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Health Assessment 125 DAY TWO: VITAL SIGNS HEALTH HISTORY PHYSICAL ASSESSMENT HEALTH ASSESSMENT OF SKIN AND MENTAL STATUS JERRY THOMPSON RN, MSN Vital Signs and Physical Assessment At the completion of this class the student will be able to: Describe factors that effect vital signs and how to measurement of them Explain how to take a health history Explain what is included in a physical assessment Demonstrate performing a general survey / mental status exam Discuss how to assess the skin The Nursing Process What is the first step? What do you do? What is the second step? What do you do? What is the third step? What do you do? What is the forth step? What do you do? What is the fifth step? What do you do? ADPIE Task Based Nurse Role Based Nurse What do they do? What do they do? Tasks.. Such as Manage patient care Vital signs Includes tasks and also… Dressing changes Collaboration with other Ambulating Giving medications health care professionals Monitoring & follow through MAKE DECISIONS Vital Signs Chapter 29 . . Temperature, pulse, respiratory rate, blood pressure Pain Oxygen saturation also frequently measured Vital signs are used to: To establish baseline data to compare to for future measurements Identify problems Evaluate response to intervention Temperature Alterations • Acceptable temperature range: • 96.8° F to 100.4° F or 36° C to 38° C • Pyrexia / Hyperthermia (fever): important defense mechanism • Febrile/afebrile • Hypothermia What causes Hyperthermia? Hypothermia? Assessing Body Temperature Electronic Thermometer Temporal Artery Thermometer Chemical Dot Thermometer Temperature sites: Oral, rectal, axillary, and tympanic membrane Assessment of Pulse + Apical Rate = normal 60-100 Bradycardia < 60 Tachycardia > 100 Pulse deficit = Difference between radial and apical pulse rates Rhythm Dysrhythmia: irregular or regularly irregular Strength: 4+, 3+, 2+ (normal), 1+, 0 Where would you assess the pulse of an infant? Unresponsive and not breathing? Assessment of Respirations Easy to assess Respiratory rate: breaths/minute Ventilatory depth: deep, normal, shallow Ventilatory rhythm: regular/irregular Diffusion and perfusion What is the preferred method of assessing Respirations? Breathing Patterns 12 to 20 for an adult. bradypnea <12 Bradypnea Tachypnea Hyperpnea tachypnea > 20 Apnea newborn / infant = 30 to 60 Hyperventilation 1 year old = 20 to 40 2 year old = 20 to 30 8 year old = 15 to 25 16 year old = 15 to 20 Hypoventilation Cheyne-Stokes respiration Kussmaul’s respiration Biot’s respiration Measurement of arterial oxygen saturation (SaO2) Percent of hemoglobin that is bound with oxygen in the arteries Usually 95% to 100% Pulse oximeter What can interfere with accurate assessment? Arterial Blood Pressure Force exerted on the walls of an artery by pulsing blood under pressure from the heart Systolic = Maximum peak pressure during ventricular contraction Diastolic = Minimal pressure during ventricular relaxation Pulse pressure = Difference between systolic and diastolic pressures http://vimeo.com/8068713 Physiology of Arterial Blood Pressure Factors affecting arterial blood pressure: Cardiac output Peripheral resistance Blood volume Viscosity Elasticity Blood pressure levels (from http://www.heart.org) Blood Pressure Category Normal Systolic mm Hg (upper #) Diastolic mm Hg (lower #) less than 120 and less than 80 Prehypertension 120 – 139 or 80 – 89 High Blood Pressure (Hypertension) Stage 1 140 – 159 or 90 – 99 High Blood Pressure (Hypertension) Stage 2 160 or higher or 100 or higher Hypertensive Crisis (Emergency care needed) Higher than 180 or Higher than 110 Hypertension versus Hypotension Hypertension More common than hypotension Thickening of walls Loss of elasticity Family history Risk factors Hypotension Systolic <90 mm Hg Dilation of arteries Loss of blood volume Decrease of blood flow to vital organs Orthostatic/postural Pain ALWAYS assess for pain when taking vitals and after providing pain relief measures Location / character / Level / what can help to relieve? Rate on a Scale of 1 to 10 Pain assessment PQRST P = Provocation and Palliation Quantity How does it feel, look or sound? How much of it is there? R = Region and Radiation What causes it? What makes it better? What makes it worse? Q = Quality and S = Severity and Scale Where is it? Does it spread? Does it interfere with activities? How