Resonant

`

Medium-loud amplitude

Low pitch

Clear, hollow quality

Moderate duration

Over normal lung tissue: sample location

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Hyperresonant

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Louder amplitude

Lower pitch

Booming quality

Longer duration

sample location:  Normal over child's lung

Abnormal in the adult, over lungs with increased amount of air, as in emphysema

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Tympany

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Loud amplitude

High pitch

Musical and drumlike (like the kettle drum) quality

Sustained longest duration

sample location:  Over air-filled viscus (e.g., the stomach, the intestine)

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Dull

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Soft amplitude

High pitch

Muffled thud quality

Short duration

sample location:  Relatively dense organ, as liver or spleen

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Flat

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Very soft amplitude

High pitch

A dead stop of sound, absolute dullness quality

Very short duration

sample location:  When no air is present, over thigh muscles, bone, or over tumor

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Age

The person appears his or her stated age.

`

Appears older than stated age, as with chronic illness, chronic alcoholism.

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Sex

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Sexual development is appropriate for gender and age.

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Delayed or precocious puberty.

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Level of consciousness

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The person is alert and oriented, attends to your questions and responds appropriately.

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Confused, drowsy, lethargic

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Skin color

Color tone is even, pigmentation varying with genetic background, skin is intact with no obvious lesions.

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Pallor, cyanosis, jaundice, erythema, any lesions

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Facial features

—

`

Immobile, masklike, asymmetric, drooping

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No signs of acute distress are present.

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Cardiac or respiratory signs— diaphoresis, clutching the chest, shortness of breath, wheezing.

Pain, indicated by facial grimace, holding body part.

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Stature—

`

Excessively short or tall

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Nutrition

—

`

Cachectic, emaciated.

Simple obesity, with even fat distribution.

Centripetal (truncal) obesity—fat concentrated in face, neck, trunk, with thin extremities, as in Cushing syndrome (hyperadrenalism)

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Symmetry

—

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Unilateral atrophy or hypertrophy.

Asymmetric location of a body part.

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Posture—

`

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).

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Position

`

Tripod—leaning forward with arms braced on chair arms; occurs with chronic pulmonary disease.

Sitting straight up and resists lying down (e.g., congestive heart failure).

Curled up in fetal position (e.g., acute abdominal pain).

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Body build, contour

1 Arm span (fingertip to fingertip) equals height.

2 Body length from crown to pubis roughly equal to length from pubis to sole.

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Elongated arm span, arm span greater than height (e.g., Marfan's syndrome hypogonadism)

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Mobility

Gait

`

Exceptionally wide base. Staggered, stumbling.

Shuffling, dragging, nonfunctional leg.

Limping with injury.

Propulsion—difficulty stopping

`>

Range of motion

Chapter 22

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Limited joint range of motion.

Paralysis—absent movement.

Movement jerky, uncoordinated.

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No involuntary movement.

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Tics, tremors, seizures

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Behavior

Facial expression

The person maintains eye contact (unless a cultural taboo exists), 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.)

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Flat, depressed, angry, sad, anxious. However, note that anxiety is common in ill people. Also, some people smile when they are anxious.

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Mood and affect

The person is comfortable and cooperative with the examiner and interacts pleasantly.

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Hostile, distrustful, suspicious, crying.

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Speech

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Dysarthria and dysphagia (see Table 5-4, Speech Disorders, p. 84). Speech defect, monotone, garbled speech.

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The stream of talking is fluent, with an even pace.

The person conveys ideas clearly.

Word choice is appropriate to culture and education.

The person communicates in prevailing language easily by himself or herself or with an interpreter.

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Extremes of few words or of constant talking.

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Dress

`

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.

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Personal hygiene

`

Hair is groomed, brushed. Women's makeup is appropriate for age and culture.

In a previously carefully groomed woman, unkempt hair and absent makeup may indicate malaise or illness.

