Patient Assessment Janet Rimmer Scotts Hill High School Fall 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. 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

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) 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

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 Dorsalis Pedis – assessment

Normal Ranges Age Pulse per Minute Birth to 1 year 80-190 2 years 80-160 6 years 75-120 10 years 70-110 12 years & older 60-100 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 respirations per minute

Assessing Respiration Respiration is measured when the person is at rest. Rate may change if 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 – 100-140 mmHg Diastolic: Constant pressure when heart is at rest Normal range – 60-90 mm Hg Hypertension—BP that remains above a systolic of 140 mm Hg or a diastolic of 90 mm Hg Hypotension—Systolic below 100 mm Hg and/or a diastolic below 60 mm Hg

LETS FIND THE BASELINE

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