BS Physical examination 2

b. Main complaint Q: The patient complains of abdominal pain Q: like being sliced R: from the upper left abdomen spreading to the lower part S: on a scale of 5 (1-10) and Q: felt continuously since three days ago at home until today patient assessment. / Pain decreases slightly when the patient rests. Patient defecate with bright red blood colored feces too. The patient complained of abdominal pain like being cut into pieces from the left side of the abdomen the upper part spreads to the lower part on a scale of 5 (1-10) and is felt continuously continuously since three days ago at home until the time of the patient assessment. Pain decreases slightly when the patient rests. The patient defecates with feces bright red blood color. c. Past medical history Since the last six months, the patient has had Kp Duplex disease. Patient receive regular therapy for six months. d. Family history of illness The patient's father suffered from tongue cancer and has died. 2. Wash your hands. 3. Measure BB and TB BMI formula (body mass index) Body weight (Kg) Height (m2) BMI size -Normal: 18.5-24.9 Kg/m2. -Underweight: < 18.5 Kg/m2. - Overweight: 25.0- 29.9 kg/m2. -Obese: > 30.0 Kg/m2 4. Take vital signs (blood pressure, pulse, respiratory rate and temperature body). A. Blood Pressure Blood Pressure Measurement Procedure -Explain the procedure for measuring blood pressure so that the client does not experiencing fear. -Position the client in the correct position (lying or sitting). -Keep the client away from anything that obstructs blood flow and effect on blood pressure readings. -Place the spigmanometer cuff on the arm. Make sure the cuff is 23 cm above the brachial artery. - Palpate the brachial pulse on the cuffed arm. - Wait 15-30 seconds then place the stethoscope on the brachial artery. - Inflate the cuff until no sound is heard pulse the brachial artery and add 30 mmHg. - Listen and record the first sound as the systolic blood pressure value. - Listen and record the last sound as the diastolic blood pressure value. - If the clinical team is not sure about the blood pressure results obtained. Repeated blood pressure measurements can be repeated by other clinicians. Source: NHS Foundation Trust, 2013 Blood pressure measures -Hypotension: systolic < 90 mmHg and diastolic < 60 mmHg. - Normal: systolic < 120 mmHg and diastolic < 80 mmHg. B. Pulse - Prehypertension: systolic 120-139 mmHg or diastolic 80-89 mmHg. - Hypertension stage 1: systolic 140-159 mmHg or diastolic 90-99 mmHg. - Stage 2 hypertension: systolic > 160 mmHg or diastolic > 100 mmHg. Pulse Measurement Procedure 1. Place your left hand open upwards and hold three fingers right (index, middle and ring fingers) on the left wrist. 2. Feel the pulse and count in 15 seconds. 3. Multiply by 4 the number of beats in 15 seconds and get that number is the pulse rate for 1 minute. Source: Suharsono, 2011. Pulse measurement - Radial artery in the wrist ÿ Brachial artery in the inner elbow ÿ Carotid artery in the neck - Temporal artery at the temple. - Femoral artery in the groin ÿ Dorsal pedis artery in the leg - Frontal artery at the crown (for babies) Heart rate measurements: -Normal: 60-100x/minute -Tachycardia: increased pulse rate up to 100x/minute. -Bradycardia: pulse rate less than 60x/minute C. Respiratory Rate (Respiratory Frequency) Respiratory Rate Measurement Procedure 1. Position the client in a good resting position, sitting position. Make sure the client is comfortable. 2. Let the client rest for at least 3 minutes. 3. Observe and count the rise and fall of the chest wall for 60 seconds. Observation rhythm, depth and effort of breathing. 4. The results of this calculation are the results of the respiratory rate. 5. Record the respiratory rate on the documentation sheet. Source: Clinical research facility Sheffield, 2010. Measures of respiratory frequency : a. Normal: 12- 20x/minute. b. Tachypnea: respiratory frequency > 20x/minute. c. Bradypnea: respiratory frequency < 12 x/minute. D. Body Temperature Body Temperature Measurement there are 9 body temperature categories: 1. Below 35: algid collapse. 2. 35-36 : collapse 3. 36- 37: subnormal 4. 37- 37.4: Normal 5. 37.4- 37.8: Subfibrille 6. 37.8- 38.3: Low fever 7. 38.3- 39.5: Moderate fever 8.39.5- 40.5: High Fever 9. Above 40.5: Hyperpyrexia Types of body temperature practices 1. Under the tongue 2. Axillary method: in the armpit 3. Rectal method: Anal opening Practice taking body temperature, axillary method -Take a thermometer, clean it with tissue & shake it to the lowest temperature. - Remove one of the ps sleeves. - Dry your armpits , in the mouth. -Insert the thermometer under the armpit until it enters 3⁄4 of the thermometer. - The thermometer is clamped with the arms crossed across the chest so that the thermometer is not fall. - leave the thermometer for 10-15 minutes. -The thermometer is taken from the armpit, then read and then shaken until it drops to a point final. Clean the thermometer with a tissue & put it in its place. 5. Condition of hair and head - Inspection: Black, brown, blonde, silver, smelly or colorful hair typically indicates vitamin A deficiency. - Palpation: easy to fall out, scalp falls out, smells (indicates lack of person's hygiene) and vesicular, pustule, crust due to varicella, dermatitis or mold. 6. Hydrate the skin of the forehead area Palpation: pressing the thumb on the skin of the forehead because it has a bony base. On Dehedration can be found " finger print " on the skin of the forehead. 7. Eyebrows Inspection: eyebrows raised and lowered, frowning, pursing lips, smiling, grimacing, whistling, puffing out the cheeks (facial nerve / Nervesus VII). 8. Eyes - Inspection: a. Eyelids (palpebrae): no edema, presence or absence of dark circles around the eyes, whether they close tightly or not. The eyelids always closed / unable to open is called "ptosis". The eyelids not being able to close tightly (keeps opening) is called "lagophthalmus".