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MEASUREMENT

Weight

Use a standardized balance or electronic standing scale (Fig. 9-1). 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.

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).

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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.

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Body Mass Index

Body mass index (BMI) is a practical marker of optimal healthy weight for height and an indicator of obesity or malnutrition. Evidence supports using BMI in obesity risk assessment because it provides a more accurate measure of total body fat compared with the measure of body weight alone.

²⁶

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Weight gain usually is due to excess caloric intake; occasionally it is due to endocrine disorders, drug therapy (e.g., corticosteroids), or depression. BMI classifications for adults²⁶:

Underweight <18.5 kg/m²

Normal weight 18.5-24.9 kg/m²

Overweight 25-29.9 kg/m²

Obesity (Class 1) 30-34.9 kg/m²

Obesity (Class 2) 35-39.9 kg/m²

Extreme obesity (Class 3) ≥40

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A healthy BMI is a level of 19 or greater to less than 25. Show the person how his or her own weight matches up to the national guidelines for optimal BMI (Table 9-1). Compare the person's current weight with that from the previous health visit. A recent weight loss may be explained by successful dieting. A weight gain usually reflects overabundant caloric intake, unhealthy eating habits, and sedentary lifestyle. Note that BMI overestimates body fat in persons who are very muscular, and it underestimates body fat in older adults who have lost muscle mas

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Waist Circumference

Excess abdominal fat is an important independent risk factor for disease, over and above that of BMI.²⁶ With the person standing, locate the hip bone and the top of its right iliac crest. Place a measuring tape around the waist, parallel to the floor, at the level of the iliac crest. The tape should be snug but not pinch in the skin. Note the measurement at the end of a normal expiration

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A weight 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 persons with a BMI between 25 and 35 kg/m².

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VITAL SIGNS

Temperature

Cellular metabolism requires a stable core, or “deep body,” temperature of a mean of 37.2° C (99° F). The body maintains a steady temperature through a thermostat, or feedback mechanism, regulated in the hypothalamus of the brain. The thermostat balances heat production (from metabolism, exercise, food digestion, external factors) with heat loss (through radiation, evaporation of sweat, convection, conduction).

`

The various routes of temperature measurement reflect the body's core temperature. 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 thermostatic function of the hypothalamus may become scrambled during illness or central nervous system disorders.

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The normal temperature is influenced by:

_ A diurnal cycle of 1° to 1.5° F, with the trough occurring in the early morning hours and the peak occurring in late afternoon to early evening.

_ The menstruation cycle in women. Progesterone secretion, occurring with ovulation at midcycle, causes a 0.5° to 1.0° F rise in temperature that continues until menses.

_ Exercise. Moderate to hard exercise increases body temperature.

_ Age. Wider normal variations occur in the infant and young child due to less effective heat control mechanisms. In older adults, temperature is usually lower than in other age-groups, with a mean of 36.2° C (97.2° F).

`

The oral temperature is accurate and convenient. The oral sublingual site has a rich blood supply from the carotid arteries that quickly responds to changes in inner core temperature.

Due to environmental concerns of mercury pollution from medical waste incinerators, mercury-containing oral thermometers and sphygmomanometers have been replaced with electronic equipment. Shake a mercury-free 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.

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Hyperthermia,

Hypothermia

`

Now palpate the brachial or the radial artery (Fig. 9-7). Inflate the cuff until the artery pulsation is obliterated and then 20 to 30 mm Hg beyond. This will avoid missing an auscultatory gap, which is a period when Korotkoff sounds disappear during auscultation (Table 9-3).

`

An auscultatory gap occurs in about 5% of people, most often in hypertension caused by a noncompliant arterial system.

`

For all age-groups, the fifth Korotkoff phase is now used to define diastolic pressure.⁴ 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 blood pressure measurement.

