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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