Patient Patient AssessmentAssessment

Teresa RogersTeresa RogersButler County ATCButler County ATC

Summer 2010Summer 2010

ObjectivesObjectives

• 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 SignsVital Signs

• Are important indicators of health• Detect changes in normal body function• May signal life-threatening conditions• Provide information about responses to

treatment

Vital SignsVital Signs

• Temperature• Pulse• Respirations• Blood Pressure

Vital Signs Are Measured: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 SignsWhen 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

TemperatureTemperature

• 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

• 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 TemperatureBody Temperature

Temperature SitesTemperature 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 SitesTemperature 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 TemperatureNormal 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 normalHyperthermia – temperature above normal

Types of ThermometersTypes 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.

PulsePulse

• 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 SitesPulse 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 RangesNormal Ranges

Age Pulse per MinuteBirth to 1 year 80-1902 years 80-1606 years 75-12010 years 70-11012 years & older 60-100

Bradycardia – Under 60 beats per minuteTachycardia – Over 100 beats per minute

Factors that Affect PulseFactors that Affect Pulse

• Factors that pulse

• Exercise• Stimulant drugs• Excitement• Fever• Shock• Nervous tension

• Factors that pulse

• Sleep• Depressant drugs• Heart disease• Coma

RespirationsRespirations

• 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 RespirationAssessing 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 RespirationAssessing 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 PressureBlood 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 PressureFactors 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 BPMeasuring 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 PressureNormal 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 WeightMeasuring 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 WeightMeasuring Height and WeightGeneral 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 ScalesTypes 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 SpecimensUrine 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 SpecimensCommon 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 UrineTesting 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 UrineTesting 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 SpecimenStool 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 SpecimenSputum 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 SpecimensOther 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

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 SignLump 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 SignNagging cough

What to Look For• Change in

voice/hoarseness • Cough that does not go

away • Sputum with blood

Warning SignObvious

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 SignDifficulty 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 ScoutsNursing 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 IllnessThe 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 appetite5. A resident complains

ABC’s of ObservationABC’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 SystemIntegumentary 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 SystemMusculoskeletal System

• Pulse – strength, regularity, rate• Blood Pressure• Skin color• Extremities – edema

Circulatory SystemCirculatory System

• Respirations – rate, regularity, depth, dyspnea, SOB (exertion, at rest), stertorous

• Cough – frequency, dry, productive• Sputum – color, consistency

Respiratory SystemRespiratory System

• Mental state – orientation• Ability to communicate

• Senses– Eyes – pupils equal, reddened, drainage– Ears – drainage, hearing– Nose – drainage, bleeding

Nervous SystemNervous System

• Frequency, amount, color, dysuria• Clarity, blood or sediment, incontinent• Pain or burning upon urination

Urinary SystemUrinary 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

Digestive SystemDigestive System

• Female– Breasts – drainage from nipples,

discoloration, lumps– Vagina – discharge, amount, color,

character

• Male– Testes – lumps– Penis – drainage, amount and character

Reproductive SystemReproductive System