Patient AssessmentMrs. Keehn

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

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

treatment

Vital Signs Temperature Pulse Respirations Blood Pressure

Vital Signs Are Measured: Upon admission As often as required by the person’s 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

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

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

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

Body temperature is usually the lowest:

a.in the evening

b.n the afternoon

c.in the morning

d.at bedtime

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

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

Normal Body TemperatureOral 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 normalHyperthermia – temperature above normal

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.

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

Clicker question You are taking Mr. James' pulse. The beats are

not spaced evenly. How would you describe his pulse when reporting to the doctor or nurse?

A. thready and bounding B. weak and feeble C. strong and full D. irregular

Pulse SitesMost 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

Clicker question Which is the most

common site for taking the pulse?

A. radial B. brachial C. apical D. carotid

Normal RangesAge Pulse per Minute

Birth to 1 year 80-190

2 years 80-160

6 years 75-120

10 years 70-110

12 years & older

60-100Bradycardia – Under 60 beats per minuteTachycardia – Over 100 beats per minute

Factors that Affect Pulse Factors that pulse Exercise Stimulant drugs Excitement Fever Shock Nervous tension

Factors that pulse Sleep Depressant drugs Heart disease Coma

For an adult, which pulse rate is immediately reported to the doctor or nurse?a. 80 beats per minute b. 62 beats per minute c. 48 beats per minute d. 74 beats per minute

SMART Response QuestionTo set the properties right click and selectSMART Response Question Object->Properties...

Clicker question To take an apical pulse

rate, you must: A. count for only 15

seconds B. feel for the artery

on the side of the neck C. have the patient

sit or lie down D. use a

stethoscope

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

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.

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

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

Factors that Affect Blood PressureFactors 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

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.

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

Hypertension—BP that remains above a systolic of 140 mm Hg or a diastolic of 90 mm Hg Hypotension—Systolic below 90 mm Hg and/or

a diastolic below60 mm Hg

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

Measuring Height and WeightGeneral 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

Clicker response question A persistent systolic pressure above 140 mmHg or

a diastolic pressure above 90 mmHg is called: A. hypertension B. hypotension C. bradycardia D. tachycardia

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 infant…keep one hand slightly

over but not touching the infant A tape measure is used to measure infant height.

Urine Specimens Can provide valuable information about the

patients state of health Urine is commonly tested for:

Bacteria, pus, or blood as found in bladder and kidney infection

Sugar and acetone as found in diabetes Hormones as found in pregnancy Drugs

Common Types of Specimens Random urine specimen

Collected for a routine urinalysis. No special measures are needed.

Midstream specimen (clean-voided or clean-catch) The perineal area is cleaned before collecting the

specimen. Sterile gloves and container are needed.

Double voided Patient voids and the specimen is discarded After 30 minutes, patient voids again and

specimen is collected for testing

Testing Urine Urine pH measures if urine is acidic or alkaline.

Normal pH is 4.6 to 8.0. Testing for glucose and ketones

These tests are usually done 30 minutes before each meal and at bedtime.

Information used to make drug and diet decisions. Double-voided specimens are best for these tests.

Testing for blood Sometimes blood is seen in the urine. At other times it is unseen (occult). A routine urine specimen is needed.

http://www.youtube.com/watch?v=TuWiy4_VDWY

Testing Urine Using reagent strips

Universal Precautions must be used at all times

Dip the strip into urine. Compare the strip with the color chart on

the bottle at the required time interval. Record and report results

Stool Specimen Stool, or feces, may be tested for:

Blood Fat Microbes Worms Other abnormal contents

The stool specimen must not be contaminated with urine.

http://www.youtube.com/watch?v=IGPVlo2bNmQ

Sputum Specimen Sputum specimens may be tested for blood,

microbes, and abnormal cells. The person coughs up sputum from the bronchi

and trachea. It is easier to collect a specimen in the morning.

http://vimeo.com/38104528

Other Types of Specimens Specimens may be obtained from other body tissue and fluid. A biopsy is done by removing a small piece of tissue for

further examination. http://www.youtube.com/watch?v=gd7j-wYwryY A culture and sensitivity is done by swabbing a body surface

and testing for the presence of microbes

Seven Warning Signs of Cancer

http://www.doctoroz.com/videos/ask-dr-oz-cancer-edition-pt-1

Warning Sign

Unusual bleeding or discharge

What to Look For

Blood in urine or stoolDischarge from any parts

of your body, for example nipples, penis, etc

Warning Sign

A sore that does not heal

What to Look ForSores that: don't seem to be getting

better over timeare getting bigger getting more painful are starting to bleed

Warning Sign

Change in bowel or bladder

habits

What to Look ForChanges in the color,

consistency, size, or shape of stools. (diarrhea, constipated)

Blood present in urine or stool

Warning Sign

Lump in breast or other part of the body

What to Look For Any lump found in the

breast when doing a self examination.

Any lump in the scrotum when doing a self exam.

Other lumps found on the body.

Warning Sign

Nagging cough

What to Look ForChange in

voice/hoarseness Cough that does not go

away Sputum with blood

Warning SignObvious

change in moles

What to Look ForUse the ABCD RULE Asymmetry: Does the mole look the

same in all parts or are there differences?

Border: Are the borders sharp or ragged?

Color: What are the colors seen in the mole?

Diameter: Is the mole bigger than a pencil eraser (6 mm)?

Warning Sign

Difficulty in swallowing

What to Look ForFeeling of pressure in

throat or chest which makes swallowing uncomfortable

Feeling full without food or with a small amount of food

C A U T I O N(Cancer’s Warning Signs) C Change in bowel or bladder habits A A sore that does not heal U Unusual bleeding or discharge T Thickening or lump in breast or body part I Indigestion or difficulty in swallowing O Obvious change in a wart or mole N Nagging cough or hoarseness

Nursing Assistants as Medical Scouts

As the primary caregiver, your observations can be the difference between a resident who receives early and effective treatment, and a resident who becomes gravely ill

A recent study by Kenneth Boockvar MD, Assistant Professor in the Department of Geriatrics at Mount Sinai School of Medicine found: That nursing assistants almost always saw that a resident

was becoming ill earlier than anything noted in the chart Illnesses that were detected early were:

UTI’s, Pneumonia, CHF, Gastroenteritis, Arrhythmias and Dehydration

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 appetite5. A resident complains

ABC’s of Observation

Appearance

Behavior – actions, conduct, pain

Communication

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.

Observations by Body Systems

Using sight, touch, hearing, and smell

Integumentary System

• Color – flushed, pale, ashen, icteric, cyanotic, (don’t forget nails)

• Temperature – warm, hot cool• Moisture – dry, moist, perspiring• Abnormalities – rashes, bruises, wounds

Musculoskeletal System

Posture – stooped, fetal position, straight Mobility – in bed, balance, ambulation Range of Motion – performance of ADL’s

Circulatory System

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

Respiratory System

Respirations – rate, regularity, depth, dyspnea, SOB (exertion, at rest), stertorous

Cough – frequency, dry, productive Sputum – color, consistency

Nervous System

Mental state – orientation Ability to communicate

Senses Eyes – pupils equal, reddened, drainage Ears – drainage, hearing Nose – drainage, bleeding

Urinary System

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

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

Reproductive System Female

Breasts – drainage from nipples, discoloration, lumps Vagina – discharge, amount, color, character

Male Testes – lumps Penis – drainage, amount and character