (4) conscious alteration of diet during the recording period. Direct observation of the feeding and eating process can detect problems not readily identified through standard nutrition interviews. For example, observing the typical feeding techniques used by a parent or caregiver and the interaction between the individual and caregiver can help when assessing failure to thrive in children or unintentional weight loss in older adults. Increasingly mobile devices and applications are being used to assess and monitor intake, including taking photos of meals and tracking weight changes and dietary adherence.

Defining Nutritional Status

Nutritional status is the balance between nutrient intake and nutrient requirements. This balance is affected by physiologic, psychosocial, developmental, cultural, and economic factors. Optimal nutritional status is achieved when sufficient nutrients are consumed to support day-to-day body needs and any increased metabolic demands caused by growth, pregnancy, or illness (Fig. 11-1). People having optimal nutritional status are more active, have fewer physical illnesses, and live longer than people who are malnourished. Undernutrition occurs when nutritional reserves are depleted and/or when nutrient intake is inadequate to meet day-to-day needs or added metabolic demands. Vulnerable groups (i.e., infants, children, pregnant women, recent immigrants, people with low incomes, hospitalized people, and aging adults) are at risk for impaired growth and development, lowered resistance to infection and disease, delayed wound healing, longer hospital stays, and higher health care costs. Overnutrition is caused by the consumption of nutrients, especially calories, sodium, and fat, in excess of body needs. A major nutritional problem today, overnutrition can lead to obesity and is a risk factor for heart disease, type 2 diabetes, hypertension, stroke, gallbladder disease, sleep apnea, certain cancers, and osteoarthritis.

Developmental Competence (nutritional) The Aging Adult

Older adults have increased risk for undernutrition or overnutrition. Poor physical or mental health, social isolation, alcoholism, limited functional ability, poverty, and polypharmacy are the major risk factors for malnutrition in older adults. Normal physiologic changes in aging adults that directly affect nutritional status include poor dentition, decreased visual acuity, decreased saliva production, slowed GI motility, decreased GI absorption, and diminished olfactory and taste sensitivity. Important nutritional features of the older years are a decrease in energy requirements caused by loss of lean body mass (the most metabolically active tissue) and an increase in fat mass. Because protein and vitamin and mineral 183needs remain the same or increase (e.g., vitamin D and calcium), nutrient-dense food choices (e.g., milk, eggs, cheese, and peanut butter) are important to offset lower energy/calorie needs. The age-related loss of muscle mass is termed sarcopenia. It is sarcopenic obesity when combined with an increase in body fat. It is attributed to a decrease in physical activity and a decreased protein intake with aging. Sarcopenic obesity results in a loss of muscle strength and function, decreased quality of life, physical frailty, and increased mortality rates.

PQRST Method of Pain Assessment

P = Provocation/Palliation What were you doing when the pain started? What caused it? What makes it better? Worse? What seems to trigger it? Stress? Position? Certain activities? What relieves it? Medications, massage, heat/cold, changing position, being active, resting? What aggravates it? Movement, bending, lying down, walking, standing? Q = Quality/Quantity What does it feel like? Use words to describe the pain such as sharp, dull, stabbing, burning, crushing, throbbing, nauseating, shooting, twisting, or stretching. R = Region/Radiation Where is the pain located? Does it radiate? Where? Does it feel as if it travels/moves around? Did it start elsewhere and is now localized to one spot? S = Severity Scale How severe is the pain on a scale of 0 to 10, with zero being no pain and 10 being the worst pain ever? Does it interfere with activities? How bad is it at its worst? Does it force you to sit down, lie down, slow down? How long does an episode last? T = Timing When/at what time did the pain start? How long did it last? How often does it occur: hourly? daily? weekly? monthly? Is it sudden or gradual? What were you doing when you first experienced it? When do you usually experience it: daytime? night? early morning? Are you ever awakened by it? Does it lead to anything else? Is it accompanied by other signs and symptoms? Does it ever occur before, during, or after meals? Does it occur seasonally?

Objective Data

PREPARATION The physical examination process can help you understand the nature of the pain. Consider whether this is an acute or a chronic condition. Recall that physical findings may not always support the patient's pain reports, particularly for chronic pain syndromes. Based on the patient's pain report, make every effort to reduce or eliminate the pain with appropriate analgesic and nonpharmacologic intervention. According to the American Pain Society2: In cases in which the cause of acute pain is uncertain, establishing a diagnosis is a priority, but symptomatic treatment of pain should be given while the investigation is proceeding. With occasional exceptions (e.g., the initial examination of the patient with an acute condition of the abdomen), it is rarely justified to defer analgesia until a diagnosis is made. In fact, a comfortable patient is better able to cooperate with diagnostic procedures. (p. 3) EQUIPMENT NEEDED Tape measure to measure circumference of swollen joints or extremities Tongue blade Penlight. NORMAL RANGE OF FINDINGS Joints Note the size and contour of the joint. Measure the circumference of the involved joint for comparison with baseline. Check active or passive range of motion (see discussion of complete technique beginning on p. 590 in Chapter 22). Joint motion normally causes no tenderness, pain, or crepitation. Abnormal findings, Swelling, inflammation, injury, deformity, diminished range of motion, increased pain on palpation (crepitation is an audible and palpable crunching that accompanies movement) Muscles and Skin Inspect the skin and tissues for color, swelling, and any masses or deformity. Abnormal Bruising, lesions, open wounds, tissue damage, atrophy, bulging, change in hair distribution. To assess for changes in sensation, ask the person to close his or her eyes. Test the person's ability to perceive sensation by breaking a tongue blade in two lengthwise. Lightly press the sharp and blunted ends on the skin in a random fashion and ask to identify it as sharp or dull (see Fig. 23-23). This test will help you identify location and extent of altered sensation. Abnormal Absent pain sensation (analgesia); increased pain sensation (hyperalgesia); or if a severe pain sensation is evoked with a stimulus that does not normally induce pain (e.g., the blunt end of the tongue blade, cotton ball, clothing) (allodynia) Abdomen Observe for contour and symmetry. Palpate for muscle guarding and organ size (see discussion of complete technique beginning on p. 555 in Chapter 21). Note any areas of referred pain (see Table 21-3). Abnormal Swelling, bulging, herniation, inflammation, organ enlargement.

