Client Assessment

1. Client Assessment

2. What is a Symptom? • Symptom: Any subjective evidence of disease. A symptom is a phenomenon that is experienced by an individual. Anxiety, lower back pain, and fatigue are all symptoms. They are sensations only the patient can perceive. In contrast, a sign is objective evidence of disease. A bloody nose is a sign. It is evident to the patient, doctor, nurse, and other observers.

3. What is a Sign? • Any objective evidence of disease. A sign can be detected by a person other than the affected individual.

4. Examples • What do you consider would be a sign? • What do you consider a symptom? • Gross blood in the stool is a sign of disease. It can be recognized by the patient, doctor, nurse, or others. • In contrast, a symptom is, by its nature, subjective. Abdominal pain is a symptom. It is something only the patient can know.

5. Scenario • You find an elderly gentleman collapsed on the foot path outside your home. It is a very hot day. He has a large graze on his left temple, and bruising is developing around his eyes. His left leg is shorter than the other one and rotated outwards. He is confused and drowsy when you try to ask him what happened. He says he feels sick, and has a lot of pain in his hip.

6. Signs Graze on temple Bruising around eyes Shortened & rotated leg Conscious but drowsy Confused Symptoms Feels sick Has pain in hip Signs & Symptoms

7. Terminology • B.D. ------ Twice Daily • QID------ Four times a day • P.R.N. ----As required • Mane ------ Morning • Nocte------- At night • AC----------- Before Meals • PC-------------- After meals

8. Vital Signs • What do you think vital signs may be? • Life signs. Include temperature, pulse , respirations and blood pressure.

9. Performing Health Assessment • The nurse to create a quiet , calm environment • Use interview techniques that enhance trust and confidence and takes into account cultural variations • Use communication techniques that ensure comprehensive, accurate information is received • Ensure all paperwork and equipment required is collected and functional • Record the information as it is received

10. Health Assessment • Biological data • Medical history- present and past • Family history of illness / disease • Any allergies – and the reaction • Medications • Psychosocial history • Spiritual requirements • Physical Assessment

11. General health / observation assesses • The patients degree of independence – how much assistance • The ability to perform ADL’S –how much assistance • The ability to interact with others –affect, cognitive ability, social aspects • Basic needs – safety, nutrition, hydration, oxygen • Specific needs – diabetes, wheel chair , aids, pain • Excretions and secretions- normal (bowel , urinary ) discharge

12. Performing physical assessment • The room is to be warm and well lit • The patient is to be informed about the procedure ( and each part of procedure) • Consent is to be gained • Patient’s dignity and privacy is to be maintained • Infection control to be maintained • The examination is to be systematic and organised

13. Skills used by a doctor Inspection A systematic approach is important to prevent omissions. The usual sequence that a doctor uses is : • – observing the general condition of various body parts, including any deviations from normal • Eg. The general appearance of patient, movement, lesion , etc

14. Palpation • Is touching or feeling body parts to determine texture, temperature, moisture, motion consistency of structures Eg chest and abdomen

15. Skills used by a doctor cont… Percussion. –Is tapping a portion of the body to elicit tenderness or sounds indication the density of underlying structures Eg – abdomen , chest

16. Auscultation Is listening ( a stethoscope may be used) Eg- heart sounds , respirations , cough, bowel sounds.

17. The assessment skills of an RN division 2 • General observation • Inspection • Hearing • Palpation • Smell

18. General observations (normal findings) of physical assessment • Physical development – as would be expected for chronological age • Behaviour- cooperative attitude and behaviour • Mood- mild anxiety or tenseness • Dress – dressed for the occasion • Gait – erect posture, coordinated, smooth and steady gait • Body build – bilateral firm , developed muscles, height / weight ratio

19. Vital signs and measurements • Vital signs are the life signs and include • Temperature • Pulse • Respirations • Blood pressure

20. Other measurements taken; • Blood glucose • Blood oxygen saturation • Height / weight • Urinalysis

21. What do they measure? • The state of the internal environment of the body. • Changes from normal can indicate alterations, in health status and may give rise to medical interventions / nursing care

22. When do we take vital signs • On admission to hospital, visit to doctor’s rooms, visit to clinics • Prior to surgery /post surgery • Pre and post diagnostic procedure • To gauge the effects of medication any change to patient’s condition. • Any change to patients condition. • When ordered by Dr. • As an assessment of patient at any time deemed necessary.

23. Internal environment • Hydrostatic pressures • Concentration of substances in the blood, body fluids and tissues (eg hormones, O2, CO2, wastes , electrolytes • Ph levels of body fluids especially blood. • Temperature of the internal environment.

24. Internal environment cont… Homeostasis of the internal environment is controlled by the nervous and endocrine systems. The central nervous system receives information from sensory organs and tissues The hypothalamus regulates temperature and relays information to the thalamus and pituitary gland (hormones) The brain stem contains the cardiac, vasomotor and respiratory centres The ANS responds to bring about homeostasis http://health.howstuffworks.com/adam-200092.htm

26. Internal environment cont… • Endocrine system • The thyroid gland (thyroxine) – controls the body’s BMR • Adrenal gland (adrenaline / nor adrenaline) places the body into fight/ flight mode or assists in returning it to rest / normal function

27. Guidelines to achieve accurate results in taking vital signs • Appropriate equipment chosen depending on patient’s requirements • Equipment s functional and calibrated. • Patient to be in a state of rest if possible. • If possible environmental, life style factors are to be controlled or minimised.

28. Guidelines to achieve accurate results The nurse to be aware of • Normal values for the patient • Medical history / therapies/ medications that may alter patient’s vital signs • How to read, interpret and record the findings accurately