Physical Assessment as a Screening Tool

Chapter 4


Physical Assessment as a Screening Tool


In the medical model, clients are often assessed from head to toe. The doctor, physician assistant, nurse, or nurse practitioner starts with inspection, followed by percussion and palpation, and finally by auscultation.


In a screening assessment, the therapist may not need to perform a complete head-to-toe physical assessment. If the initial observations, client history, screening questions, and screening tests are negative, move on to the next step. A thorough examination may not be necessary.


In most situations, it is advised to assess one system above and below the area of complaint based on evidence supporting a regional-interdependence model of musculoskeletal impairments (i.e., symptoms present may be caused by musculoskeletal impairments proximal or distal to the site of presenting symptoms distinct from the phenomenon of referred pain).1


When screening for systemic origins of clinical signs and symptoms, the therapist first scans the area(s) that directly relate to the client’s history and clinical presentation. For example, a shoulder problem can be caused by a problem in the stomach, heart, liver/biliary, lungs, spleen, kidneys, and ovaries (ectopic pregnancy). Only the physical assessment tests related to these areas would be assessed. These often can be narrowed down by the client’s history, gender, age, presence of risk factors, and associated signs and symptoms linked to a specific system.


More specifically, consider the postmenopausal woman with a primary family history of heart disease who presents with shoulder pain that occurs 3 to 4 minutes after starting an activity and is accompanied by unexplained perspiration. This individual should be assessed for cardiac involvement. Or think about the 45-year-old mother of five children who presents with scapular pain that is worse after she eats. A cardiac assessment may not be as important as a scan for signs and symptoms associated with the gallbladder or biliary system.


Documentation of physical findings is important. From a legal standpoint, if you did not document it, you did not assess it. Look for changes from the expected norm, as well as changes for the client’s baseline measurements. Use simple and clear documentation that can be understood and used by others. As much as possible, record both normal and abnormal findings for each client.2 Keep in mind that the client’s cultural and educational background, beliefs, values, and previous experiences can influence his or her response to questions.


Finally, screening and ongoing physical assessment is often a part of an exercise evaluation, especially for the client with one or more serious health concerns. Listening to the heart and lung sounds before initiating an exercise program may bring to light any contraindications to exercise. A compromised cardiopulmonary system may make it impossible and even dangerous for the client to sustain prescribed exercise levels.


The use of quick and easy screening tools such as the Physical Therapist Community Screening Form for Aging Adults can help therapists identify limitations to optimal heath, wellness, and fitness in any of seven areas (e.g., posture, flexibility, strength, balance, cardiovascular fitness) for adults aged 65 and older. With the 2007 House of Delegates position statement recommending that all individuals visit a physical therapist at least once a year to promote optimal health and wellness, evidence-based tests of this type will become increasingly available.3



General Survey


Physical assessment begins the moment you meet the client as you observe body size and type, facial expressions, evaluate self-care, and note anything unusual in appearance or presentation. Keep in mind (as discussed in Chapter 2) that cultural factors may dictate how the client presents himself (e.g., avoiding eye contact when answering questions, hiding or exaggerating signs of pain).


A few pieces of equipment in a small kit within easy reach can make the screening exam faster and easier (Box 4-1). Using the same pattern in screening each time will help the therapist avoid missing important screening clues.



Box 4-1   Contents of a Screening Examination Kit




As the therapist makes a general survey of each client, it is also possible to evaluate posture, movement patterns and gait, balance, and coordination. For more involved clients the first impression may be based on level of consciousness, respiratory and vascular function, or nutritional status.


In an acute care or trauma setting the therapist may be using vital signs and the ABCDE (airway, breathing, circulation, disability, exposure) method of quick assessment. A common strategy for history taking in the trauma unit is the mnemonic AMPLE: Allergies, Medications, Past medical history, Last meal, and Events of injury.


In any setting, knowing the client’s personal health history will also help guide and direct which components of the physical examination to include. We are not just screening for medical disease masquerading as neuromusculoskeletal (NMS) problems. Many physical illnesses, diseases, and medical conditions directly impact the NMS system and must be taken into account. For example inspection of the integument, limb inspection, and screening of the peripheral vascular system is important for someone at risk for lymphedema.


Neurologic function, balance, reflexes, and peripheral circulation become important when screening a client with diabetes mellitus. Peripheral neuropathy is common in this population group, often making walking more difficult and increasing risk of other problems developing.


Therapists in all settings, especially primary care therapists, can use a screening physical assessment to provide education toward primary prevention, as well as intervention and management of current dysfunctions and disabilities.



Mental Status


Level of consciousness, orientation, and ability to communicate are all part of the assessment of a client’s mental status. Orientation refers to the client’s ability to answer correctly questions about time, place, and person. A healthy individual with normal mental status will be alert, speak coherently, and be aware of the date, day, and time of day.


The therapist must be aware of any factor that can affect a client’s current mental status. Shock, head injury, stroke, hospitalization, surgery (use of anesthesia), medications, age, and the use of substances and/or alcohol (see discussion, Chapter 2) can cause impaired consciousness.


Other factors affecting mental status may include malnutrition, exposure to chemicals, and hypothermia or hyperthermia. Depression and anxiety (see discussion, Chapter 3) also can affect a client’s functioning, mood, memory, ability to concentrate, judgment, and thought processes. Educational and socioeconomic background along with communication skills (e.g., English as a second language, aphasia) can affect mental status and function.


In a hospital, transition unit, or extended care facility, mental status is often evaluated and documented by the social worker or nursing service. It is always a good idea to review the client’s chart or electronic record regarding this information before beginning a physical therapy evaluation.