Neuroanatomic Pathway

Pain is a highly complex and subjective experience that originates from the central nervous system (CNS) and/or peripheral nervous system (PNS). Specialized nerve endings called nociceptors are designed to detect painful sensations from the periphery and transmit them to the CNS. Nociceptors are located primarily within the skin; joints; connective tissue; muscle; and thoracic, abdominal, and pelvic viscera. Nociceptors carry the pain signal to the CNS by two primary sensory (or afferent) fibers: Aδ and C fibers (see Fig. 10-1). Aδ fibers are myelinated and larger in diameter; thus they transmit the pain signal rapidly to the CNS. The sensation is very localized, short term, and sharp in nature because of the Aδ fiber stimulation. In contrast, C fibers are unmyelinated and smaller, and they transmit the signal more slowly. The "secondary" sensations are diffuse and aching, and they last longer after the initial injury. peripheral sensory Aδ and C fibers enter the spinal cord by posterior nerve roots within the dorsal horn by the tract of Lissauer. The fibers synapse with interneurons located within a specified area of the cord called the substantia gelatinosa.

Subjective data

Pain is defined as an "unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Pain is always subjective. Do you have pain? Where is your pain? When did it start? What does it feel like? • Burning, stabbing, aching • Throbbing, firelike, squeezing • Cramping, sharp, itching, tingling • Shooting, crushing, sharp, dull. How much pain do you have now? What makes your pain better or worse? How does it limit your activities? How do you react to the pain? What does this pain mean to you?

Pain Assessment Tools

Pain is multidimensional in scope, encompassing physical, affective, and functional domains. Various tools have been developed to capture unidimensional aspects (i.e., intensity) or multidimensional components. Select the pain assessment tool based on its purpose, time involved in administration, and the patient's ability to comprehend and complete the tool. First teach patients how to use each tool, with practice sessions to strengthen the validity and reliability of the response. Enlarge the print when appropriate for individuals with impaired vision. The printed language should be translated to the patient's native language. All words should be direct and free of medical jargon, at a 6th-grade reading level. Ask the patient to rate and evaluate all of the pain sites. Some forms allow for only one number; therefore be sure to add to your documentation. Standardized overall pain assessment tools are more useful for chronic pain conditions or particularly problematic 168acute pain problems. A few examples include the Initial Pain Assessment, the Brief Pain Inventory, and the McGill Pain Questionnaire. The Initial Pain Assessment asks the patient to answer 8 questions concerning location, duration, quality, intensity, and aggravating/relieving factors. Further, the clinician adds questions about the manner of expressing pain and the effects of pain that impair one's quality of life. The Brief Pain Inventory11 asks the patient to rate the pain within the past 24 hours using graduated scales (0 to 10) with respect to its impact on areas such as mood, walking ability, and sleep (Fig. 10-5). The short-form McGill Pain 169Questionnaire27 (not illustrated) asks the patient to rank a list of descriptors in terms of their intensity and to give an overall intensity rating to his or her pain. Pain-rating scales are unidimensional and intended to reflect pain intensity. They come in various forms. They can indicate baseline intensity, track changes, and give some degree of evaluation to a treatment modality. Numeric rating scales ask the patient to choose a number that rates the level of pain for each painful site, with 0 being no pain and the highest anchor 10 indicating the worst pain ever experienced (Fig. 10-6). This makes recording of results easy and consistent with those of numerous clinicians. The Verbal Descriptor Scale uses words to describe the patient's feelings and the meaning of the pain for the person. The Visual Analogue 170Scale lets the patient make a mark along a 10-cm horizontal line from "no pain" to "worst pain imaginable."

Palpation

Palpation follows and often confirms points that you noted during inspection. Palpation applies your sense of touch to assess these factors: texture; temperature; moisture; organ location and size; and any swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and presence of tenderness or pain. Different parts of the hands are best suited for assessing different factors: • Fingertips—Best for fine tactile discrimination, as of skin texture, swelling, pulsation, and determining presence of lumps • A grasping action of the fingers and thumb—To detect the position, shape, and consistency of an organ or mass • The dorsa (backs) of hands and fingers—Best for determining temperature because the skin here is thinner than on the palms • Base of fingers (metacarpophalangeal joints) or ulnar surface of the hand—Best for vibration Your palpation technique should be slow and systematic, calm and gentle. Warm your hands by kneading them together or holding them under warm water. Identify any tender areas and palpate them last. Start with light palpation to detect surface characteristics and accustom the person to being touched. Then perform deeper palpation, perhaps by helping the person use relaxation techniques such as imagery or deep breathing. With deep palpation (as for abdominal contents), intermittent pressure is better than one long, continuous palpation. Avoid any situation in which deep palpation could cause internal injury or pain. Bimanual palpation requires the use of both of your hands to envelop or capture certain body parts or organs such as the kidneys, uterus, or adnexa for more precise delimitation

Pain Assessment The Fifth Vital Sign

Pathologic pain develops by two main processes: nociceptive (Fig. 10-1) and/or neuropathic processing. It is important to understand how these two types of pain develop because patients present with distinguishing sensations and respond differently to analgesics. An accurate pain assessment allows clinicians to more accurately select effective pharmacologic and nonpharmacologic strategies to interrupt the pain processing along multiple points within the pain messaging system and ultimately provide improved pain relief.