does it rate on a severity scale of 1 to 10? T = Timing and Type of Onset When did it begin? How often does it occur? Is it sudden or gradual Health History Primary subjective data Biographical data : name, age, sex Chief complaint / reason for visit History of present illness History of other illnesses Family history of illnesses Review of systems head to toe (asking questions, receiving subjective data) Life style = personal habits, diet, sleep patterns, amount of exercise etc… Social data = support systems, occupation Psychological data, observations of both verbal and nonverbal queues. Description of Chief complaint When did the symptoms first appear? Was it sudden or gradual? How often does the problem occur? Exact location of distress? Character of the complaint Intensity of pain / quality of sputum / amount of discharge … Factors that aggravate or relieve symptoms Methods of Data Collection Patient-centered interview = An organized conversation with the patient Set the stage (preparation, environment, greeting). Set an agenda/gather information about patient’s concerns. Collect the assessment or nursing health history; assure the patient of confidentiality. Terminate the interview (cue the end). Interview Techniques Open-ended vs. closed-ended questions Back-channeling Probing ------------------------------------------ Because a patient’s report includes subjective information, validate data from the interview later with objective data. Obtain information (as appropriate) about a patient’s physical, developmental, emotional, intellectual, social, and spiritual dimensions. Physical Examination Chapter 30 , Assessment of each body system Follows the nursing history Systematic and organized Head-to-toe approach Techniques of Physical Assessment Inspection Palpation Percussion Auscultation Inspection Use adequate lighting. Use direct lighting to inspect body cavities. Inspect each area for size, shape, color, symmetry, position, and abnormality. Position and expose body parts as needed so all surfaces can be viewed but privacy can be maintained. When possible, check for symmetry. Validate findings with the patient. What do you assess by inspection? Palpation Used to gather information Use different parts of hands to detect different characteristics Hands should be warm, fingernails short. Start with light palpation; end with deep palpation. What do you assess by Palpation? Percussion Tap body with fingertips to produce a vibration. Sound determines location, size, and density of structures. Auscultation Involves listening to sounds Learn normal sounds first before identifying abnormal sounds or variations. Requires a good stethoscope Requires concentration and practice Bed Side Assessment Your lab “final” will consist of a Bed Side Assessment Vital signs General Survey & Mental Status Skin Chest / Lungs Heart & Major Vessels Peripheral Vascular Assessment Abdominal Assessment Neurological Assessment General Survey / Mental Status what are we assessing? Mental status Overall observation (grooming / appearance / odor? posture & gait) Oriented to Person, Place, Time (oriented X 3) Affect / Mood (appropriateness of responses / cooperative) Speech (fast / slurred / slow / clear) Able to express thought clearly / reality based Any expressed concerns? General Survey / Mental Status documentation Slender female with good posture and steady gait. Cooperative and friendly, able to maintain eye contact while conversing. Speech at normal rate and easily understood, she is oriented to person, place and time and situation. Able to express thoughts clearly. Skin Integument Color Pigmentation Cyanosis Jaundice Erythema Moisture Temperature Texture Turgor Skin (cont’d) Vascularity ABCD: Edema Lesions Asymmetry Border irregularity Color Diameter Skin (cont’d) Skin Inspect for color Assess edema if present List any lesions / describe Assess for moisture Assess for temperature / compare bilaterally Assess for skin turgor Assessment Condition of the Skin documentation Client has no current complaints associated with the skin. Skin color is uniform and warm to touch. Skin intact with no moisture, edema or lesions noted. Skin turgor is good with no tenting. HESI Go to: https://evolve.elsevier.com COURSE ID: 10358_nhaugen_1007 USE SAMUEL MERRITT EMAIL WHEN SETTING UP AN ACCOUNT What did we cover today? Vital signs Health history Physical assessment Assessing General survey & the skin