Patient Assessment

1. Patient Assessment

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

3. Vital Signs • Temperature • Pulse • Respirations • Blood Pressure • Oxygen level per protocol – Pulse Oximeter

4. Vital Signs Are Measured: As often as required by the person’s condition or physician’s orders. Examples: • Upon admission • 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.

5. 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

6. 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

7. Body Temperature • Factors that  body temperature • Starvation or fasting • Sleep • Decreased muscle activity • Exposure to cold in the environment • Factors that  body temperature • Illness • Infection • Exercise • Excitement • High temperatures in the environment • Temperature is usually higher in the evening

8. 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

9. 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

10. 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

11. Types of Thermometers • Electronic: Used orally, rectally, or axillary. Must use disposable probe covers. • Tympanic: Placed in auditory canal and must use disposable cover. • Strips: Strip that contains special chemicals or dots that change colors.

12. 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

13. Pulse Sites Most Commonly Used: • Carotid • Apical • Brachial • Radial (most common site to check pulse) • Femoral • Popliteal • DorsalisPedis • Posterior tibial artery

14. Normal Ranges Bradycardia – Under 60 beats per minute Tachycardia – Over 100 beats per minute

15. Factors that Affect Pulse • Factors that  pulse • Exercise • Stimulant drugs • Excitement • Fever • Shock • Nervous tension • Factors that  pulse • Sleep • Depressant drugs • Heart disease • Coma

16. 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 breaths per minute

17. Assessing Respiration • Respirations are 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.

18. 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

19. 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

20. 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

21. 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.

22. Normal Range of Blood Pressure • Systolic: Pressure on the walls of arteries when the heart is contracting. • Diastolic: Constant pressure when heart is at rest • 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

23. Measuring Height and Weight • Used to determine if patient is underweight or overweight • Height and weight charts are used as averages • 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

24. 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

25. Types of Scales • Clinical scales: balanced manually or digital with an attached or detached measuring rod for height. • Bed scales or Chair scales: used for patients unable to stand • Infant scales: balanced manually 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.