Vital signs pulse

Pulse With every beat the heart pumps an amount of blood—the stroke volume—into the aorta. This is about 70 mL in the adult. The force flares the arterial walls and generates a pressure wave, which is felt in the periphery as the pulse. Palpating the peripheral pulse gives the rate and rhythm of the heartbeat and local data on the condition of the artery. Using the pads of your first three fingers, palpate the radial pulse at the flexor aspect of the wrist laterally along the radius bone (Fig. 9-4). If the rhythm is regular, count the number of beats in 30 seconds and multiply by 2. Although the 15-second interval is frequently practiced, any one-beat error in counting results in a recorded error of 4 beats/min. The 30-second interval is most accurate and efficient when heart rates are normal or rapid and when rhythms are regular. However, if the rhythm is irregular, count for a full minute. As you begin the counting interval, start your count with "zero" for the first pulse felt. The second pulse felt is "one," and so on. Assess the pulse, including (1) rate, (2) rhythm, and (3) force.

The Procedure: Rectal Temperature

Rectal temperatures are the most accurate route, and the result is as close to core temperature as possible without using more invasive measures reserved for the operating room and critical care environments. Although the rectal temperature provides the closest approximation to core temperature, it is more invasive than other measures; therefore you must weigh the risks and benefits. In children the temporal artery route misses fever in as many as 30% of children 6 to 36 months old14; therefore it may be advantageous to use rectal temperature in children with a suspected fever or infection. The rectal temperature is the preferred route when the other routes are not practical (e.g., for the comatose or confused person; people in shock; or those who cannot close the mouth because of breathing or oxygen tubes, wired mandible, or other facial dysfunction). Wear gloves and insert a lubricated rectal probe cover on an electronic thermometer only 2 to 3 cm (1 in) into the adult rectum, directed toward the umbilicus. (For a glass thermometer, leave in place for minutes.) Do not let go of the temperature probe while it is inserted into the rectum. Disadvantages to the rectal route are patient discomfort and the invasive nature of the procedure.

Orthostatic (or Postural) Vital Signs

Take serial measurements of pulse and BP when (1) you suspect volume depletion; (2) when the person is known to have hypertension or is taking antihypertensive medications; or (3) when the person reports fainting or syncope. Have the person rest supine for 2 or 3 minutes, take baseline readings of pulse and BP, and repeat the measurements with the person sitting and then standing. For the person who is too weak or dizzy to stand, assess supine and then sitting with legs dangling. When the position is changed from supine to standing, normally a slight decrease (less than 10 mm Hg) in systolic pressure may occur. Record the BP using even numbers. Also record the person's position, the arm used, and the cuff size if different from the standard adult cuff. Record the pulse rate and rhythm, noting whether the pulse is regular. Orthostatic hypotension, a drop in systolic pressure of ≥20 mm Hg or increase in pulse of ≥20 beats/min occurs with a quick change to a standing position. These changes are caused by abrupt peripheral vasodilation without a compensatory increase in cardiac output. Orthostatic changes occur with prolonged bed rest, older age, hypovolemia, and some medications.

Vital Signs Temp

Temperature Cellular metabolism requires a stable core, or "deep body," temperature of a mean of 37.2° C (99° F). The various routes of temperature measurement reflect the core temperature of the body. The normal oral temperature in a resting person is 37° C (98.6° F), with a range of 35.8° to 37.3° C (96.4° to 99.1° F). The rectal temperature measures 0.4° to 0.5° C (0.7° to 1° F) higher. The oral temperature is the most convenient and accurate site. The sublingual pocket has a rich blood supply from the carotid arteries that quickly responds to changes in inner core temperature. Hyperthermia, or fever, is caused by pyrogens secreted by toxic bacteria during infections or from tissue breakdown such as that following myocardial infarction, trauma, surgery, or malignancy. Neurologic disorders (e.g., a stroke, cerebral edema, brain trauma, tumor, or surgery) also can reset the thermostat of the brain at a higher level, resulting in heat production and conservation. Hypothermia is usually caused by accidental, prolonged exposure to cold. It also may be purposefully induced to lower the body's oxygen requirements during heart or peripheral vascular surgery or neurosurgery, amputation, postcardiac arrest, or gastrointestinal (GI) hemorrhage.

The Preschool Child

The child at this stage displays developing initiative. The preschooler takes on tasks independently and plans the task and sees it through. A child of this age is often cooperative, helpful, and easy to involve. However, he or she may have fantasies and see illness as punishment for being "bad." The concept of body image is limited. The child fears any body injury or mutilation; therefore he or she will recoil from invasive procedures. Position • With a 3-year-old child the parent should be present and may hold the child on his or her lap. • A 4- or 5-year-old child usually feels comfortable on the Big Girl or Big Boy (examining) table with the parent present. Preparation • A preschooler can talk. Verbal communication becomes helpful now, but remember that the child's understanding is still limited. Use short, simple explanations. • The preschooler is usually willing to undress. Leave underpants on until the genital examination. • Talk to the child and explain the steps in the examination exactly. • Do not allow a choice when there is none. • As with the toddler, enhance the autonomy of the preschooler by offering choice when possible. • Allow the child to play with equipment to reduce fears (see Fig. 8-13). • A preschooler likes to help; have the child hold the stethoscope for you. • Use games. Have the child "blow out" the light on the penlight as you listen to the breath sounds. Or pretend to listen to the heart sounds of the child's teddy bear first. One technique that is absorbing to a preschooler is to trace his or her shape on the examining table paper. You can comment on how big the child is, then fill in the outline with a heart or stomach and listen to the paper doll first. After the examination the child can take the paper doll home as a souvenir. • Use a slow, patient, deliberate approach. Do not rush. • During the examination give the preschooler needed feedback and reassurance: "Your tummy feels just fine." • Compliment the child on his or her cooperation. Sequence • Examine the thorax, abdomen, extremities, and genitalia first. Although the preschooler is usually cooperative, continue to assess head, eye, ear, nose, and throat last.