Risk Factors for Delirium


It is not uncommon for older adults to experience a change in mental status or go through a stage of confusion about 24 hours after hospitalization for a serious illness or trauma, including surgery under a general anesthetic. Physicians may refer to this as iatrogenic delirium, anesthesia-induced dementia, or postoperative delirium. It is usually temporary but can last several hours to several weeks.


The cause of deterioration in mental ability is unknown. In some cases, delirium/dementia appears to be triggered by the shock to the body from anesthesia and surgery.4 It may be a passing phase with complete recovery by the client, although this can take weeks to months. The likelihood of delirium associated with hospitalization is much higher with hip fractures and hip and knee joint replacements,5,6 possibly attributed to older age, slower metabolism, and polypharmacy (more than four prescribed drugs at admission).7


The therapist should pay attention to risk factors (Box 4-2) and watch out for any of the signs or symptoms of delirium. Physical exam should include vital signs with oxygen concentration measured, neurologic screening exam, and surveillance for signs of infection. A medical diagnosis is needed to make the distinction between postoperative delirium, baseline dementia, depression, and withdrawal from drugs and alcohol.5



Clinical Signs and Symptoms


Iatrogenic Delirium



Cognitive Impairment



Box 4-2


Risk Factors for Iatrogenic or Postoperative Delirium




• Stress, trauma, pain, infection


• Hospitalization (for hip fracture, serious illness or trauma including surgery) or change in residence


• Older age (65 years old or older)


• Anesthesia


• Hip or knee joint replacement


• Poor cognitive function, underlying dementia, previous cognitive impairment


• Vision or hearing deficits


• Decreased physical function


• History of alcohol abuse


• Medications (e.g., benzodiazepine, narcotics, NSAIDs, anticholinergics prescribed for sleep, psychoactive drugs/antidepressants/antipsychotics, dopamine agents, analgesics, sedative agents for pain and anxiety after surgery)*


• Dehydration


• Urinary retention, fecal impaction, diarrhea


• Sleep deprivation


• Postoperative low hemoglobin, abnormal fluid and/or electrolytes, low oxygen saturation


• Malnutrition, vitamin B12/folate deficiency, low albumin


NSAIDs, Nonsteroidal antiinflammatory drugs.


*Higher risk medications commonly associated with delirium; lower risk medications associated with delirium include some cardiovascular agents (e.g., antiarrhythmics, beta blockers, clonidine, digoxin), antimicrobials (e.g., fluoroquinolones, penicillins, sulfonamides, acyclovir), anticonvulsants, and medications for gastroesophageal reflux or nausea.


Data from Alfonso DT: Nonsurgical complications after total hip and total knee arthroplasty, Am J Orthop 35(11):503-510, 2006; Short M, Winstead PS: Delirium dilemma: pharmacology update, Orthopedics 30(4):273-277, 2007.






Several scales are used to assess level of consciousness, performance, and disability. The Confusion Assessment Method (CAM) is a bedside rating scale physical therapists can use to assess hospitalized or institutionalized individuals for delirium. This tool has been adapted for use with patients who are ventilated and in an intensive care unit (CAM-ICU).8


There are two parts to the assessment instrument: part one screens for overall cognitive impairment. Part two includes four features that have the greatest ability to distinguish delirium or reversible confusion from other types of cognitive impairment. The tool identifies the presence of delirium but does not assess the severity of the condition.9


As a screening tool, the CAM has been validated for use by physicians and nurses in palliative care and intensive care settings (sensitivity of 94% to 100% and specificity of 90% to 95%). Values for positive predictive accuracy were 91% to 94%, and values for negative predictive accuracy were 100% and 90% for the two populations assessed (general medicine, outpatient geriatric center).9


The Glasgow Outcome Scale10,11 describes patients/clients on a 5-point scale from good recovery (1) to death (5). Vegetative state, severe disability, and moderate disability are included in the continuum. This and other scales and clinical assessment tools are not part of the screening assessment but are available online for use by health care professionals.12


The Karnofsky Performance Scale (KPS) in Table 4-1 is used widely to quantify functional status in a wide variety of individuals, but especially among those with cancer. It can be used to compare effectiveness of intervention and to assess individual prognosis. The lower the Karnofsky score, the worse the prognosis for survival.



The most practical performance scale for use in any rehabilitation setting for most clients is the Eastern Cooperative Oncology Group (ECOG) Performance Status Scale (Table 4-2). Researchers and health care professionals use these scales and criteria to assess how an individual’s disease is progressing, to assess how the disease affects the daily living abilities of the client, and to determine appropriate treatment and prognosis.



Any observed change in level of consciousness, orientation, judgment, communication or speech pattern, or memory should be documented regardless of which scale is used. The therapist may be the first to notice increased lethargy, slowed motor responses, or disorientation or confusion.


Confusion is not a normal change with aging and must be reported and documented. Confusion is often associated with various systemic conditions (Table 4-3). Increased confusion in a client with any form of dementia can be a symptom of infection (e.g., pneumonia, urinary tract infection), electrolyte imbalance, or delirium. Likewise, a sudden change in muscle tone (usually increased tone) in the client with a neurologic disorder (adult or child) can signal an infectious process.




Nutritional Status


Nutrition is an important part of growth and development and recovery from infection, illness, wounds, and surgery. Clients can exhibit signs of malnutrition or overnutrition (obesity).



Clinical Signs and Symptoms


Undernutrition or Malnutrition




Be aware in the health history of any risk factors for nutritional deficiencies (Box 4-3). Remember that some medications can cause appetite changes and that psychosocial factors such as depression, eating disorders, drug or alcohol addictions, and economic variables can affect nutritional status.