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Hypotension,

hypertension,

`

Orthostatic hypotension,

`

When BP measured at the arm is excessively high, particularly in adolescents and young adults, compare it with the thigh pressure to check for coarctation of the aorta (a congenital form of narrowing). Normally, the thigh pressure is higher than that in the arm. If possible, turn the person to the prone position on the abdomen. (If the person must remain in the supine position, bend the knee slightly.) Wrap a large cuff, 18 to 20 cm, around the lower third of the thigh, centered over the popliteal artery on the back of the knee. Auscultate the popliteal artery for the reading (Fig. 9-9). Normally, the systolic value is 10 to 40 mm Hg higher in the thigh than in the arm, and the diastolic pressure is the same.

`

With coarctation of the aorta, arm pressures are high. Thigh pressure is lower because the blood supply to the thigh is below the constriction.

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Korotkoff Sounds

Cuff correctly inflated

No sound

Cuff inflation compresses brachial artery. Cuff pressure exceeds heart's systolic pressure, occluding brachial artery blood flow.

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Korotkoff Sounds

phase I

quality: Tapping

description: Soft, clear tapping, increasing in intensity

rationale:  The systolic pressure. As the cuff pressure lowers to reach intraluminal systolic pressure, the artery opens and blood first spurts into the brachial artery. Blood is at very high velocity because of small opening of artery and large pressure difference across opening. This creates turbulent flow, which is audible.

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Korotkoff Sounds

auscultatory gap

quality: No sound

description:  Silence for 30-40 mm Hg during deflation, an abnormal finding

rationale:  Sounds temporarily disappear during end of phase I and then reappear in phase II. Common with hypertension. If undetected, results in falsely low systolic or falsely high diastolic reading.

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korotkoff sounds

phase II

quality: Swooshing

description: Softer murmur follows tapping

rationale: Turbulent blood flow through still partially occluded artery.

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korotkoff sounds

phase III

quality:  Knocking

description: Crisp, high-pitched sounds

rationale:  Longer duration of blood flow through artery. Artery closes just briefly during late diastole.

korotkoff sounds

phase IV

quality: Abrupt muffling

description: Sound mutes to a low-pitched, cushioned murmur; blowing quality

rationale: Artery no longer closes in any part of cardiac cycle. Change in quality, not intensity.

korotkoff sounds

phase V

quality: Silence

rationale: Decreased velocity of blood flow. Streamlined blood flow is silent. The last audible sound (marking the disappearance of sounds) is diastolic pressure. The fifth Korotkoff sound is now used to define diastolic pressure in all age-groups.

⁴

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Physical appearance

measuring weight and height, p. 130

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Posture

Gait

`

Weight.

The aging person appears sharper in contour with more prominent bony landmarks than the younger adult. Body weight decreases during the 80s and 90s. This factor is more evident in males, perhaps because of greater muscle shrinkage. The distribution of fat also changes during the 80s and 90s. Even with good nutrition, subcutaneous fat is lost from the face and periphery (especially the forearms), whereas additional fat is deposited on the abdomen and hips (Fig. 9-18).

(`

This change in fat distribution and loss in muscle mass can affect the BMI interpretation in older adults. For any given BMI, an older adult has more fat tissue than lean tissue when compared with a younger adult. As an aging person becomes shorter (see below), the BMI reflecting the shorter height may overestimate the body fat content. However, these factors do not affect the validity of BMI classification in order to monitor the person's weight status.

²⁶

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Height.

By their 80s and 90s, many people are shorter than they were in their 70s. This results from shortening in the spinal column from thinning of the vertebral disks and shortening of the individual vertebrae and from the postural changes of kyphosis and slight flexion in the knees and hips. Because long bones do not shorten with age, the overall body proportion looks different—a shorter trunk with relatively long extremities (see Fig. 9-18).

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Temperature.

Changes in the body's temperature regulatory mechanism leave the aging person less likely to have fever but at a greater risk for hypothermia. Thus the temperature is a less reliable index of the older person's true health state. Sweat gland activity is also diminished.

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Pulse.