Setting

The examination room should be warm and comfortable, quiet, private, and well lit. When possible, stop any distracting noises such as humming machinery, radio or television, or talking that could make it difficult to hear body sounds. Your time with the individual should be secure from interruptions from other health care personnel. Lighting with natural daylight is best, although it is often not available; artificial light from two sources suffices and prevents shadows. Position the examination table so both sides of the person are easily accessible (Fig. 8-5). The table should be at a height at which you can stand without stooping and should be equipped to raise the person's head up to 45 degrees. A roll-up stool is used for the sections of the examination for which you must be sitting. A bedside stand or table is needed to lay out all your equipment.

Vital signs Force

The force of the pulse shows the strength of the heart's stroke volume. A "full, bounding" pulse denotes an increased stroke volume (e.g., as with anxiety, exercise, and some abnormal conditions). The pulse force is recorded using a three-point scale: 3+—Full, bounding 2+—Normal 1+—Weak, thready 0—Absent A "weak, thready" pulse reflects a decreased stroke volume (e.g., as occurs with hemorrhagic shock).

Objective Data

The general appearance (i.e., obese, cachectic [fat and muscle wasting], or edematous) can provide clues to overall nutritional status. More specific clinical signs of nutritional deficiencies can be detected through a physical examination. Because clinical signs are late manifestations of malnutrition, only in areas of rapid turnover of epithelial tissue (i.e., skin, hair, mouth, lips, and eyes) are the deficiencies readily detectable. These signs may also be non-nutritional in origin. Therefore laboratory testing is required to make an accurate diagnosis.

The Adolescent

The major task of adolescence is developing a self-identity. This takes shape from various sets of values and different social roles (son or daughter, sibling, and student). In the end each person needs to feel satisfied and comfortable with who he or she is. In the process the adolescent is increasingly self-conscious and introspective. Peer group values and acceptance are important. Position • The adolescent should be sitting on the examination table. Try to keep street clothes on and work around them as much as possible. • Examine the adolescent alone, without parent or sibling present. Preparation • The body is changing rapidly. During the examination the adolescent needs feedback that his or her own body is healthy and developing normally. • The adolescent has keen awareness of body image, often comparing himself or herself to peers. Apprise the adolescent of the wide variation among teenagers on the rate of growth and development. • Communicate with some care. Do not treat the teenager like a child, but do not overestimate and treat him or her like an adult either. • Because the person is idealistic at this age, the adolescent is ripe for health teaching. Positive attitudes developed now may last through adult life. Focus your teaching on ways the adolescent can promote wellness. Sequence • As with the adult, a head-to-toe approach is appropriate. Examine genitalia last and do it quickly.

The Procedure: Temporal Artery Thermometer

The newest noninvasive temperature measurement method uses infrared emissions from the temporal artery. The temporal artery thermometer (TAT) is used by sliding the probe across the forehead and behind the ear. The thermometer works by taking multiple readings and providing an average. The reading takes approximately 6 seconds. This approach is well tolerated and is more accurate than TMTs; however, there are conflicting reports about its accuracy. Report the temperature in degrees Celsius unless your agency uses the Fahrenheit scale. Familiarize yourself with both scales. Note that it is far easier to learn to think in the centigrade scale than to take the time for paper-and-pencil conversions. Begin by memorizing these convenient equivalents: 104 Degrees F = 4- degrees C. 98.6 f= 37 c 95 f= 35 c

Ophthalmoscope

The ophthalmoscope illuminates the internal eye structures. Its system of lenses and mirrors enables you to look through the pupil at the fundus (background) of the eye, much like looking through a keyhole at a room beyond. 1. Viewing aperture, with five different apertures 2. Aperture selector dial on the front 3. Mirror window on the front 4. Lens selector dial 5. Lens indicator

Assessment Techniques and Safety in the Clinical Setting

The physical examination requires you to develop technical skills and a knowledge base. The technical skills are the tools to gather data. You use your senses—sight, smell, touch, and hearing—to gather data during the physical examination. The skills requisite for the physical examination are inspection, palpation, percussion, and auscultation. They are performed one at a time and in this order.

Vital signs Rhythm

The pulse normally has a regular, even tempo. One irregularity that is commonly found in children and young adults is sinus arrhythmia. In sinus arrhythmia the heart rate varies with the respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. Inspiration momentarily causes a decreased stroke volume from the left side of the heart; to compensate the heart rate increases.

The Procedure: Tympanic Membrane Temperature

The tympanic membrane thermometer (TMT) senses infrared emissions of the tympanic membrane (eardrum). The tympanic membrane shares the same vascular supply that perfuses the hypothalamus (the internal carotid artery); thus it is an accurate measurement of core temperature. The TMT is a noninvasive, nontraumatic device that is extremely quick and efficient. The probe tip has the shape of an otoscope, the instrument used to inspect the ear. Gently place the covered probe tip in the person's ear canal and aim the infrared beam at the tympanic membrane (see Fig. 9-17 on p. 148). Do not occlude the canal. Activate the device and read the temperature in 2 to 3 seconds. There is minimal chance of cross-contamination with the tympanic thermometer because the ear canal is lined with skin and not mucous membrane. Current evidence is conflicting; some studies do not support use of tympanic thermometry in critically ill patients.11a TMT has fallen out of favor in many acute care settings but is still used by some clinics.

Marfan Syndrome

This inherited connective tissue disorder is characterized by tall, thin stature (≥95th percentile), arachnodactyly (long, thin fingers), hyperextensible joints, arm span greater than height, pubis-to-sole measurement exceeding crown-to-pubis measurement, sternal deformity (note pectus excavatum), high-arched narrow palate, narrow face, and pes planus (flat feet). Early morbidity and mortality occur as a result of cardiovascular complications such as mitral regurgitation and aortic dissection.