Box 4-3   Risk Factors for Nutritional Deficiency




• Economic status


• Living alone


• Older age (metabolic rate slows in older adults; altered sense of taste and smell affects appetite)


• Depression, anxiety


• Eating disorders


• Lactose intolerance (common in Mexican Americans, African Americans, Asians, Native Americans)


• Alcohol/drug addiction


• Chronic diarrhea


• Nausea


• Gastrointestinal impairment (e.g., bowel resection, gastric bypass, pancreatitis, Crohn’s disease, pernicious anemia)


• Chronic endocrine or metabolic disorders (e.g., diabetes mellitus, celiac sprue)


• Liver disease


• Dialysis


• Medications (e.g., captopril, chemotherapy, steroids, insulin, lithium) including over-the-counter drugs (e.g., laxatives)


• Chronic disability affecting activities of daily living (ADLs; e.g., problems with balance, mobility, food preparation)


• Burns


• Difficulty chewing or swallowing (dental problems, stroke or other neurologic impairment)


It may be necessary to determine the client’s ideal body weight by calculating the body mass index (BMI).13,14 Several websites are available to help anyone make this calculation. There is a separate website for children and teens sponsored by the National Center for Chronic Disease Prevention and Health Promotion.15


Whenever nutritional deficiencies are suspected, notify the physician and/or request a referral to a registered dietitian.



Body and Breath Odors


Odors may provide some significant clues to overall health status. For example, a fruity (sweet) breath odor (detectable by some but not all health care professionals) may be a symptom of diabetic ketoacidosis. Bad breath (halitosis) can be a symptom of dental decay, lung abscess, throat or sinus infection, or gastrointestinal (GI) disturbances from food intolerances, Helicobacter pylori bacteria, or bowel obstruction. Keep in mind that ethnic foods and alcohol can affect breath and body odor.


Clients who are incontinent (bowel or bladder) may smell of urine, ammonia, or feces. It is important to ask the client about any unusual odors. It may be best to offer an introductory explanation with some follow-up questions:



image Follow-Up Questions


Mrs. Smith, as part of a physical therapy exam, we always look at our client’s overall health and general physical condition. Do you have any other health concerns besides your shoulder/back (Therapist: name the involved body part)?


Are you being treated by anyone for any other problems? (Wait for a response but add prompts as needed: chiropractor? acupuncturist? naturopath?)


[If you suspect urinary incontinence]: Are you having any trouble with leaking urine or making it to the bathroom on time? (Ask appropriate follow-up questions about cause, frequency, severity, triggers, and so on; see Appendix B-5).


[If you suspect fecal incontinence]: Do you have trouble getting to the toilet on time for a bowel movement?


Do you have trouble wiping yourself clean after a bowel movement? (Ask appropriate follow-up questions about cause, frequency, severity, triggers, and so on).


[If you detect breath odor]: I notice an unusual smell on your breath. Do you know what might be causing this? (Ask appropriate follow-up questions depending on the type of smell you perceive; you may have to conduct an alcohol screening survey [see Chapter 2 or Appendices B-1 and B-2].)



Vital Signs


The need for therapists to assess vital signs, especially pulse and blood pressure is increasing.16 Without the benefit of laboratory values, physical assessment becomes much more important. Vital signs, observations, and reported associated signs and symptoms are among the best screening tools available to the therapist.


Vital sign assessment is an important tool because high blood pressure is a serious concern in the United States. Many people are unaware they have high blood pressure. Often primary orthopedic clients have secondary cardiovascular disease.17


Physical therapists practicing in a primary care setting will especially need to know when and how to assess vital signs. The Guide to Physical Therapist Practice18 recommends that heart rate (pulse) and blood pressure measurements be included in the examination of new clients. Exercise professionals are strongly encouraged to measure blood pressure during each visit.19


Taking a client’s vital signs remains the single easiest, most economic, and fastest way to screen for many systemic illnesses. All the vital signs are important (Box 4-4); temperature and blood pressure have the greatest utility as early screening tools for systemic illness or disease, while pulse, blood pressure, and oxygen (O2) saturation level offer valuable information about the cardiovascular/pulmonary systems.



Box 4-4   Vital Signs




*One thermistor, the PhysioQ, is a handheld device used to measure skin temperature (fingertips, hand). Similar tools are available as part of some biofeedback equipment. Using skin temperature is an excellent tool for teaching clients how to modulate the autonomic nervous system, a technique called physiologic quieting. This tool is commercially available with a guided relaxation tape [www.phoenixpub.com; 1-800-549-8371]. It can be a useful intervention with clients who have chronic fatigue syndrome, fibromyalgia, Raynaud’s phenomenon or disease, sleep disturbance, and peripheral vascular disease. Results can be measured using all the vital signs, but especially by measuring and recording changes in skin temperature.


As an aside comment: using vital signs is an easy, yet effective way to document outcomes. In today’s evidence-based practice, the therapist can use something as simple as pulse or blood pressure to document changes that occur with intervention.


For example, if ambulating with a client morning and afternoon results in no change in ease of ambulation, speed, or distance, consider taking blood pressure, pulse, and O2 saturation levels before and after each session. Improvement in O2 saturation levels or faster return to normal of heart rate after exercise are just two examples of how vital signs can become an important part of outcomes documentation.


Assessment of baseline vital signs should be a part of the initial data collected so that correlations and comparisons with future values are available when necessary. The therapist compares measurements taken against normal values and also compares future measurements to the baseline units to identify significant changes (normalizing values or moving toward abnormal findings) for each client.


Normal ranges of values for the vital signs are provided for the therapist’s convenience. However, these ranges can be exceeded by a client and still represent normal for that person. Keep in mind that many factors can affect vital signs, especially pulse and blood pressure (Table 4-4). Substances such as alcohol, caffeine, nicotine, and cocaine/cocaine derivatives as well as pain and stress/anxiety can cause fluctuations in blood pressure. Adults who monitor their own blood pressure may report wide fluctuations without making the association between these and other factors listed. It is the unusual vital sign in combination with other signs and symptoms, medications, and medical status that gives clinical meaning to the pulse rate, blood pressure, and temperature.



