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ADV-Lesson 2- Physical Assessment

 

AIRWAY: Check for a patent airway. Ensure the mouth and throat are clear of obstructions.

BREATHING: Observe if the patient is breathing and if they are breathing effectively. Note if there is any extra effort taken. Determine if there is a need for supplemental oxygen. Listen to the lungs’ sounds. Listen to different areas to see if the sounds are different. See if the patient’s head and neck are extended or the elbows are abducted. Check the color of the mucous membranes and the capillary refill time. Note any abnormal signs/sounds. Respiratory distress may present with no chest wall movement, nasal flaring, open mouth breathing, head and neck extension, exaggerated effort, and paradoxical breathing.

RESPIRATION: Normal = 15 – 40 breaths/minute with no visible effort. The respiratory rate and effort are a sign of how well the patient is breathing and can be an indicator of non-pulmonary problems such as pain or hyperthermia. Monitor the patient for changes in their respiratory rate or effort. These changes can be life threatening.

CIRCULATION: Check for a heartbeat and note the heart rate and rhythm. Palpate the femoral or other distal arterial pulse. Feel the gums, ears, and extremities to see if they are cool. See if there is any evidence of bleeding. Look for any bruising or petechiae.

HEART RATE:

Dog normal = 70 – 160 beats/minute dependent on size – normal values for canine heart rates depend on their size. A heart rate of 140 may be normal in a Yorkshire terrier but would be abnormal for a Mastiff.

Cat normal = 180 – 240 beats/minute. Trends should be monitored over a period of time when nursing critical patients. A change in a patient’s heart rate may indicate an issue.

PULSES: Normal pulses are strong and consistent. The pulse is the difference between the systolic and diastolic pressures within the cardiovascular system. A strong pulse may not necessarily mean the patient has adequate blood pressure. The pulse can be felt on the inside of the thigh (femoral), the space on the distal aspect of the paw (pedal). The pulse strength helps you to evaluate perfusion. The pulse will deteriorate with worsening conditions such as shock, dehydration, or heart function. Normal pulses are steady and even, beating in a constant pattern with the same strength to each beat and will disappear under moderate pressure. An irregular pulse may be due to sinus arrhythmia (which is considered normal in dogs) or various other cardiovascular conditions. Weak pulses are slightly stronger than thready pulses and will disappear with light pressure. A weak pulse signifies a decreased difference between systolic and diastolic pressure that may be due to low cardiac output. Thready pulses are not easily felt and may feel like a small fine thread under the finger and will disappear with slight pressure. A bounding pulse feels full and spring-like on palpation and will not disappear under moderate pressure. A bounding pulse may be due to low peripheral resistance, increased cardiac output, and increased stroke volume.

PULSE DEFICITS: Pulse deficit is not a normal state. A pulse deficit is defined as an inefficient heartbeat that does not generate a palpable pulse. When listening to the heart with a stethoscope at the same time you palpate the pulse, you will hear a heartbeat, but no pulse will be generated. The most common cause of a pulse deficit is ventricular premature contractions (VPC). VPCs can be seen in cases of splenic ruptures or torsions, GDVs, and primary cardiovascular disease. It can take up to 36 hours for the VPCs to develop, and they can progress to a life-threatening arrhythmia. Palpating a pulse deficit is an indication to connect an ECG (if not already placed on the animal) and alert the doctor immediately.

MUCOUS MEMBRANE COLOR: Normal = pink

CAPILLARY REFILL TIME (CRT): Normal = 1-2 seconds

Mucous membrane color and capillary refill time (CRT) serve to evaluate perfusion, oxygenation, and some underlying diseases. Mucous membrane color is assessed by lifting the upper lip and quickly pressing on the gums with your finger to push the blood out of the tissue, then removing your finger and counting the number of seconds it takes for the color to return. This should normally take 1 to 2 seconds.

BODY TEMPERATURE: Normal = 101.0 to 102.5 degrees Fahrenheit

Hyperthermia may be due to infection, immune-mediated diseases, allergic reaction, and prolonged exposure to heat, seizures, and stress/anxiety. Temperatures >106 can cause diminished clotting ability (DIC). Hypothermia may result from shock, blood loss, dehydration, heart failure, prolonged exposure to cold, or the patient being very immature or a toy breed. External re-warming alone can often help improve hemodynamic stability for hypothermic cats.

PAIN: No pain is the normal state. Pain has also been shown to delay healing. Pain increases the stress response and causes tachycardia. This increased workload puts more pressure on the cardiovascular system. If a patient is pained, judge whether the level of pain is more intense than expected. The pain may be an indication of a new issue and should be brought to the doctor’s attention. Usually pain medications are not withheld, but there are some exceptions. Pain medication may alter the responses during the neurological exam. This is particularly important in trauma cases or neurologic patients.

ABDOMINAL DISTENTION: Distention of the patient’s abdomen can suggest severe life-threatening complications. Blood in the abdomen may be due to a clotting problem, ruptured spleen or ruptured tumor, or a ruptured blood vessel post-surgery. An infection in the abdomen may be the result of a rupture of the gastrointestinal tract from a foreign body, abscess, or tumor. A rupture from blockages, trauma, or tumors in the urinary tract will cause urine in the abdomen. Sterile inflammation in the abdomen may be caused by pancreatitis, FIP, or cancers. Fluid

in the abdomen may result from low protein, heart failure, low protein levels/liver disease. Air in the stomach/not free in the abdomen is from GDV or bloat.

NEUROLOGIC or DISABILITY/DYSFUNCTION – The patient’s level of consciousness should be bright, alert and responsive. Abnormal responses would be dull, stuporous, obtunded or comatose. Their posture, response to pain, and if they are ambulatory or not may indicate an issue. The patient should be evaluated for any seizure activity, whether the forelimbs and hind limbs both shift or if the hind limbs are flaccid. If there is a decrease in gag or no gag reflex, this puts the patient at high risk for aspiration. The patient may need to be intubated to protect the airway. Suction may be needed. [2]

Neurological considerations:

  • Levels of consciousness
  • Alert: Normal awake and responsive
  • Obtunded/depressed/dull: State of decreased responsiveness. Drowsy, but rousable. Patients are generally inattentive and display little spontaneous activity.
  • Stuporous/semi-comatose: The patient is in a sleep state, can be aroused only with painful stimuli. Coma: Cannot be aroused, even with painful stimuli

Quality of consciousness:

  • Dementia or delirium: the patient is alert with normal level of consciousness but exhibits abnormal behavior and responds inappropriately to interactions or stimuli
  • Ambulatory non-ambulatory Ataxia, hemiparesis, tetraparesis, hemiplegia, or tetraplegiaDecerebrate posture: the patient is usually rigid with an arched back, head thrown backward, and extensor rigidity of all 4 limbs. Mentation is stuporous to comatose
  • Decerebellate posture: the patient is usually rigid with an arched back, head thrown backward, and extensor rigidity of the thoracic limbs and either extension or flexion of the pelvic limbs The patient should be responsive and have voluntary movement
  • Schiff-Sherrington occurs when there is a spinal cord lesion or injury somewhere between T3-L3. In these paraplegic animals, the forelimbs are rigid while the hind limbs are flaccid

EYES: Normal = equally sized responsive pupils, centrally positioned eyes. Normal pupils should be midrange, of equal size, and constrict when exposed to light. Pupillary abnormalities may appear:

  • Unilateral mydriatic, unilateral miosis or anisocoria
  • Bilateral pinpoint pupils or miosis.
  • Bilateral mydriatic, midrange fixed pupils or dilated fixed pupils

 

 

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