The Toddler

This is Erikson's stage of developing autonomy. However, the need to explore the world and be independent is in conflict with the basic dependency on the parent. This often results in frustration and negativism. The toddler may be difficult to examine; do not take this personally. Because he or she is acutely aware of the new environment, the toddler may be frightened and cling to the parent. The toddler also has fear of invasive procedures and dislikes being restrained. Position • The toddler should be sitting up on the parent's lap for all of the examination. When he or she must be supine (as in the abdominal examination), move chairs to sit knee-to-knee with parent. Have the toddler lie in the parent's lap with his or her legs in your lap. • Enlist the aid of a cooperative parent to help position the toddler during invasive procedures such as using the otoscope or taking a rectal temperature. Preparation • Children 1 or 2 years of age can understand symbols; thus a security object such as a special blanket or teddy bear is helpful. • Begin by greeting the child and the accompanying parent by name, but with a child 1 to 6 years old focus more on the parent. By essentially "ignoring" the child at first, you allow him or her to adjust gradually and size you up from a safe distance. Then turn your attention gradually to the child, at first to a toy or object the child is holding or perhaps to compliment a dress, the hair, or what a big girl or boy the child is. If the child is ready, you will note these signals: eye contact with you, smiling, talking with you, or accepting a toy or a piece of equipment. • A 2-year-old child does not like to take off his or her clothes; have the parent undress the child one part at a time. • Children 1 or 2 years of age like to say "No." Do not offer a choice when there really is none. Avoid saying, "May I listen to your heart now?" When the 1- or 2-year-old child says "No" and you go ahead and do it anyway, you lose trust. Instead use clear, firm instructions in a tone that expects cooperation, "Now it is time for you to lie down so I can check your tummy." • Also, 1- or 2-year-old children like to make choices. When possible, enhance autonomy by offering the limited option: "Shall I listen to your heart next or your tummy?" • Demonstrate the procedures on the parent. • Praise the child when he or she is cooperative. Sequence • Collect some objective data during the history, which is a less stressful time. While you are focusing on the parent, note the child's gross motor and fine motor skills and gait. • Begin with "games" such as the Denver II test or cranial nerve testing. • Start with nonthreatening areas. Save distressing procedures such as examination of the head, ear, nose, or throat for last.

Developmental Competence (nutritional) Pregnancy and Lactation

To support the synthesis of maternal and fetal tissues, sufficient calories, protein, vitamins, and minerals must be consumed during pregnancy. In particular, iron, folate, and zinc are essential for fetal growth, and vitamin and mineral supplements are often required. The National Academy of Sciences (NAS) recommends a weight gain of 25 to 35 lbs during pregnancy for women of normal weight, 28 to 40 lbs for underweight women, 15 to 25 lbs for overweight women, and 11 to 20 lbs for obese women, a new weight gain category.

Sources of Pain

Visceral pain originates from the larger internal organs (i.e., stomach, intestine, gallbladder, pancreas). It often is described as dull, deep, squeezing, or cramping. The pain can stem from direct injury to the organ or stretching of the organ from tumor, ischemia, distention, or severe contraction. Examples of visceral pain include ureteral colic, acute appendicitis, ulcer pain, and cholecystitis. The pain impulse is transmitted by ascending nerve fibers along with nerve fibers of the autonomic nervous system (ANS). That is why visceral pain often presents along with autonomic responses such as vomiting, nausea, pallor, and diaphoresis. Somatic pain originates from musculoskeletal tissues or the body surface. Deep somatic pain comes from sources such as the blood vessels, joints, tendons, muscles, and bone. Pain may result from pressure, trauma, or ischemia. Cutaneous pain is derived from skin surface and subcutaneous tissues. Deep somatic pain often is described as aching or throbbing, whereas cutaneous pain is superficial, sharp, or burning. Whether somatic pain is sharp or dull, it is usually well localized and easy to pinpoint. Somatic pain, like visceral pain, can be accompanied by nausea, sweating, tachycardia, and hypertension caused by the ANS response. Pain that is felt at a particular site but originates from another location is known as referred pain. Both sites are innervated by the same spinal nerve, and it is difficult for the brain to differentiate the point of origin.

Measurement

Weight Normal Weight- Use a standardized balance or electronic standing scale (Fig. 9-2). Instruct the person to remove his or her shoes and heavy outer clothing before standing on the scale. When a sequence of repeated weights is necessary, aim for approximately the same time of day and the same type of clothing worn each time. Record the weight in kilograms and in pounds. Abnormal An unexplained weight loss may be a sign of a short-term illness (e.g., fever, infection, disease of the mouth or throat) or a chronic illness (e.g., endocrine disease, malignancy, depression, anorexia nervosa, bulimia). Unexplained weight gain may indicate fluid retention (e.g., heart failure). Height Use a wall-mounted device or the measuring pole on the balance scale. Align the extended headpiece with the top of the head. The person should be shoeless, standing straight with gentle traction under the jaw, and looking straight ahead. Feet, shoulders, and buttocks should be in contact with the hard surface. Body Mass Index Underweight < 18.5 kg/m2 Normal weight 18.5 to 24.9 kg/m2 Overweight 25 to 29.9 kg/m2 Obesity (class 1) 30 to 34.9 kg/m2 Obesity (class 2) 35 to 39.9 kg/m2 Extreme obesity (class 3) ≥ 40 Weight divided by height in inches divided by height in inches multiply by 703. Waist Circumference Abnormal A waist circumference (WC) ≥35 inches in women and ≥40 inches in men increases the risk for type 2 diabetes, dyslipidemia, hypertension, and cardiovascular disease (CVD) in people with a BMI between 25 and 35.