TABLE 4-4


Factors Affecting Pulse and Blood Pressure


image


SBP, Systolic blood pressure; ACE, angiotensin-converting enzyme.


*Conditions, such as chronic kidney disease, renovascular disorders, primary aldosteronism, and coarctation of the aorta, are identifiable causes of elevated blood pressure. Chronic overtraining in athletes, use of steroids and/or nonsteroidal antiinflammatory drugs (NSAIDs), and large increases in muscle mass can also contribute to hypertension.38 Treatment for hypertension, dehydration, heart failure, heart attack, arrhythmias, anaphylaxis, shock (from severe infection, stroke, anaphylaxis, major trauma), and advanced diabetes can cause low blood pressure.


From Goodman CC, Fuller K: Pathology: implications for the physical therapist, ed 3, Philadelphia, 2009, WB Saunders.



Pulse Rate


The pulse reveals important information about the client’s heart rate and heart rhythm. A resting pulse rate (normal range: 60 to 100 beats per minute [bpm]) taken at the carotid artery or radial artery (preferred sites) pulse point should be available for comparison with the pulse rate taken during treatment or after exercise. A pulse rate above 100 bpm indicates tachycardia; below 60 bpm indicates bradycardia.


Do not rely on pulse oximeter devices for pulse rate because these units often take a sample pulse rate that reflects a mean average and may not reveal dysrhythmias (e.g., a regular irregular pulse rate associated with atrial fibrillation). It is recommended that the pulse always be checked in two places in older adults and in anyone with diabetes (Fig. 4-1). Pulse strength (amplitude) can be graded as




















0 Absent, not palpable
1+ Pulse diminished, barely palpable
2+ Easily palpable, normal
3+ Full pulse, increased strength
4+ Bounding, too strong to obliterate

Keep in mind that taking the pulse measures the peripheral arterial wave propagation generated by the heart’s contraction—it is not the same as measuring the true heart rate (and should not be recorded as heart rate when measured by palpation). A true measure of heart rate requires auscultation or electrocardiographic recording of the electrical impulses of the heart. The distinction between pulse rate and heart rate becomes a matter of concern in documentation liability and even greater importance for individuals with dysrhythmias. In such cases, the output of blood by some beats may be insufficient to produce a detectable pulse wave that would be discernible with an electrocardiogram.20


Pulse amplitude (weak or bounding quality of the pulse) gives an indication of the circulating blood volume and the strength of left ventricle ejection. Normally, the pulse increases slightly with inspiration and decreases with expiration. This slight change is not considered significant.


Pulse amplitude that fades with inspiration instead of strengthening and strengthens with expiration instead of fading is paradoxic and should be reported to the physician. Paradoxic pulse occurs most commonly in clients with chronic obstructive pulmonary disease (COPD) but is also observed in clients with constrictive pericarditis.21


Constriction or compression around the heart from pericardial effusion, tension pneumothorax, pericarditis with fluid, or pericardial tamponade may be associated with paradoxical pulse. When the person breathes in, the increased mechanical pressure of inspiration added to the physiologic compression from the underlying disease prevents the heart from contracting fully and results in a reduced pulse. When the person breathes out, the pressure from chest expansion is reduced and the pulse increases.


A pulse increase with activity of more than 20 bpm lasting for more than 3 minutes after rest or changing position should also be reported. Other pulse abnormalities are listed in Box 4-5.



Box 4-5   Pulse Abnormalities




The resting pulse may be higher than normal with fever, anemia, infections, some medications, hyperthyroidism, anxiety, or pain. A low pulse rate (below 60 bpm) is not uncommon among trained athletes. Medications, such as beta-blockers and calcium channel blockers, can also prevent the normal rise in pulse rate that usually occurs during exercise. In such cases the therapist must monitor rates of perceived exertion (RPE) instead of pulse rate.


When taking the resting pulse or pulse during exercise, some clinicians measure the pulse for 15 seconds and multiply by 4 to get the rate per minute. For a quick assessment, measure for 6 seconds and add a zero. A 6-second pulse count can result in an error of 10 bpm if a 1-beat error is made in counting. For screening purposes, it is always best to palpate the pulse for a full minute. Longer pulse counts give greater accuracy and provide more time for detection of some dysrhythmias (Box 4-6).19



Box 4-6   Tips on Palpating Pulses




• Assess each pulse for strength and equality for one full minute; pulse rate should NOT be taken for part of a minute and then multiplied by a factor (e.g., 15 seconds × 4, 30 seconds × 2, 6 seconds × 10).


• Expect to palpate 60 to 90 pulses per minute at all pulse sites. Begin the pulse count with zero, not “one.”


• Normal pulse is 2+ and equal bilaterally (see scale in text).


• Apply gentle pressure; pulses are easily obliterated in some people.


• Popliteal pulse requires deeper palpation.


• Normal veins are flat; pulsations are not visible.


• Flat veins in supine that become distended in sitting may indicate heart disease.


• Pulses should be the same from side to side and should not change significantly with inspiration, expiration, or change in position.


• Pulses tend to diminish with age; distal pulses are not palpable in many older adults.


• If pulses are diminished or absent, listen for a bruit to detect arterial narrowing.


• Pedal pulses can be congenitally absent; the client may or may not know if absent pulse at this pulse site is normal or a change in pulse pressure.


• In the case of diminished or absent pulses observe the client for other changes (e.g., skin temperature, texture, color, hair loss, change in toenails); ask about pain in calf or leg with walking that goes away with rest (intermittent claudication, peripheral vascular disease [PVD]).


