Position of pt by mikesanye

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									Position of pt
            o Sitting
            o Lying down - semirecumbant position
                   Rec - flat on bed
                   Semirecumbant position- at least 45 degrees

Blood pressure exam
          o Many things to observe
          o Arm cuff - at the level of the heart
                  Arm should be at heart level so that
                        Muscles should be relaxed
          o Bp instruments
                  Mercurial
                        Can be wheeled from one room to another
                  Sphigmomenometer
                        Put on a table
                        If it's on the table, don't take bp while you're standing
                           because the calibration should always be at eye level
                                So you have to sit to make calibration eye level
                        If pt's on the bed, sphigmo has a wheel
                                Pull a chair and sit down so you're a the level
                  Digital
                        No problem with whatever position
                  Anaroid
                        Demonstrated in movie
                        Tycos anaroid - big and standing; esp if in hospital
                                Has a stand

Those with high blood pressure
140/90 or higher --
          o Std mercurial form of sphigmomenometer
          o Sometimes, leakage of mercury found -- which is poisonous
                  So mercurial sphigmomenometers production stopped
                  WHO prohibiting use of it now esp in USA

BP is an indirect measurement
           o You're trying to listen to flow of blood as it flows along arterial blood
               vessel
           o The true arterial bp is when you insert the catheter; and measure
               directly inside artery connected to a menometer

Digital
           o Battery operated
                 Life span
                 If battery low, gives a false reading
Onron type recommended



Blood Pressure
          o Importance of knowing taking bp
          o Arm cuff -width of cuff determines accuracy of bp
                For bigger arms, need a wider one
        Pediatrics, need narrower
o   Arm cuffs also for the thigh
        For dx of pts with different bp -lower in lower body
               Renal pt --shunt in both arms --can't take it so you use
                  lower extremity
                       Rap around arm --popliteal artery
                       Or tibia -- tibial artery
o   Make sure cuff free from air when wrap around arm
        Use the brachial fossa
        Palpate arterial pulsation
        Also feel the radial --whichever stronger pulsation --use it
               As much as possible use brachial --where you place the
                  stethescope
o   When you inflate, don't ascultate right away
        Feel the brachial pulsation and inflate up to the level of
          disappearance of pulsation
        Then inflate faster 30 mm higher ---time when you ascultate
          and wait for reappearance for koratkoff sound --as blood flows
          thru the recently occluded brachila artery --hear low pitch
          sound --so you use the bell of the stethescope because it's low
          pitch
        The reappearance of sound ---corr to disappearnace of
          pulsation --diastolic pressure --10 by 10
               Koratkoff sound ---becomes louder and louder, muffled,
                  then disappears --true diastolic bp

o   If the pt Is a woman (asian), hard to tell them to undress unlike
    Western women
         Male --better if they're stripped of their shirt to see the
            pulsations
                 Apex of heart - rotating and moving forward and can be
                    seen thru pulsati --apical beat

                 Aorta/pulmonary dilated --see pulsations in 2nd
                  intercostal space
o   Always stay at the right side of the patient
        So you have more room to move the pt as he turns to left
          lateral --so you can easily folloow it --makes pulsation
          appreciated --apex is nearer the chest wall
        Ask pt to stoop forward --to feel puslatin --aortic/pulmonic --
          nearer chest wall
        Observe everything --head, neck , chest, abdomen, extremities

          Not only looking at heart, head to abdomen also --to correlate
           with underlying cardio condition

o   Audio played
o   Notice that stethescope placed at brachial at time of deflation
        When you inflate, you're palpating --whe you inflate the arm
           cuff --palpate arm position --brachial, palpebral
                During inflation, time when steth placed at brachial a.
                   site
                Disappearance of sound is diastolic
                Reappearance --dis of pulsation --systolic
                In btw --phase 2,3,4
                      Murmur signifies turbulent flow --due to artery
                         being occluded when you inflate --whe you
                         release cuff --sudden rush of blood --so
                         turbulence as blood rushes thru recently occluded
                         artery
o   There are phys ex findings in eyes, muscles, extremities
        Could imply underlying cardiac disease
               Marfan's syn ---long extremities, upper and lowe
                      Abnormality in heart sounds --aortic valve
                         regurgitation murmur

