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Patient Assessment Teresa Rogers Butler County ATC Summer 2010. 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.
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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
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 • Starvation or fasting • Sleep • Decreased muscle activity • Exposure to cold in the environment • Factors that body temperature • Illness • Infection • Exercise • Excitement • High temperatures in the environment • Temperature is usually higher in the evening
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 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
Types of Thermometers • Clinical (glass) thermometerno 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
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 • DorsalisPedis – assessment
Normal Ranges Bradycardia – Under 60 beats per minute Tachycardia – 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
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 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
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 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
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.
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.
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.
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. • A culture and sensitivity is done by swabbing a body surface and testing for the presence of microbes
Warning Sign Unusual bleeding or discharge What to Look For • Blood in urine or stool • Discharge from any parts of your body, for example nipples, penis, etc
Warning Sign A sore that does not heal What to Look For • Sores that: • don't seem to be getting better over time • are getting bigger • getting more painful • are starting to bleed
Warning Sign Change in bowel or bladder habits What to Look For • Changes 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 For • Change in voice/hoarseness • Cough that does not go away • Sputum with blood
Warning Sign Obvious change in moles What to Look For • Use 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 For • Feeling 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
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 Nursing Assistants as Medical Scouts
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
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
Posture – stooped, fetal position, straight Mobility – in bed, balance, ambulation Range of Motion – performance of ADL’s Musculoskeletal System
Pulse – strength, regularity, rate Blood Pressure Skin color Extremities – edema Circulatory System