• Carotid pulse: Assess in the seated position; have client turn the head slightly toward the side being palpated. Gently and carefully palpate along the medial edge of the sternocleidomastoid muscle (see Fig. 4-1). Palpate one carotid artery at a time; apply light pressure; deep palpation can stimulate carotid sinus with a sudden drop in heart rate and blood pressure. Do not poke or mash around to find the pulse; palpation must not provide a massage to the artery due to the risk of liberating a thrombus or plaque, especially in older adults.


• Femoral pulse: Femoral artery is palpable below the inguinal ligament midway between the anterior superior iliac spine (ASIS) and the symphysis pubis. It can be difficult to assess in the obese client; place fingertips of both hands on either side of the pulse site; femoral pulse should be as strong (if not stronger) than radial pulse.


• Posterior tibial pulse: Foot must be relaxed with ankle in slight plantar flexion (see Fig. 4-1).


Pulse assessment following vascular injuries (especially dislocation of the knee) should not be relied upon as the only diagnostic testing procedure as occult arterial injuries can be present even when pulses are normal. A meta-analysis of 284 dislocated knees concluded that abnormal pulse examinations have a sensitivity of .79 and specificity of .91 for detection of arterial injuries.22,23 On the other hand, there are reports of normal pulse examinations at the time of the initial knee injury in people who later developed ischemia leading to amputation.24,25



Respirations


Try to assess the client’s breathing without drawing attention to what is being done. This measure can be taken right after counting the pulse while still holding the client’s wrist.


Count respirations for 1 minute unless respirations are unlabored and regular, in which case the count can be taken for 30 seconds and multiplied by 2. The rise and fall of the chest equals 1 cycle.


The normal rate is between 12 and 20 breaths per minute. Observe rate, excursion, effort, and pattern. Note any use of accessory muscles and whether breathing is silent or noisy. Watch for puffed cheeks, pursed lips, nasal flaring, or asymmetric chest expansion. Changes in the rate, depth, effort, or pattern of a client’s respirations can be early signs of neurologic, pulmonary, or cardiovascular impairment.



Pulse Oximetry


O2 saturation on hemoglobin (SaO2) and pulse rate can be measured simultaneously using pulse oximetry. This is a noninvasive, photoelectric device with a sensor that can be attached to a well-perfused finger, the bridge of the nose, toe, forehead, or ear lobe. Digital readings are less accurate with clients who are anemic, undergoing chemotherapy, or who use fingernail polish or nail acrylics. In such cases, attach the sensor to one of the other accessible body parts.


The sensor probe emits red and infrared light, which is transmitted to the capillaries. When in contact with the skin, the probe measures transmitted light passing through the vascular bed and detects the relative amount of color absorbed by the arterial blood. The SaO2 level is calculated from this information.


The normal SaO2 range at rest and during exercise is 95% to 100%. Referral for medical evaluation is advised when resting saturation levels fall below 90%. The exception to the normal range listed here is for clients with a history of tobacco use and/or COPD. Some individuals with COPD tend to retain carbon dioxide and can become apneic if the oxygen levels are too high. For this reason, SaO2 levels are normally kept lower for this population.


The drive to breathe in a healthy person results from an increase in the arterial carbon dioxide level (PaCO2). In the normal adult, increased CO2 levels stimulate chemoreceptors in the brainstem to increase the respiratory rate. With some chronic lung disorders these central chemoreceptors may become desensitized to PaCO2 changes resulting in a dependence on the peripheral chemoreceptors to detect a fall in arterial oxygen levels (PaO2) to stimulate the respiratory drive.


Too much oxygen delivered as a treatment can depress the respiratory drive in those individuals with COPD who have a dampening of the CO2 drive. Monitoring respiratory rate, level of oxygen administered by nasal canula, and SaO2 levels is very important in this client population.


Some pulmonologists agree that supplemental oxygen levels can be increased during activity without compromising the individual because they will “blow it (carbon dioxide) off” anyway. To our knowledge, there is no evidence yet to support this clinical practice.


Any condition that restricts blood flow (including cold hands) can result in inaccurate SaO2 readings. Relaxation and physiologic quieting techniques can be used to help restore more normal temperatures in the distal extremities. A handheld device such as the PhysioQ26 can be used by the client to improve peripheral circulation. Do not apply a pulse oximetry sensor to an extremity with an automatic blood pressure cuff.27


SaO2 levels can be affected also by positioning because positioning can impact a person’s ability to breathe. Upright sitting in individuals with low muscle tone or kyphosis can cause forward flexion of the thoracic spine compromising oxygen intake. Tilting the person back slightly can open the trunk, ease ventilation, and improve SaO2 levels.28 Using SaO2 levels may be a good way to document outcomes of positioning programs for clients with impaired ventilation.


Other factors affecting pulse oximeter readings can include nail polish and nail coverings, irregular heart rhythms, hyperemia (increased blood flow to the area), motion artifact, pressure on the sensor, electrical interference, and venous congestion.20


In addition to SaO2 levels, assess other vital signs, skin and nail bed color and tissue perfusion, mental status, breath sounds, and respiratory pattern for all clients using pulse oximetry. If the client cannot talk easily whether at rest or while exercising, SaO2 levels are likely to be inadequate.



Blood Pressure


Blood pressure (BP) is the measurement of pressure in an artery at the peak of systole (contraction of the left ventricle) and during diastole (when the heart is at rest after closure of the aortic valve, which prevents blood from flowing back to the heart chambers). The measurement (in mm Hg) is listed as:


image


BP depends on many factors; the normal range differs slightly with age and varies greatly among individuals (see Table 4-4). Normal systolic BP (SBP) ranges from 100 to 120 mm Hg, and diastolic BP (DBP) ranges from 60 to 80 mm Hg. Highly trained athletes may have much lower values. Target ranges for BP are listed in Table 4-5 and Box 4-7.