Subjective Data

1. Eating patterns 2. Usual weight 3. Changes in appetite, taste, smell, chewing, swallowing 4. Recent surgery, trauma, burns, infection 5. Chronic illnesses 6. Nausea, vomiting, diarrhea, constipation 7. Food allergies or intolerances 8. Medications and/or nutritional supplements 9. Patient-centered care 10. Alcohol or illegal drug use 11. Exercise and activity patterns 12. Family history

The Procedure: Arm Pressure

A comfortable, relaxed person yields a valid BP. Many people are anxious at the beginning of an examination; allow at least a 5-minute rest before measuring the BP. Then take two or more BP measurements separated by 2 minutes. For each person, verify BP in both arms once, either on admission or for the first complete physical examination. It is not necessary to continue to check both arms for screening or monitoring. Occasionally a 5- to 10-mm Hg difference may occur in BP in the two arms (if values are different, use the higher value), which is caused by artifact or subtle differences in technique. The person may be sitting or lying, with the bare arm supported at heart level. When sitting, the patient's feet should be flat on the floor because BP has a false-high measurement when legs are crossed versus uncrossed. Palpate the brachial artery, which is located just above the antecubital fossa, medial to the biceps tendon. With the cuff deflated, center it about 2.5 cm (1 in) above the brachial artery and wrap it evenly. Now palpate the brachial or radial artery (Fig. 9-8). Inflate the cuff until the artery pulsation is obliterated and then 20 to 30 mm Hg beyond. This helps you to avoid missing an auscultatory gap, which is a period when Korotkoff sounds disappear during auscultation. Deflate the cuff quickly and completely; then wait 15 to 30 seconds before reinflating so the blood trapped in the veins can dissipate. Place the bell or diaphragm of the stethoscope over the site of the brachial artery, making a light but airtight seal (Fig. 9-9). The diaphragm endpiece is usually adequate, but the bell is designed to pick up low-pitched sounds such as the sounds of a BP reading. Most novice practitioners find it easier to use the diaphragm than the bell. You can use either side to obtain an accurate reading. Rapidly inflate the cuff to the maximal inflation level that you determined. Then deflate the cuff slowly and evenly, about 2 mm Hg per heartbeat. Note the points at which you hear the first appearance of sound, the muffling of sound, and the final disappearance of sound. These are phases I, IV, and V of Korotkoff sounds, which are the components of a BP reading first described by a Russian surgeon in 1905 For all age-groups the fifth Korotkoff phase is now used to define diastolic pressure.7 However, when a variance greater than 10 to 12 mm Hg exists between phases IV and V, record both phases along with the systolic reading (e.g., 142/98/80). Clear communication is important because the results significantly affect diagnosis and planning of care. See Table 9-4 for a list of common errors in BP measurement. A reproducible difference in the two arms of more than 10 to 15 mm Hg may indicate arterial obstruction on the side with the lower reading. This warrants referral. An auscultatory gap occurs in about 5% of people, most often in hypertension caused by a noncompliant arterial system.

A Safer Environment

A Safer Environment In addition to monitoring the cleanliness of your equipment, take all steps to avoid any possible transmission of infection between patients or between patient and examiner (Table 8-2). A health care-associated (nosocomial) infection is a hazard because hospitals have sites that are reservoirs for virulent microorganisms. Some of these microorganisms are resistant to antibiotics such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), or multidrug-resistant tuberculosis or are microorganisms for which there is currently no known cure such as human immunodeficiency virus (HIV).

Achondroplastic Dwarfism

A genetic disorder in converting cartilage to bone results in normal trunk size, short arms and legs, and short stature. It is characterized by a relatively large head with frontal bossing; midplace hypoplasia; and often thoracic kyphosis, prominent lumbar lordosis, and abdominal protrusion. The mean adult height in men is about 131.5 cm (4 ft 4 in) and in women about 125 cm (4 ft 1 in).

Types of Pain

Acute pain is short term and self-limiting, often follows a predictable trajectory, and dissipates after an injury heals. Examples of acute pain include surgery, trauma, and kidney stones. Acute pain has a self-protective purpose; it warns the individual of actual or threatened tissue damage. Incident pain is an acute type that happens predictably when certain movements take place. Examples include pain in the lower back on standing or whenever turning a hospitalized patient from side to side. In contrast, chronic (persistent) pain is diagnosed when the pain continues for 6 months or longer. It can last 5, 15, or 20 years and beyond. Chronic pain can be divided into malignant (cancer-related) and nonmalignant. Malignant pain often parallels the pathology created by the tumor cells. The pain is induced by tissue necrosis or stretching of an organ by the growing tumor. Finally breakthrough pain is a transient spike in pain level, moderate to severe in intensity, in an otherwise controlled pain syndrome. It can result from end-of-dose medication failure. This occurs when a patient taking a long-acting opioid has a recurrence of pain before the next scheduled dose. Treatment of end-of-dose failure includes shortening the interval between doses or increasing the dose of medication. Breakthrough pain can also be the result of incident or episodic pain.

Normal Respiratory Rates

Age/ Breathes per min Neonate 30-40 1 yr 20-40 2 yr 25-32 8-10 yr 20-26 12-14 yr 18-22 16 yr 12-20 Adult 10-20

Tools for Infants and Children

Because infants are preverbal and incapable of self-report, pain assessment depends on behavioral and physiologic cues. Refer to the Objective Data section. It is important to underscore the point that infants do feel pain. Children 2 years of age can report pain and point to its location. They cannot rate pain intensity at this developmental level. It is helpful to ask the parent or caregiver what words the child uses to report pain. The Faces Pain Scale-Revised (FPS-R) has six drawings of faces that show pain intensity, from "no pain" on the left (score of 0) to "very much pain" on the right (score of 10)

Developmental Competence

Children are different from adults. Their difference in size is obvious. Their bodies grow in a predictable pattern that is assessed during the physical examination. However, their behavior is also different. Behavior grows and develops through predictable stages, just as the body does.

Hypopituitary Dwarfism

Deficiency in growth hormone in childhood results in retardation of growth below the 3rd percentile, delayed puberty, hypothyroidism, and adrenal insufficiency.

Gigantism

Excessive secretion of growth hormone by the anterior pituitary results in overgrowth of the entire body. When this occurs during childhood before closure of bone epiphyses in puberty, it causes increased height and weight and delayed sexual development.

Acromegaly (Hyperpituitarism)

Excessive secretion of growth hormone in adulthood after normal completion of body growth causes overgrowth of bone in face, head, hands, and feet but no change in height. Internal organs also enlarge (e.g., cardiomegaly); and metabolic disorders (e.g., diabetes mellitus) may be present.

