Patient Assessment Rachel Hillard RN

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Patient AssessmentRachel Hillard RN
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Objectives

• Students will
• Identify normal and abnormal V/S measurements.
• Measure and record vital signs according to
  industry standards.
• Measure and record height and weight according to
  industry standards.
• Explain why urine, stool, and sputum specimens
  are collected.
• Explain the rules for collecting different
  specimens
• Describe the seven warning signs of cancer

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Vital Signs

• Are important indicators of health
• Detect changes in normal body function
• May signal life-threatening conditions
• Provide information about responses to treatment

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Vital Signs

• Temperature
• Pulse
• Respirations
• Blood Pressure

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Vital Signs Are Measured

• Upon admission
• As often as required by the persons condition
• Before after surgery and other procedures
• After a fall or accident
• When prescribed drugs that affect the respiratory
  or circulatory system
• When there are complaints of pain, dizziness,
  shortness of breath, chest pain
• As stated on the care plan

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When Measuring Vital Signs

• Usually taken with the person sitting or lying
• The person is at rest
• Always report
• A change from a previous measurement
• Vital signs above or below the normal range
• If you are unable to measure the vital signs

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Temperature

• Measurement of balance between heat lost and
  produced by the body.
• Heat is produced by
• Metabolism of food
• Muscle and gland activity
• Heat may be lost through
• Perspiration, Respiration, Excretion
• Measured with the Fahrenheit (F)
• or Celsius or Centigrade (C) scales

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Body Temperature

• Factors that ? body temperature
• Illness
• Infection
• Exercise
• Excitement
• High temperatures in the environment
• Temperature is usually higher in the evening

• Factors that ? body temperature
• Starvation or fasting
• Sleep
• Decreased muscle activity
• Exposure to cold in the environment

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Temperature Sites

• Oral - by mouth most common method
• May be affected by hot or cold food, smoking,
  oxygen, chewing gum
• Wait 15 minutes or use alternate site
• Rectal - in the rectum -most accurate site
• Do not use if patient has rectal surgery or
  bleeding
• Axillary - under arm less reliable site
• Used when other sites are inaccessible
• Do not use immediately after bathing

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Temperature Sites

• Tympanic or aural - in the ear
• Measures in 1 to 3 seconds
• Temporal Artery temporal artery on the forehead
• Record route temperature was taken
• O - Oral
• R- Rectal
• T Tympanic
• A Axillary

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Normal Body Temperature

• Oral 98.6 ( 97.6 - 99.6)
• Rectal 99.6 (98.6 - 100.6)
•  Axillary 97.6 (96.6 - 98.6)
•  Typmanic 98.6 (98.6 - 100.6)
• Temporal 99.6 (98.6 - 100.6)
• Hypothermia temperature below normal
• Hyperthermia temperature above normal

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Types of Thermometers

• Clinical (glass) thermometer no longer contain
  mercury.
• Come in oral and rectal.
• Disposable covers are usually used.
• Electronic can be used for oral, rectal, or
  axillary and use disposable probe covers.
• Tympanic placed in auditory canal and uses
  disposable cover.
• Strips that contain special chemicals or dots
  that change colors can also be used.

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Pulse

• The pressure of blood pushing against the wall of
  an artery as the heart beats and rests.
• Measured for one minute while noting
• rate - beats per minute
• rhythm - regular or irregular
• volume - strength or intensity - described as
  strong, weak, thready, bounding

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Pulse Sites

• Most Commonly Used
• Carotid during CPR
• Apical use stethoscope
• Brachial for Blood Pressure
• Radial - to count pulse
• Femoral assessment and procedures
• Popliteal assessment
• Dorsalis Pedis assessment

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Normal Ranges
Age Pulse per Minute
Birth to 1 year 80-190
2 years 80-160
6 years 75-120
10 years 70-110
12 years older 60-100
Bradycardia Under 60 beats per
minute Tachycardia Over 100 beats per minute
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Factors that Affect Pulse

• Factors that ? pulse
• Exercise
• Stimulant drugs
• Excitement
• Fever
• Shock
• Nervous tension

• Factors that ? pulse
• Sleep
• Depressant drugs
• Heart disease
• Coma

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Respirations

• Process of breathing air into (inhalation) and
  out of (exhalation) the lungs.
• Oxygen enters the lungs during inhalation.
• Carbon dioxide leaves the lungs during
  exhalation.
• The chest rises during inhalation and falls
  during exhalation.
• Normal rate 12-20 breaths per minute

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Assessing Respiration

• Respirations is measured when the person is at
  rest.
• Rate may change is patient is aware that it is
  being counted.
• To prevent this, count respirations right after
  taking a pulse.
• Keep your fingers or stethoscope over the pulse
  site.
• To count respirations, watch the chest
  rise and fall.

