1. Patient Assessment Mrs. Keehn

2. 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

3. Vital Signs Are important indicators of health
Detect changes in normal body function
May signal life-threatening conditions
Provide information about responses to treatment

4. Vital Signs
Temperature
Pulse
Respirations
Blood Pressure

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. Normal Body Temperature
Oral ( )
Rectal ( )
 Axillary ( )
 Typmanic ( )
Temporal ( )
Hypothermia – temperature below normal
Hyperthermia – temperature above normal

12. 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.

13. 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

14. 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

15. 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

16. Clicker question Which is the most common site for taking the pulse?
A. radial
B. brachial
C. apical
D. carotid

17. 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

18. 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

19. 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

20. 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 breaths per minute

21. 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.

22. 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

23. 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

24. 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

25. 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.

26. 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

27. 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

28. 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

29. 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

30. 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.

31. 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

32. 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

33. 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.

34. 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

35. 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.

36. 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.

37. 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

38. Seven Warning Signs of Cancer

39. 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

40. 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

41. 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

42. 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.

43. Warning Sign What to Look For Change in voice/hoarseness Nagging cough
Cough that does not go away
Sputum with blood

44. 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)?

45. 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

46. 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

47. 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

48. 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

49. ABC’s of Observation Appearance Behavior – actions, conduct, pain
Communication

50. 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.

51. Observations by Body Systems
Using sight, touch, hearing, and smell

52. Integumentary System
Color – flushed, pale, ashen, icteric, cyanotic, (don’t forget nails)
Temperature – warm, hot cool
Moisture – dry, moist, perspiring
Abnormalities – rashes, bruises, wounds

53. Musculoskeletal System
Posture – stooped, fetal position, straight
Mobility – in bed, balance, ambulation
Range of Motion – performance of ADL’s

54. Circulatory System Pulse – strength, regularity, rate Blood Pressure
Skin color
Extremities – edema

55. Respiratory System
Respirations – rate, regularity, depth, dyspnea, SOB (exertion, at rest), stertorous
Cough – frequency, dry, productive
Sputum – color, consistency

56. Nervous System Mental state – orientation Ability to communicate
Senses
Eyes – pupils equal, reddened, drainage
Ears – drainage, hearing
Nose – drainage, bleeding

57. Urinary System Frequency, amount, color, dysuria
Clarity, blood or sediment, incontinent
Pain or burning upon urination

58. 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

59. Reproductive System Female Male
Breasts – drainage from nipples, discoloration, lumps
Vagina – discharge, amount, color, character
Male
Testes – lumps
Penis – drainage, amount and character