The Infant

Erikson defines the major task of infancy as establishing trust. An infant is completely dependent on the parent for his or her basic needs. If these needs are met promptly and consistently, the infant feels secure and learns to trust others. Position • The parent always should be present to understand normal growth and development and for the child's feeling of security. • Place the neonate or young infant flat on a padded examination table. The infant also may be held against the parent's chest for some steps. • Once the baby can sit without support (around 6 months), as much of the examination as possible should be performed while the infant is in the parent's lap. • By 9 to 12 months the infant is acutely aware of the surroundings. Anything outside the infant's range of vision is "lost"; thus the parent must be in full view. Preparation • Timing should be 1 to 2 hours after feeding, when the baby is not too drowsy or too hungry. • Maintain a warm environment. A neonate may require an overhead radiant heater. • An infant will not object to being nude. Have the parent remove outer clothing, but leave a diaper on a boy. • An infant does not mind being touched, but make sure that your hands and stethoscope endpiece are warm. • Use a soft, crooning voice during the examination; the baby responds more to the feeling in the tone of the voice than to what is actually said. • An infant likes eye contact; lock eyes from time to time. • Smile; a baby prefers a smiling face to a frowning one. (Often beginning examiners are so absorbed in their technique that they look serious or stern.) Take time to play. • Keep movements smooth and deliberate, not jerky. • Use a pacifier for crying or during invasive steps. • Offer brightly colored toys for a distraction when the infant is fussy. • Let an older baby touch the stethoscope or tongue blade. Sequence • Seize the opportunity with a sleeping baby to listen to heart, lung, and abdominal sounds first. • Perform least distressing steps first. (See the sequence in Chapter 27.) Save the invasive steps of examination of the eye, ear, nose, and throat until last. • If you elicit the Moro or "startle" reflex, do it at the end of the examination because it may cause the baby to cry.

The III Person

For the person in some distress, alter the position during the examination. For example, a person with shortness of breath or ear pain may want to sit up, whereas a person with faintness or overwhelming fatigue may want to be supine. Initially it may be necessary just to examine the body areas appropriate to the problem, collecting a mini-database. You may return to finish a complete assessment after the initial distress is resolved.

Classification of Malnutrition

Obesity caused by caloric excess refers to weight more than 20% above ideal body weight or body mass index (BMI) of 30.0-39.9. The causes are complex and multifaceted—genetic, social, cultural, pathologic, psychological, and physiologic factors. In most cases a small caloric surplus over a long period results in the extra pounds. Although visceral protein levels are normal in the obese individual, anthropometric measures are above normal. Marasmus (protein-calorie malnutrition) is caused by inadequate intake of protein and calories or prolonged starvation. Anorexia, bowel obstruction, cancer cachexia, and chronic illness are among the clinical conditions leading to marasmus. It is characterized by decreased anthropometric measures (i.e., weight loss and subcutaneous fat and muscle wasting). Visceral protein levels may remain within normal ranges. Kwashiorkor (protein malnutrition) is caused by diets high in calories but little or no protein (e.g., low-protein liquid diets, fad diets, and long-term use of dextrose-containing intravenous fluids). In contrast to individuals with marasmus, those with kwashiorkor have decreased visceral protein levels but adequate anthropometric measures. Therefore they may appear well nourished or even obese. Marasmus/kwashiorkor mix is caused by prolonged inadequate intake of protein and calories such as severe starvation and severe catabolic states. Nutritional assessment findings include muscle, fat, and visceral protein wasting. Individuals have usually undergone acute catabolic stress such as major surgery, trauma, or burns in combination with prolonged starvation or have AIDS wasting. Without nutritional support, this type of malnutrition is associated with the highest risk for morbidity and mortality. Scorbutic Gums Rickets Deficiency of vitamin C. Gums are swollen, ulcerated, and bleeding because of vitamin C-induced defects in oral epithelial basement membrane and periodontal collagen fiber synthesis. Rickets Sign of vitamin D and calcium deficiencies in children (disorders of cartilage cell growth, enlargement of epiphyseal growth plates) and adults (osteomalacia). Bitot's Spots Foamy plaques of the cornea that are a sign of vitamin A deficiency. Severe depletion may result in conjunctival xerosis (drying) and progress to corneal ulceration and finally destruction of the eye (keratomalacia). Pellagra Pigmented keratotic scaling lesions resulting from a deficiency of niacin. These lesions are especially prominent in areas exposed to the sun such as hands, forearms, neck, and legs. Follicular Hyperkeratosis Dry, bumpy skin associated with vitamin A and/or linoleic acid (essential fatty acid) deficiency. Linoleic acid deficiency may also result in eczematous skin, especially in infants. Magenta Tongue A sign of riboflavin deficiency. In contrast, a pale tongue is probably attributable to iron deficiency; a beefy red-colored tongue is caused by vitamin B-complex deficiency.