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Assessing Respiration

• Character and quality of respirations is also
  assessed
• Deep
• Shallow
• Labored or difficult
• Noises wheezing, stertorous (a heavy, snoring
  type of sound)
• Moist or rattling sounds
•  Dyspnea difficult or labored breathing
• Apnea absence of respirations
• Cheyne-Stokes periods of dyspnea followed by
  periods of apnea
• often noted in the dying patient
• Rales bubbling or noisy sounds caused by fluids
  or mucus in
• the air passages

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Blood Pressure

• Measure of the pressure blood exerts on the walls
  of arteries
• Blood pressure is controlled by
• The force of heart contractions
• weakened heart ? drop in BP
• The amount of blood pumped with each heartbeat
• loss of blood ? drop in BP
• How easily the blood flows through the
• blood vessels
• Narrowing of vessels ? increase in BP
• Dilatation of vessels ? decrease in BP

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Factors that Affect Blood Pressure

• Factors that ? blood pressure
• Excitement, anxiety, nervous tension
• Stimulant drugs
• Exercise and eating

• Factors that ? blood pressure
• Rest or sleep
• Depressant drugs
• Shock
• Excessive loss of blood

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Measuring BP

• A sphygmomanometer is used to measure BP
• Aneroid has a round dial and needle
• Mercury has a column of mercury
• Electronic automated device
• BP is measured in millimeters (mm) of mercury
  (Hg).
• The systolic pressure is recorded over the
  diastolic pressure.

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Normal Range of Blood Pressure

• Systolic Pressure on the walls of arteries when
  the heart is contracting.
• Normal range less than 120 mm Hg
• Diastolic Constant pressure when heart is at
  rest
• Normal range less than 80 mm Hg
• HypertensionBP that remains above a systolic
• of 140 mm Hg or a diastolic of 90 mm
  Hg
• HypotensionSystolic below 90 mm Hg and/or
  a diastolic below60 mm
  Hg

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Measuring Height and Weight

• Used to determine if patient is underweight or
  overweight
• Height and weight charts are used as averages
• Weight greater or less than 20 considered normal
• BMI or Body Mass Index a statistical measure of
  body weight based on a person's weight and
  height.
• BMI from 18.5 to 24.9 is considered normal

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Measuring Height and Weight

• General Guidelines
• Use the same scale every day
• Make sure the scale is balanced before use
• Weigh the patient at the same time each day
• Remove jacket, robe, and shoes before weighing
• OBSERVE SAFETY PRECAUTIONS!
• Prevent injury from falls and the protruding
  height lever.
• Some people are weight conscious.
• Make only positive comments when weighing
  patients

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Types of Scales

• Clinical scales contain a balance beam and
  measuring rod
• Bed scales or Chair scales are used for patients
  unable to stand
• Infant scales come in balanced, aneroid, or
  digital
• When weighing an infantkeep one hand slightly
  over but not touching the infant
• A tape measure is used to measure infant height.

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The 5 Early Warning Signs of Illness

• 1. Weakness sudden onset TIA, pneumonia,
  dehydration, CHF, infection, liver failure
• 2. A sudden change in greeting severe hearing
  loss, depression confusion
• 3. Nervousness or Agitation
• being emotionally off can signal physical
  illness
• 4. Loss of appetite
• 5. A resident complains

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ABCs of Observation

• Appearance
• Behavior actions, conduct, pain
• Communication

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Signs and Symptoms

• Signs -- Objective data are seen, heard, felt,
  smelled. You can see urine, hear a cough,
  feel a pulse and smell a foul odor.
• Symptoms -- Subjective data are thing a person
  tells you about that you cannot observe through
  your senses. Examples include nausea, pain
  and dizziness.

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• Observations by Body Systems
• Using sight, touch, hearing, and smell

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Integumentary System

• Color flushed, pale, ashen, icteric, cyanotic,
  (dont forget nails)
• Temperature warm, hot cool
• Moisture dry, moist, perspiring
• Abnormalities rashes, bruises, wounds

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Musculoskeletal System

• Posture stooped, fetal position, straight
• Mobility in bed, balance, ambulation
• Range of Motion performance of ADLs

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Circulatory System

• Pulse strength, regularity, rate
• Blood Pressure
• Skin color
• Extremities edema

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Respiratory System

• Respirations rate, regularity, depth, dyspnea,
  SOB (exertion, at rest), stertorous
• Cough frequency, dry, productive
• Sputum color, consistency

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Nervous System

• Mental state orientation
• Ability to communicate
• Senses
• Eyes pupils equal, reddened, drainage
• Ears drainage, hearing
• Nose drainage, bleeding

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Urinary System

• Frequency, amount, color, dysuria
• Clarity, blood or sediment, incontinent
• Pain or burning upon urination

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Digestive System

• Appetite amount of solids/liquids consumed,
  belching, burping, intolerance to foods
• Eating difficulty chewing or swallowing
• Nausea/Vomiting
• Bowel elimination frequency, amount,
  consistency, color, diarrhea, constipation,
  flatus

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Reproductive System

• Female
• Breasts drainage from nipples, discoloration,
  lumps
• Vagina discharge, amount, color, character
• Male
• Testes lumps
• Penis drainage, amount and character