The normal range of heart rate is 50 to 90 bpm, but the rhythm may be slightly irregular. The radial artery may feel stiff, rigid, and tortuous in an older person, although this condition does not necessarily imply vascular disease in the heart or brain. The increasingly rigid arterial wall needs a faster upstroke of blood, so the pulse is actually easier to palpate.

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Respirations.

Aging causes a decrease in vital capacity and a decreased inspiratory reserve volume. You may note a shallower inspiratory phase and an increased respiratory rate.

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Blood Pressure.

The aorta and major arteries tend to harden with age. As the heart pumps against a stiffer aorta, the systolic pressure increases, leading to a widened pulse pressure. With many older people, both the systolic and diastolic pressures increase, making it difficult to distinguish normal aging values from abnormal hypertension.

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ADDITIONAL TECHNIQUES

Measurement of Oxygen Saturation

`

The pulse oximeter is a noninvasive method to assess arterial oxygen saturation (Spo₂). A sensor attached to the person's finger or earlobe has a diode that emits light and a detector that measures the relative amount of light absorbed by oxyhemoglobin (Hbo₂) and unoxygenated (reduced) hemoglobin (Hb). The pulse oximeter compares the ratio of light emitted with light absorbed and converts this ratio into the percentage of oxygen saturation. Because it only measures light absorption of pulsatile flow, the result is arterial oxygen saturation. A healthy person with no lung disease and no anemia normally has an Spo₂ of 97% to 98%.

Select the appropriate pulse oximeter probe. The finger probe is spring loaded and feels like a clothespin attached to the finger but does not hurt (Fig. 9-19). At lower oxygen saturations, the earlobe probe is more accurate and is less affected by peripheral vasoconstriction.

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The Doppler Technique

`

In many situations, pulse and BP measurement are enhanced by using an electronic device, the Doppler ultrasonic flowmeter. The Doppler technique works by a principle discovered in the nineteenth century by an Austrian physicist, Johannes Doppler. Sound varies in pitch in relation to the distance between the sound source and the listener; the pitch is higher when the distance is small, and the pitch lowers as the distance increases. Think of a railroad train speeding toward you; its train whistle sounds higher the closer it gets, and the pitch of the whistle lowers as the train fades away.

In this case, the sound source is the blood pumping through the artery in a rhythmic manner. A handheld transducer picks up changes in sound frequency as the blood flows and ebbs, and it amplifies them. The listener hears a whooshing pulsatile beat.

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The Doppler Technique

`

The Doppler technique is used to locate the peripheral pulse sites (see Chapter 20 for further discussion of this technique). For BP measurement, the Doppler technique will augment Korotkoff sounds (Fig. 9-21). Through this technique, you can evaluate sounds that are hard to hear with a stethoscope, such as those in critically ill individuals with a low BP, in infants with small arms, and in obese persons in whom the sounds are muffled by layers of fat. Also, proper cuff placement is difficult on the obese person's cone-shaped upper arm. In this situation, you can place the cuff on the more even forearm and hold the Doppler probe over the radial artery. For either location, use the following procedure:

`

The Doppler Technique

`

_ Apply coupling gel to the transducer probe.

_ Turn Doppler flowmeter on.

_ Touch the probe to the skin, holding the probe perpendicular to the artery.

_ A pulsatile whooshing sound indicates location of the artery. You may need to rotate the probe, but maintain contact with the skin. Do not push the probe too hard or you will wipe out the pulse.

_ Inflate the cuff until the sounds disappear; then proceed another 20 to 30 mm Hg beyond that point.

_ Slowly deflate the cuff, noting the point at which the first whooshing sounds appear. This is the systolic pressure.

_ It is difficult to hear the muffling of sounds or a reliable disappearance of sounds indicating the diastolic pressure (phases IV and V of Korotkoff sounds). However, the systolic pressure alone gives valuable data on the level of tissue perfusion and on blood flow through patent vessels.

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