Box 4-7   Guidelines for Blood Pressure in a Physical Therapist’s Practice


Consider the following as yellow (caution) flags that require closer monitoring and possible medical referral:



• SBP greater than 120 mm Hg and/or DBP greater than 80 mm Hg, especially in the presence of significant risk factors (age, medications, personal or family history)


• Decrease in DBP below 70 mm Hg in adults age 75 or older (risk factor for Alzheimer’s)


• Persistent rise or fall in BP over time (at least 3 consecutive readings over 2 weeks), especially in a client taking NSAIDs (check for edema) or any woman taking birth control pills (should be closely monitored by physician)


• Steady fall in BP over several years in adult over 75 (risk factor for Alzheimer’s)


• Lower standing SBP (less than 140 mm Hg) in adults over age 65 with a history of falls (increased risk for falls)


• A difference in pulse pressure greater than 40 mm Hg


• More than 10 mm Hg difference (SBP or DBP) from side to side (upper extremities)


• Approaching or more than 40 mm Hg difference (SBP or DBP) from side to side (lower extremities)


• BP in lower extremities is lower than in the upper extremities


• DBP increases more than 10 mm Hg during activity or exercise


• SBP does not rise as workload increases; SBP falls as workload increases


• SBP exceeds 200 mm Hg during exercise or physical activity; DBP exceeds 100 mm Hg during exercise or physical activity; these values represent the upper limits and may be too high for the client’s age, general health, and overall condition.


• BP changes in the presence of other warning signs such as first-time onset or unstable angina, dizziness, nausea, pallor, extreme diaphoresis


• Sudden fall in BP (more than 10 to 15 mm Hg SBP) or more than 10 mm Hg DBP with concomitant rise (10% to 20% increase) in pulse (orthostatic hypotension); watch for postural hypotension in hypertensive clients, especially anyone taking diuretics (decreased fluid volume/dehydration)


• Use a manual sphygmomanometer to measure BP during exercise; most standard automatic units are not designed for this purpose


BP, Blood pressure; SBP, systolic blood pressure; DBP, diastolic blood pressure; NSAIDs, nonsteroidal antiinflammatory drugs.




Assessing Blood Pressure: BP should be taken in the same arm and in the same position (supine or sitting) each time it is measured. The baseline BP values can be recorded on the Family/Personal History form (see Fig. 2-2).


Cuff size is important and requires the bladder width-to-length be at least 1 : 2. The cuff bladder should encircle at least 80% of the arm. BP measurements are overestimated with a cuff that is too small; if a cuff is too small, go to the next size up. Keep in mind that if the cuff is too large, falsely lower BPs may be recorded.29


Do not apply the blood pressure cuff above an intravenous (IV) line where fluids are infusing or an arteriovenous (AV) shunt, on the same side where breast or axillary surgery has been performed, or when the arm or hand have been traumatized or diseased. Until research data supports a change, it is recommended that clients who have undergone axillary node dissection (ALND) avoid having BP measurements taken on the affected side.


Although it is often recommended that anyone who has had bilateral axillary node dissection should have BP measurements taken in the leg, this is not standard clinical practice across the United States.30 Leg pressures can be difficult to assess and inaccurate.


Some oncology staff advise taking BP in the arm with the least amount of nodal dissection. Technique in measuring BP is a key factor in all clients, especially those with ALND (Box 4-8).



Box 4-8


Assessing Blood Pressure




• Client should avoid tobacco for 30 minutes and caffeine for 60 minutes before BP reading142; let the client sit quietly for a few minutes; this can help offset the physical exertion of moving to the exam room or the emotional stress of being with a health care professional (white-coat hypertension). The client should be seated comfortably in a chair with the back and arm supported, legs uncrossed, feet on the floor, and not talking.


• Assess for factors that can affect BP (see Table 4-4).


• Position the arm extended in a forward direction (sitting) at the heart’s level or parallel to the body (supine); avoid using an arm with a fistula, IV or arterial line, or with a previous history of lymph node biopsy or breast or axillary surgery.


• Wrap the cuff around the client’s upper arm (place over bare skin) 1 inch (2.5 cm) above the antecubital fossa (inside of the elbow); cuff size is critical to accurate measurement.


• The length of the bladder cuff should encircle at least 80% of the upper arm. The width of the cuff should be about 40% of the upper arm circumference. If a cuff is too short or too narrow, the BP reading will be erroneously high; if the cuff is too long or too wide, the BP reading will be erroneously low. BP measurement errors are usually worse in cuffs that are too small compared to those that are too big.


• If you are measuring BP at the ankle, an arm cuff is usually appropriate, but BPs taken at the thigh require a thigh cuff unless the person is very thin.


• Slide your finger under the cuff to make sure it is not too tight.


• Close the valve on the rubber bulb.


• Place the stethoscope (diaphragm or bell side) lightly over the brachial artery at the elbow (about 2 to 3 cm above the antecubital fossa)142; you may hear the low-pitched Korotkoff sounds more clearly using the bell.


• Inflate the cuff until you no longer hear a pulse sound and then inflate 30 mm more; this is the point of reference for auscultation.


• Slowly release the valve on the bulb (deflate at a rate of 2 to 3 mm Hg/second) as you listen for the first Korotkoff sound (2 consecutive beats signals the systolic reading) and the last Korotkoff sound (diastolic reading).


• If you are new to BP assessment or if the BP is elevated, check the BP twice. Wait 1 minute and retest. Some sources say to wait at least 2 minutes before retaking BP on the same arm, but this is not always done in the typical clinical setting.


• Record date, time of day, client position, extremity measured (arm or leg, left or right), and results for each reading. Record any factors that might affect BP readings (e.g., recent tobacco use, caffeine intake).


