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Health Skills I. Unit 102 Vital Signs. Objectives. Identify observational techniques for determining the health status of a patient. Unit 102.1 Observational Techniques. Observation of Patient observe physical signs and alertness listen to patient and ask questions. Objective Data.

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health skills i

Health Skills I

Unit 102

Vital Signs

objectives
Objectives
  • Identify observational techniques for determining the health status of a patient.
unit 102 1 observational techniques
Unit 102.1Observational Techniques
  • Observation of Patient
    • observe physical signs and alertness
    • listen to patient and ask questions
objective data
Objective Data
  • can be observed or tested by healthcare provider
  • overt, not concealed
  • Examples:
    • observe that a patient refused to eat
    • measure an increased temperature
    • observe drainage from a wound
    • skin is warm to the touch
    • vomited 300 cc
subjective data
Subjective Data
  • information perceived only by the affected person
  • Examples:
    • feels nervous
    • pain in the abdomen
    • nauseated
    • feels chilled
senses to collect data
Senses to Collect Data
  • Look
    • observe visible signs that indicate a problem
  • Listen
    • patient’s complaints, description of the problem in their words
  • Feel
    • degree’s in body temperature, pulse quality
  • Smell
    • unusual odors
collecting data inspection
Collecting DataInspection
  • visual examination
    • signs of movement and posture
    • skin color signs of distress
    • ability to maintain health practices (hygiene, dress)
    • gait
collecting data auscultation
Collecting Data Auscultation
  • listening with use of a stethoscope
    • blood pressure
    • heart sounds and/or rate
    • lung sounds
    • bowel sounds
    • detecting bruits
collecting data palpation
Collecting Data Palpation
  • examination of body parts through feeling with fingertipsand hands to
    • assess skin temperature
    • determine pulse rate, quality,rhythm, absence or presence
    • lumps/masses
    • abdominal tenderness/distention
collecting data percussion
Collecting Data Percussion
  • tapping body parts with your fingers and listening to sounds produced to
    • detect presence of air
    • evaluate amount of fluid in a body cavity
    • determine size, borders and consistency of body organs or masses
purpose of systematic physical assessment
Purpose of Systematic Physical Assessment
  • to determine physical and emotional changes through step by step observation
  • NOTE:
    • apparent state of health, does patient seem acutely ill?
signs of distress
Signs of Distress
  • NOTE:
  • dyspnea (difficulty breathing)
  • vomiting
  • pallor
  • pain
  • crying
  • evidence of nervousness
skin color
Skin Color
  • NOTE:
    • pink
      • indicates adequate oxygen levels
    • pallor (pale)
      • major organs being challenged with fluid or blood loss, peripheral blood is being shunted to the core of the body to self protect them
    • ashen (gray)
      • body systems begin to suffer due to decreasing oxygen level in blood
skin color1
Skin Color
  • NOTE:
    • cyanotic (blue)
      • indicates that body systems are in critical state due to an excessive amount of blood not carrying oxygen
    • flushed (pink/red)
      • harmful levels of carbon monoxide or increased carbon dioxide levels are present
      • Ketoacidosis (high blood glucose levels) will cause flushing, as will hypertension (high blood pressure)
stature build
Stature & Build
  • NOTE:
    • large/small body frame
    • obesity
    • congenital anomalies (changes from normal at birth)
posture motor activity and gait
Posture, Motor Activityand Gait
  • NOTE:
    • deformities
    • spine curvature
    • gait
      • shuffling
      • stable
dress grooming and hygiene
Dress, Grooming and Hygiene
  • NOTE:
    • if appropriate
    • clean
    • neat
odors body and breath
OdorsBody and Breath
  • NOTE:
    • breath for acetone odor (may be diabetic)
    • alcohol odor (may be cause of problem)
    • urine odor (incontinence)
    • poor hygiene (emotional disturbances or social issues)
relationships manner and mood
Relationships, Manner and Mood
  • NOTE are they:
    • pleasant
    • smiling
    • making eye contact
    • initiating conversation
    • crying
    • appropriate conversation
    • following directions
  • depressed
  • anxious
  • agitated
  • elated
  • flat
speech
Speech
  • NOTE:
    • clarity
    • slurring
state of awareness and consciousness
State of Awarenessand Consciousness
  • NOTE, are they:
    • alert
    • oriented to:
      • person
      • place
      • time and significant others
    • drowsy
    • is response time appropriate
support or monitoring devices
Support or Monitoring Devices
  • NOTE, does the patient use a:
    • walker
    • wheelchair
    • prosthesis
    • hearing aid
    • glasses
    • dentures
    • are these supports and devices working properly and is the patient knowledgeable in using them?
facial expressions
Facial Expressions
  • NOTE:
    • tension
    • grimacing
    • affect
      • happy
      • sad
      • flat
reporting observed data
Reporting Observed Data
  • reporting should be done promptly, accurately, and objectively
  • identify need for emergency care
  • may play role in treatment plan by others
  • may indicate a need for medication changes
  • to know if patient is improving or not
  • documentation important for 3rd party payment (Insurance)
knowledge assessment
Knowledge Assessment
  • Compare and contrast objective and subjective data and give examples of each.
  • Define and give examples of when inspection, auscultation, palpitation, and percussion are used.
  • Describe items of a physical assessment. (Example skin color, stature and build)