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Health Skills I

Health Skills I. Unit 102 Vital Signs. Objectives. Identify observational techniques for determining the health status of a patient. Unit 102.1 Observational Techniques. Observation of Patient observe physical signs and alertness listen to patient and ask questions. Objective Data.

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Health Skills I

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  1. Health Skills I Unit 102 Vital Signs

  2. Objectives • Identify observational techniques for determining the health status of a patient.

  3. Unit 102.1Observational Techniques • Observation of Patient • observe physical signs and alertness • listen to patient and ask questions

  4. Objective Data • can be observed or tested by healthcare provider • overt, not concealed • Examples: • observe that a patient refused to eat • measure an increased temperature • observe drainage from a wound • skin is warm to the touch • vomited 300 cc

  5. Subjective Data • information perceived only by the affected person • Examples: • feels nervous • pain in the abdomen • nauseated • feels chilled

  6. Senses to Collect Data • Look • observe visible signs that indicate a problem • Listen • patient’s complaints, description of the problem in their words • Feel • degree’s in body temperature, pulse quality • Smell • unusual odors

  7. Collecting DataInspection • visual examination • signs of movement and posture • skin color signs of distress • ability to maintain health practices (hygiene, dress) • gait

  8. Collecting Data Auscultation • listening with use of a stethoscope • blood pressure • heart sounds and/or rate • lung sounds • bowel sounds • detecting bruits

  9. Collecting Data Palpation • examination of body parts through feeling with fingertipsand hands to • assess skin temperature • determine pulse rate, quality,rhythm, absence or presence • lumps/masses • abdominal tenderness/distention

  10. Collecting Data Percussion • tapping body parts with your fingers and listening to sounds produced to • detect presence of air • evaluate amount of fluid in a body cavity • determine size, borders and consistency of body organs or masses

  11. Purpose of Systematic Physical Assessment • to determine physical and emotional changes through step by step observation • NOTE: • apparent state of health, does patient seem acutely ill?

  12. Signs of Distress • NOTE: • dyspnea (difficulty breathing) • vomiting • pallor • pain • crying • evidence of nervousness

  13. Skin Color • NOTE: • pink • indicates adequate oxygen levels • pallor (pale) • major organs being challenged with fluid or blood loss, peripheral blood is being shunted to the core of the body to self protect them • ashen (gray) • body systems begin to suffer due to decreasing oxygen level in blood

  14. Skin Color • NOTE: • cyanotic (blue) • indicates that body systems are in critical state due to an excessive amount of blood not carrying oxygen • flushed (pink/red) • harmful levels of carbon monoxide or increased carbon dioxide levels are present • Ketoacidosis (high blood glucose levels) will cause flushing, as will hypertension (high blood pressure)

  15. Stature & Build • NOTE: • large/small body frame • obesity • congenital anomalies (changes from normal at birth)

  16. Posture, Motor Activityand Gait • NOTE: • deformities • spine curvature • gait • shuffling • stable

  17. Dress, Grooming and Hygiene • NOTE: • if appropriate • clean • neat

  18. OdorsBody and Breath • NOTE: • breath for acetone odor (may be diabetic) • alcohol odor (may be cause of problem) • urine odor (incontinence) • poor hygiene (emotional disturbances or social issues)

  19. Relationships, Manner and Mood • NOTE are they: • pleasant • smiling • making eye contact • initiating conversation • crying • appropriate conversation • following directions • depressed • anxious • agitated • elated • flat

  20. Speech • NOTE: • clarity • slurring

  21. State of Awarenessand Consciousness • NOTE, are they: • alert • oriented to: • person • place • time and significant others • drowsy • is response time appropriate

  22. Support or Monitoring Devices • NOTE, does the patient use a: • walker • wheelchair • prosthesis • hearing aid • glasses • dentures • are these supports and devices working properly and is the patient knowledgeable in using them?

  23. Facial Expressions • NOTE: • tension • grimacing • affect • happy • sad • flat

  24. Reporting Observed Data • reporting should be done promptly, accurately, and objectively • identify need for emergency care • may play role in treatment plan by others • may indicate a need for medication changes • to know if patient is improving or not • documentation important for 3rd party payment (Insurance)

  25. Knowledge Assessment • Compare and contrast objective and subjective data and give examples of each. • Define and give examples of when inspection, auscultation, palpitation, and percussion are used. • Describe items of a physical assessment. (Example skin color, stature and build)

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