University:
Georgetown University
Course:
NURS 528 | Advanced Health Assessment
Academic year:

2023
Views:

378

Pages:

2
Author:

Martin Ray

Health Assessment for the Clinical Nurse Leader Skills Lab General Survey, Measurement & Vital Signs General Survey:  Describe o Patient’s demeanor: o Dress: o Posture: o Speech: o Energy level: o Mental status:  Patient’s height & weight: o use metric system, cm = height, kg = weight, estimated or actual o Unable to stand: physically measure height o Zero-weight of bed beforehand Vital Signs 1.) Temperature *Varies per provider, service, surgical history Baseline temp: 35.8 to 37.3 Celsius ● Oral Temp ○ Blue tip is oral ○ Programmed in Celsius ● Rectal Temp ○ the red tip is rectal ○ most accurate method ● Tympanic Membrane Thermometer (ear) ● Temporal Temperature ○ Least accurate ○ Begin at the forehead, continue along the ear 2.) Pulse Normal sinus rhythm: (60-100) Abnormal: bradycardia/tachycardia ● Rate ○ Rate at which the pulse is ‘hitting your finger’ ○ 15 seconds X 4 = BPM (beats per minute) ○ Look at the patient breathing and assess the pulse ● Rhythm ● Force ○ 2+ = normal ○ ‘faint +’ ○ 3+, 4+ = full, bounding pulse 3.) Respirations - regular respirations: 10 – 20 breaths per minute - 15 seconds: watch chest rises and fall (Written as breaths per minute) - Sometimes more beneficial to do 30 seconds - Full minute: patient concern 4.) Blood Pressure Normal Ranges of BP - 110 – 140: systolic - 60-90: diastolic 5.) Oxygen Saturation (SpO2) Normal range - Greater than 92% - Patient-specific 6.) Pain ● Numeric rating scale (0-10) ○ “What pain are you? 10 is ____, 1 is ____.” ● Faces Pain Scale ○ Used for non-verbal, children, non-English speakers ● OLD CARTS (onset, location, duration, character, aggravating factors, relieving factors, timing and severity) ○ Mnemonic to remember what each stand for

Health Assessment For The Clinical Nurse Leader Worksheet

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