o   Radial pulses ---both sides taken together
o   Palpation of peripheral pulses
         Should be conducted simultaneously on both extremities
         So you palpate radial simul and brachial simul
                Should be equal pulses --strong and equal
                       If difference in amplitude --obstruction in
                          pathway somewhere along artery
         Radial and brachial should be simultaneously
                Should there be radial delay, weaker and delayed
                   compared to brachial
                Coarctation of aorta --higher bp in upper extremity
                       Bp lower in lower ext
         Palpating femoral and radial simult --helps you know the
           problem

o   Tibialis posterior and dorsalis pedis
o   Peripheral vasculatures also suffer atheroscleroisis
         Diabetes complain of pain of walking --intermittent claudicatin
                 Palpate dorsalis pedis or tib pos artery
                 A diminished pulsation/difficulty in recognizing pulsation
                    in dors pedis --peripheral arterial disease
                         Feel extremity if cold --means less perfusion ---
                           look at color of extremity --if difference in color
                           with other --venous stasis --hyperdiscoloration of
                           lower extremity ---peripheral venous insufficiency
                           maybe
                                Why you're legs and feet get tired from
                                   standing too long or sitting too long ---
                                   why you should walk around

o   Pt with dyspnea --bluish discoloration of lips
         Ortopnic - pt having pulmonary shunting due to pulmonary
           hypertension
                Extremities are cold
         In central cyanosis --intracardiac shunt --atrial septal defect -
           reversal of shunt
                Instead of let ot right ---right to left
                Vent sep def --instead of l to r ----right to left
                       Have cyanosis --sign of heart disease
o   Pts with hypertension should routine procedure to due fungal eye
    exam
         Funguscopic examination --HEENT
                Ophtalmoscope --used before
                      Normal appearance of retinal vessels --very
                         smooth; when they become narrow --some
                         hemorrhage and exudates --pt is chronically
                         hypertensive with very poor control of
                         hypertension ---grade 3 fungus
                Classificatio of atherosclerosis
                      Grade 1 and 2
                      3 and 4
                      3 --shown
                              Bp 230/140
                              Accelerated hypertension/malignant
                                 hypertension
                                      Fundoscopic exam
                                             Accelerated -grade 3 fungus
                                             Malignant --papal edema --
                                               suspect pt to be
                                               unconscious with stroke --
                                               cva --cerebral vascular
                                               accident
                      4 --massive papal edema

o   Jugular venous pulse
        Reflects changes in right atrial pressure over coarse of cardiac
           cycle
        When you look at pulsations, some evidence of distended
           jugulars; in normal people, look at neck of neighbor; in the
           region of neck use SCM muscle -- maybe confused with neck
           vein; also have carotid artery
        Vein is more superficial than the artery; they don't pulsate
           either
                If you see vessel that's visible, feel it first; if it pulsates,
                  then it's not a vein but an artery actively pulsating
                If ever there is the max pulsation above the clavicle --
                  seen above the clavicle --but you're asked to indirectly
                  measure jug ven pressure --pressure in right atrium
                  indirectly --about pressure in right side of heart; look at
                  top most level of pulsation (visibility of neck vein); that's
                  where you place the ruler --another ruler is pointing to
                  the position of r atrium --at 2nd intercostal space on the
                  right --where you stand the ruler ---the other ruler
                  coming from neck --see the height ---where you
                  measure the height ---add whatever the height + 4.5
                  cm (because it's approximated --dist btw r atrial cavity
                  and skin is 4.5 cm); placed on top of skin -----45 degree
                  angle elevation
                Jug ven pressure to determine r atrial pressure
        Normal atrial pressure --curve
                Seen by estimating the jugular venous pressure
                Monometer measures this
                   Correlated with heart sound ---s1 and s2
                        Q T in ecg --total ventricular contraction and
                           relaxation; period of systole
                        Btw s2 to another s1 to occurrence of P wave is
                           the period of diastole
                        Shown ---s3 --early filling period
                        S4 --late filling period
                        A wave ---corresponds to period of late diastole
                           on the ventricle --but it's atrial systole ---atrium
                           is contracting ---later period --where there's slow
                           filling
                                  In pts with tricuspid regurg --will be some
                                   reversal ---very high ---approxi a wave --
                                   stronger period during later …of diastole

