Patient Asssessment

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

Seven Warning Signs of Cancer

Unusual bleeding or discharge 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 What to Look For A sore that does not heal Sores that: don't seem to be getting better over time are getting bigger getting more painful are starting to bleed

Change in bowel or bladder habits 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 What to Look For 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 What to Look For Change in voice/hoarseness Nagging cough Cough that does not go away Sputum with blood

Warning Sign What to Look For Obvious change in moles 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)?

Difficulty in swallowing 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

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 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

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