• As soon as the blood begins to flow through the artery again, Korotkoff sounds are heard. The first sounds are tapping sounds that gradually increase in intensity. The initial tapping sound that is heard for at least 2 consecutive beats is recorded as SBP.


• The first phase of sound may be followed by a momentary disappearance of sounds that can last from 30 to 40 mm Hg as the needle descends. Following this temporary absence of sound, there are murmuring or swishing sounds (second Korotkoff sound). As deflation of the cuff continues, the sounds become sharper and louder. These sounds represent phase 3. During phase 4, the sounds become muffled rather abruptly and then are followed by silence, which represents phase 5. Phase 5 (the fifth Korotkoff sound or K5), the point at which sounds disappear, is most often used as the DBP.


BP, Blood pressure; SBP, systolic blood pressure; DBP, diastolic blood pressure.


From American Heart Association Updates Recommendations for Blood Pressure Measurements, Available at: http://www.americanheart.org. Accessed Jan. 25, 2011.


A common mistake is to pump the BP cuff up until the systolic measurement is 200 mm Hg and then take too long to lower the pressure or to repeat the measurement a second time without waiting. Repeating the BP without a 1-minute wait time may damage the blood vessel and set up an inflammatory response.31 This poor technique is to be avoided, especially in clients at risk for lymphedema or who already have lymphedema.


Take the BP twice at least a minute apart in both arms. If both measurements are within 5 mm Hg of each other, record this as the resting (baseline) measurement. If not, wait 1 minute and take the BP a third time. Monitor the BP in the arm with the highest measurements.21 Record measurements exactly; do not round numbers up or down as this can result in inaccuracies.32


For clients who have had a mastectomy without ALND (i.e., prophylactic mastectomy), BP can be measured in either arm. These recommendations are to be followed for life.33


Until automated BP devices are improved enough to ensure valid and reliable measurements, the BP response to exercise in all clients should be taken manually with a BP cuff (sphygmomanometer) and a stethoscope.33


It is advised to invest in the purchase of a well-made, reliable stethoscope. Older models with tubing long enough to put the earpieces in your ears and still place the bell in a lab coat pocket should be replaced. Tubing should be no more than 50 to 60 cm (12 to 15 inches) and 4 mm in diameter. Longer and wider tubing can distort transmitted sounds.34


For the student or clinician learning to take vital signs, it may be easier to hear the BP (tapping, Korotkoff) sounds in adults using the left arm because of the closer proximity to the left ventricle. Arm position does make a difference in BP readings. BP measurements are up to 10% higher when the elbow is at a right angle to the body with the elbow flexed at heart level. The preferred position is seated with the arms parallel and extended in a forward direction (if supine, then parallel to the body).35


It is more accurate to evaluate consecutive BP readings over time rather than using an isolated measurement for reporting BP abnormalities. BP also should be correlated with any related diet or medication.


Before reporting abnormal BP readings, measure both sides for comparison, re-measure both sides, and have another health professional check the readings. Correlate BP measurements with other vital signs, and screen for associated signs and symptoms such as pallor, fatigue, perspiration, and/or palpitations. A persistent rise or fall in BP requires medical attention and possible intervention.



Pulse Pressure: The difference between the systolic and diastolic pressure readings (SBP − DBP) is called pulse pressure normally around 40 mm Hg. Pulse pressure is an index of vascular aging (i.e., loss of arterial compliance and indication of how stiff the arteries are). A widened resting pulse pressure often results from stiffening of the aorta secondary to atherosclerosis. Resting pulse pressure consistently greater than 60 to 80 mm Hg is a yellow (caution) flag and is a risk factor for new onset of atrial fibrillation.36


Widening of the pulse pressure is linked to a significantly higher risk of stroke and heart failure after the sixth decade. Some BP medications increase resting pulse pressure width by lowering diastolic pressure more than systolic while others (e.g., angiotensin-converting enzyme [ACE] inhibitors) can lower pulse pressure.37


Narrowing of the resting pulse pressure (usually by a drop in SBP as the DBP rises) can suggest congestive heart failure (CHF) or a significant blood loss such as occurs in hypovolemic shock. A high pulse pressure accompanied by bradycardia is a sign of increased intracranial pressure and requires immediate medical evaluation.


In a normal, healthy adult, the pulse pressure generally increases in direct proportion to the intensity of exercise as the SBP increases and DBP stays about the same.38 A difference of more than 80 to 100 mm Hg taken during or right after exercise should be evaluated carefully. In a healthy adult, pulse pressure will return to normal within 3 to 10 minutes following moderate exercise.


The key is to watch for pulse pressures that are not accommodating during exercise. Expect to see the systolic rise slightly while diastolic stays the same. If diastolic drops while systolic rises or if the pulse width exceeds 100 mm Hg, further assessment and evaluation is needed. Depending on all other parameters (e.g., general health of the client, past medical history, medications, concomitant associated signs and symptoms), the therapist may monitor pulse pressures over a few sessions and look for a pattern (or lack of pattern) to report if/when generating a medical consult.39



Variations in Blood Pressure: There can be some normal variation in SBP from side to side (right extremity compared to left extremity). This is usually no more than 5 to 10 mm Hg DBP or SBP (arms) and 10 to 40 mm Hg SBP (legs). A difference of 10 mm Hg or more in either systolic or diastolic measurements from one extremity to the other may be an indication of vascular problems (look for associated symptoms; in the upper extremity test for thoracic outlet syndrome).


Normally the SBP in the legs is 10% to 20% higher than the brachial artery pressure in the arms. BP readings that are lower in the legs as compared with the arms are considered abnormal and should prompt a medical referral for assessment of peripheral vascular disease.33


With a change in position (supine to sitting), the normal fluctuation of BP and heart rate increases slightly (about 5 mm Hg for systolic and diastolic pressures and 5 to 10 bpm in heart rate).