           How to visualize the vein
                Dr trying to make neck wider to have wider vision of it --
                  esp the vein
                Staying at the right side, he turns the head towards the
                  opposite --so you have a wider visual field
                       Elevate the chin first
                       Then turn the head to opposite side
                       See the topmost --lesser amplitude than max
                          pulsation above the clavicle --where you measure
                          estimated jugular venous pressure


           Different abnormalites of pulsation
                 With carotid pulsation --stronger; strongest arterial
                   pulsation
                        Brief upstroke --gradual downstroke
                 Aortic stenosis/regurg pts
                        Double peak during systole peak --pulsis
                           experiecn
                        Stenosis --valve small
                               Long time for systole to finish --slow rising
                                  pulse --pulsus varbus???
                        Aortic regurg -l vent overlad/PDA --large
                           ventricular volume
                               L ventricle contracts --large vol of blood
                                  goes out --collapses --collapsing pulse --
                                  water hammer pulse
                 Note when you visualize jugular, turn head opposite side,
                   this time you palpate now --not moving the head ---
                   palpate to the same side for stronger pulsation
                        Simpler to palpate the carotid as demo shows


o   Chest   examinations
            As mentioned, when you ascultate, also examine the lungs
            As shown in demo, pt seems to be very comfortable
            In heart failure pts, inc in rate of breathing, inc rate of
             excursion of chest
                 When ascultate, you can hear crackles
                 Both percussion and ascultation done one at a time with
                  heart failure pts
                      Can hear crackles all over lung fields --pulmonary
                         edem

o   Demo
          Movements of hands shown
          Apex felt; didn't remove fingers
          When you palpate use the palm, apical beat
          Don't remove the fingers; try to measure the clavicular line and
           drop a line
          He felt the sternal angle of louis, counted 2,3,4,5 coincide it
           with line
               Time where you can say apical beat is ant ax, mid
                   axillary line
          From there you can move to feel the tricuspide wherein r
           ventricle hypertrophied --feel epigastric --pulsations and
           movement of r ventricle
          Then you feel pulmonic and aortic

o   Ascultation of the heart
        Movement from mitral area or apex, then tricuspid, then
           pulmonic, then aortic
        Different areas where you move steth from one to another esp
           where you hear murmurs

o   Palpation of liver
         Hepatomegaly - liver enlarged
                Chronic passive congestion of liver
         Combined r and l heart failure
                Chronic rheumatic heart disease……mitral defect
         Pathojugular reflux should be done
                Palpate liver area as you observe jugular vein distend
                         Positive hepato jugular reflex
         Abdomen -examined thoroughl
                Palpate for any pulsation
                Dilation
         Kidney palpation
                Polyp --2ndry form of hypertension
                Ascultate for presence of brui --signifies stenosis ---
                    renal artery stenoic --common form of congenital heart
                    disease
         Abdominal aortic --brui also
                Pts with diabetes


o   Hand examinations
        Extremities also sites of physical exam findings that could
          indicate cardiac disorder
        Clubbing of finger you can see
                  Example shown -- picture --to detect clubbing, oppose
                   two thumbs --if you see a hole --pts with clubbing, if
                   there's no hole, then there is clubbing
                        Cyanosis can also accompany and some linear
                           hemorrhages
          Evidence of edema, leg heaviness and pain --venous
           insufficiency
          Pallor --smokers prone to ulcers --suggests vascular
           insufficiency


o   Edema
        Sign of heart failure
        Look for indentation --pitting edema
             Press against the bone --should be bony part to apply
                 pressure; not on the muscle but on top of bone to be
                 able to see indentation
        Not all edema due to heart failure
             Jugular venous engorgement --pt ortopnic --edema --
                 then heart failure
        But edema with pitting but no heart failure
             Venous insufficiency
             Edema pitting --concern
        Non pitting edema of malnutrition --non pitting in character
             Edema of renal and liver diseases also


o   Complete cardiac exam has been done

								
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