Percussion

Percussion is tapping the person's skin with short, sharp strokes to assess underlying structures. The strokes yield a palpable vibration and a characteristic sound that depicts the location, size, and density of the underlying organ. Why learn percussion when an x-ray image is so much more accurate? It's because your percussing hands are always available, are easily portable, and give instant feedback. Percussion has the following uses: • Mapping out the location and size of an organ by exploring where the percussion note changes between the borders of an organ and its neighbors • Signaling the density (air, fluid, or solid) of a structure by a characteristic note • Detecting an abnormal mass if it is fairly superficial; the percussion vibrations penetrate about 5 cm deep—a deeper mass would give no change in percussion • Eliciting a deep tendon reflex using the percussion hammer. The Stationary Hand Hyperextend the middle finger (the pleximeter) and place its distal joint and tip firmly against the person's skin. Avoid the person's ribs and scapulae. Percussing over a bone yields no data because it always sounds "dull." Lift the rest of the stationary hand up off the person's skin (Fig. 8-1). Otherwise the resting hand will dampen off the produced vibrations, just as a drummer uses the hand to halt a drum roll. The Striking Hand Use the middle finger of your dominant hand as the striking finger (the plexor) (Fig. 8-2). Hold your forearm close to the skin surface, with your upper arm and shoulder steady. Scan your muscles to make sure that they are steady but not rigid. The action is all in the wrist, and it must be relaxed. Spread your fingers, swish your wrist, and bounce your middle finger off the stationary one. Aim for just behind the nail bed or at the distal interphalangeal joint; the goal is to hit the portion of the finger that is pushing the hardest into the skin surface. Flex the striking finger so its tip, not the finger pad, makes contact. It hits directly at right angles to the stationary finger. Percuss 2 times in this location using even, staccato blows. Lift the striking finger off quickly; a resting finger dampens vibrations. Then move to a new body location and repeat, keeping your technique even. The force of the blow determines the loudness of the note. You do not need a very loud sound; use just enough force to achieve a clear note. The thickness of the person's body wall will be a factor. You need a stronger percussion stroke for people with obese or very muscular body walls. Production of Sound All sound results from vibration of some structure. Percussing over a body structure causes vibrations that produce characteristic waves and are heard as "notes" (Table 8-1), which are differentiated by the following components: (1) amplitude (or intensity), a loud or soft sound; (2) pitch (or frequency), the number of vibrations per second; (3) quality (timbre), a subjective difference caused by the distinctive overtones of a sound; and (4) duration, the length of time the note lingers. A basic principle is that a structure with relatively more air (e.g., the lungs) produces a louder, deeper, and longer sound because it vibrates freely; whereas a denser, more solid structure (e.g., the liver) gives a softer, higher, shorter sound because it does not vibrate as easily. Although Table 8-1 describes five "normal" percussion notes, variations occur in clinical practice. The "note" you hear depends on the nature of the underlying structure, the thickness of the body wall, and your correct technique.

Documentation and Critical Thinking Sample Charting

Subjective Starting within the past 2 weeks, states having severe epigastric pain within a half-hour of eating greasy, fatty foods. Pain is stabbing and squeezing in nature with radiation to right shoulder blade. Rates pain as a 10 on a 0-to-10 scale. Nausea accompanies pain. Takes antacids with minimal relief. Pain diminishes after bringing knees to chest and "not moving" for a 1-hour period. 175 Objective Patient diaphoretic, grimacing, and having difficulty concentrating. Breathless during history. Arms guarding upper abdominal area. Abdomen distended. Severe tenderness noted on light LUQ and epigastric palpation. Bowel sounds hyperactive in all 4 quadrants. Assessment Acute episodic pain

Otoscope

The otoscope funnels light into the ear canal and onto the tympanic membrane.

Nonverbal Behaviors of Pain

When the individual cannot verbally communicate the pain, you can (to a limited extent) identify it using behavioral cues. Recall that individuals react to painful stimuli with a wide variety of behaviors. Behaviors are influenced by a wide variety of factors, including the nature of the pain (acute versus chronic), age, and cultural and gender expectations. Acute Pain Behaviors Because acute pain involves autonomic responses and has a protective purpose, individuals experiencing moderate-to-intense levels of pain may exhibit the following behaviors: guarding, grimacing, vocalizations such as moaning, agitation, restlessness, stillness, diaphoresis, or change in vital signs. Persistent (Chronic) Pain Behaviors People with persistent pain live with the experience for months and years. One cannot function physiologically and go on with life in a repetitive state of behaviors such as grimacing, diaphoresis, and guarding. The person adapts over time, and clinicians cannot look for or anticipate the same acute pain behaviors to exist to confirm a pain diagnosis. Infants Most pain research on infants has focused on acute procedural pain. Much effort and time is spent on decoding facial expressions (e.g., taut tongue, bulging brow, closing of eye fissures), which may be difficult for the general practitioner to carry out in a busy clinical setting. The CRIES score is one tool for postoperative pain in preterm and term neonates.21 It measures physiologic and behavioral indicators on a three-point scale A second tool often used is the FLACC scale.28 This is a nonverbal assessment tool for infants and young children under 3 years. The FLACC scale is designed to be simple for practitioners to administer while providing a reliable and objective assessment of pain in young children. The tool assesses five behaviors of pain: facial expression, leg movement, activity level, cry, and consolability (Fig 10-10). You can summarize the scores as: 0 = relaxed and comfortable; 1-3 = mild discomfort; 4-6 = moderate pain; 7-10 = severe discomfort/pain The Aging Adult Although pain should not be considered a "normal" part of aging, it is prevalent. When an older adult reports a history of conditions such as osteoarthritis, peripheral vascular disease, cancer, osteoporosis, angina, or chronic constipation, be alert and anticipate a pain problem. When you look for behavioral cues, look at changes in functional status. Observe for changes in dressing, walking, toileting, or involvement in activities. A slowness and rigidity may develop, and fatigue may occur. Use the PAINAD scale (Fig. 10-11), which evaluates five common behaviors: breathing, vocalization, facial expression, body language, and consolability.39 Specific behaviors in these categories are quantified from 0 to 2, with a total score ranging from 0 to 10. This is consistent with the commonly used 0-to-10 metric on other pain tool scores. For the PAINAD a score of 4 or more indicates a need for pain management.

The Procedure: Oral Temperature

hake a glass thermometer down to 35.5° C (96° F) and place it at the base of the tongue in either of the posterior sublingual pockets—not in front of the tongue. Instruct the person to keep his or her lips closed. Leave in place 3 to 4 minutes if the person is afebrile and up to 8 minutes if febrile. (Take other vital signs during this time.) Wait 15 minutes if the person has just taken hot or iced liquids and 2 minutes if he or she has just smoked. The electronic thermometer has the advantages of swift and accurate measurement (usually in 20 to 30 seconds). The instrument must be fully charged and correctly calibrated. Most children enjoy watching their temperature numbers advance on the box. Electronic thermometers can be used for both oral and rectal temperatures. Blue-tipped probes are for the oral route, whereas red-tipped probes are rectal.