Systolic pressure increases with age and with exertion in a linear progression. If systolic pressure does not rise as workload increases, or if this pressure falls, it may be an indication that the functional reserve capacity of the heart has been exceeded.


The deconditioned, menopausal woman with coronary heart disease (CHD) requires careful monitoring, especially in the presence of a personal or family history of heart disease and myocardial infarct (personal or family) or sudden death in a family member.


On the other hand, women of reproductive age taking birth control pills may be at increased risk for hypertension, heart attack, or stroke. The risk of a cardiovascular event is very low with today’s low-dose oral contraceptives. However, smoking, hypertension, obesity, undiagnosed cardiac anomalies, and diabetes are factors that increase a woman’s risk for cardiovascular events. Any woman using oral contraceptives who presents with consistently elevated BP values must be advised to see her physician for close monitoring and follow-up.40,41


The left ventricle becomes less elastic and more noncompliant as we age. The same amount of blood still fills the ventricle, but the pumping mechanism is less effective. The body compensates to maintain homeostasis by increasing the blood pressure. BP values greater than 120 mm Hg (systolic) and more than 80 mm Hg (diastolic) are treated with lifestyle modifications first then medication.



Blood Pressure Changes with Exercise: As mentioned, the SBP increases with increasing levels of activity and exercise in a linear fashion. In a healthy adult under conditions of minimal to moderate exercise, look for normal change (increase) in SBP of 20 mm Hg or more.


The American College of Sports Medicine (ACSM) suggests the normal SBP response to incremental exercise is a progressive rise, typically 10 mm + 2 mm Hg for each metabolic equivalent (MET) where 1 MET = 3.5 mL O2/kg/min. Expect to see a 40 to 50 mm change in SBP with intense exercise (again, this is in the healthy adult). These values are less likely with individuals taking BP medications, anyone with a significant history of heart disease, and well-conditioned athletes.


Diastolic should be the same side to side with less than 10 mm Hg difference observed. DBP generally remains the same or decreases slightly during progressive exercise.38


In an exercise-testing situation, the ACSM recommends stopping the test if the SBP exceeds 260 mm Hg.38 In a clinical setting without the benefit of cardiac monitoring, exercise or activity should be reduced or stopped if the systolic pressure exceeds 200 mm Hg.


This is a general guideline that can be changed according to the client’s age, general health, use of cardiac medications, and other risk factors. DBP increases during upper extremity exercise or isometric exercise involving any muscle group. Activity or exercise should be monitored closely, decreased, or halted if the diastolic pressure exceeds 100 mm Hg.


This is a general (conservative) guideline when exercising a client without the benefit of cardiac testing (e.g., electrocardiogram [ECG]). This stop-point is based on the ACSM guideline to stop exercise testing at 115 mm Hg DBP. Other sources suggest activity should be decreased or stopped if the DBP exceeds 130 mm Hg.42


Other warning signs to moderate or stop exercising include the onset of angina, dyspnea, and heart palpitations. Monitor the client for other signs and symptoms such as fever, dizziness, nausea/vomiting, pallor, extreme diaphoresis, muscular cramping or weakness, and incoordination. Always honor the client’s desire to slow down or stop.



Hypertension (See Further Discussion on Hypertension in Chapter 6): In recent years, an unexpected increase in illness and death caused by hypertension has prompted the National Institutes of Health (NIH) to issue new guidelines for more effective BP control. More than one in four Americans has high blood pressure, increasing their risk for heart and kidney disease and stroke.43


In adults hypertension is a systolic pressure above 140 mm Hg or a diastolic pressure above 90 mm Hg. Consistent BP measurements between 120 and 139 (systolic) and between 80 and 89 diastolic is classified as pre-hypertensive. The overall goal of treating clients with hypertension is to prevent morbidity and mortality associated with high blood pressure. The specific objective is to achieve and maintain arterial blood pressure below 120/80 mm Hg, if possible (Box 4-9).34



Box 4-9


Guidelines for Hypertension and Management


The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure provides a new guideline for hypertension prevention and management. The following are the report’s key messages:



• In persons older than 50 years, systolic blood pressure greater than 140 mm Hg is a much more important cardiovascular disease (CVD) risk factor than DBP. Elevated systolic pressure raises the risk of heart attacks, congestive heart failure (CHF), dementia, end-stage kidney disease, and cardiovascular mortality.


• The risk of CVD beginning at 115/75 mm Hg doubles with each increment of 20/10 mm Hg; individuals who are normotensive at age 55 have a 90% lifetime risk for developing hypertension.


• Individuals with a SBP of 120-139 mm Hg or a DBP of 80-89 mm Hg should be considered as prehypertensive and require health-promoting lifestyle modifications to prevent CVD.


• Thiazide-type diuretics should be used in drug treatment for most clients with uncomplicated hypertension, either alone or combined with drugs from other classes. Certain high-risk conditions are compelling indications for the initial use of other antihypertensive drug classes (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, calcium channel blockers).


• Most clients with hypertension will require two or more antihypertensive medications to achieve goal BP (less than 140/90 mm Hg, or less than 130/80 mm Hg for clients with diabetes or chronic kidney disease).


• If BP is more than 20/10 mm Hg above goal BP, consideration should be given to initiating therapy with two agents, one of which usually should be a thiazide-type diuretic.


• The most effective therapy prescribed by the most careful clinician will control hypertension only if clients are motivated. Motivation improves when clients have positive experiences with and trust in the clinician.

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Mar 20, 2017 | Posted by in MANUAL THERAPIST | Comments Off on Physical Assessment as a Screening Tool

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