General Survey Health Assessment

General survey Health assessment 1/29/2022 Video demonstration Name , DOB, physician name MRN # Allergies . height , code status Weight & comments Patient summary below; principle problem Vital signs Heart rate , blood pressure , respiratory rate , temperature ● ● ● ● ● ● ● ● ● ● ● ● ● Nurse introduces himself. Ask the patient name , dob , and age. After the exam , shell check weight and BMI. Can you tell me about your general health ? The nurse identifies the client as oriented. She stated her name , and identified her birth date , reason , and why she is here. I have an initial sense of her health status by observing her. She doesnt show any signs of visible stress. I don't see any wounds / lesions. I noticed acne on her face though. Maybe this is routine for her . I am going to ask her about it to see if it pertains to any of her symptoms. The nurse asks the patient about her cane Patient states she has been feeling more stressed lately. Do you know what's causing your stress ? She thinks the client should discuss more with her provider The nurse sees her facial features are symmetrical. She has a good posture She noticed stiffness in her right leg. The client says she does have some pain in her knee when she walks. She asks the client about her pain rate on a scale 0-10. ● Approach to initial survey and assessment - It helps determine a client's general health status 1/32 - During initial survey ;perform a quick overall assessment of the client ; also add any body system issues that needs a focused assessment ● Observation begins soon as you walk in the room. ESTABLISH TRUST AND BUILD RAPPORT through therapeutic communication 2 forms of communication a. Verbal b. Non verbal Verbal communication ● Active Listening ● Empathy ● Being respectful ● Showing acceptance Try to prevent interruptions; promotes active listening Show empathy by identifying with what a client is feeling and allowing the client to express those feelings; communicating acceptance. Allowing the client to express concerns early in the assessment helps build rapport and establish trust. Nonverbal communication Therapeutic communication ; warmth , interest, availability. Ensure 4-5 ft for personal space when performing a physical assessment. Sit at client eye level. Maintained a calm and relaxed posture. Gestures ; nodding to encourage the client to continue conversation Display pleasant facial expression ; smile when greeting the client. Miscommunication Cultural / personal reason , past experiences, current emotional and physical state. The client's verbal and nonveral responses will indicate how they have interpreted what you said. Ex. client looking away. → uncomfortable Initial assessment checklist Observe client appearance , behavior , body , structure , and mobility. Note indications ; abuse . neglect , human tracking. 2/32 Obtain measurements; height , weight , BMI , vital signs , and assess pain. ‘ General appearance Notice respiratory signs of acute distress Considered relative to clients stated age Sexual development is observee in realtion to age Identify abnormalities in skin color and integrity. Note movement and symmetry of facial features . Assess level of consciousness to determine the client is alert/ oriented person , place , and time. Behavior Observation of client speech , mood, and aect a. Does the client articulate clearly and express coherent thoughts ? b. Is the flow of speech evenly paced ? c. Is the client pleasant and cooperative ? d. Are the client's facial expressions fitting for the situation ? e. Is the client appropriately dressed and groomed ? Indicators of abuse, neglect , and human tracking Note any signs the client may be experiencing elder or vulnerale adult abue or negelct , intimate partner violence , human tracking. Older adults ( dementia , functional deficits ) more likely to experience physical and psychological abuse or neglect; unrecognized and underreported Human tracking can include sexual and labor traficking Clients may be reluctant to talk about this. Body structure Note the client's body structure and assess the client's posture and positioning 3/32 ● Does the client have observable body alterations ? ● Are body parts symmetrical and proportional ? Mobility Focuses on gait and range of motion. Observation of the client walking toward and away from you. The client's ability to fully move each joint. Identify and involuntary movements. Measurement Height and weight - Results relation to age - Calculate and evaluate body mass index Vital signs Obtained baseline assessment of a client's health status. Correct order : 1. temperature ; consider route. 2. Pulse; observe rhythm ,, rate , & strength 3. Pulse oximetry 4. Respirations 5. Blood pressure The frequency of measuring vital signs depends on the stability of the client. Less stable ; more often to obtain vital signs Pain Observation of nonverbal cures Asking client subjective questions Nonverbal cues; grimacing , lying still , bracing. Ask the client about provocation/palliation factor and pattern of the pain , quality or intensity of pain, region of pain , and if the pain radiates , severity and time the paion started . Also ask about aggravating / relieving factors. Appearance 4/32 Objective and subjective data Findings may be present ; shortness of breath , wheezing . verbal/nonverbal manifestations of severe indications of pain. Facial features Symmetry and facial features and movement are expected. Unexpected findings ● Expressionless / mask like face ● Asymmetrical facial features ( drooping eyelid . drooping one side of the mouth ) ● Involuntary facial movements ( twitching, excessive blinking) ● Swelling and lesions The emotional state can be determined ; survey of clients behaviors and statements. A relaxed posture , smiling , responsiveness to communication is indication for calmness Unexpected; restless ,grimacing , or quiet. ● This can indicate the client is in pain , anxious. Upset. ● Anger , distrust , depression, and sadness as well. They may propose these emotions through uncooperative ,withdrawn/tearful. Eye contact Findings; eye contact. - Culture and shyness can aect this. Unexpected findings : ● Avoidance can indicate confusion , anxiety , defensiveness ● Communication of negative feelings ● squinting/staring can be manifestations of eye dysfunction Level of consciousness Note the client is alert and oriented ; person , place, time , and situation Determined when greeted and asked questions. If the client is awake or aroused , does the client respond appropriately. Unexpected findings ; 5/32 Confusion , lethargy , stupor, obtundation, and coma. Lethargy ; lack of energy and enthusiasm. Stupor; near anxiousness or insensibility Obtundation; ; similar to lethargic. ( lessen interest in the environment , slowed response to stimulation, and tends to sleep more than normal with drowsiness in between sleep states). a. Delirium has acute confusion that comes and goes b. Chronic dementia ; progressive confusion c. Lethargic and not fully awake. Quick to fall asleep , and lack of interaction , but easily awakened by calling their name. d. Obtunded is sleep and only easily aroused with a loud auditory / physical stimulation. Client is confused and speaks in one word sentences when awake and falls back asleep without constant stimulation e. stupor/unconscious , but will respond to physical stimuli / pain with movement or incoherent vocalizations. f. Comatose is completely unconscious. Has no response to physical or painful stimuli. Skin Make this the skin is intact and warm to the touch. Unexpected ; cool , hot , sweaty ( diaphoretic) , clammy skin. Abnormalities in color tone. Uneven tone ; whitish ( pallor) blueishe(cyanosis) , yellowish ( jaundice ) , reddish ( erythema) skin color. Note any obvious lesions Behavior Assessed during the initial survey. Speech , mood , and aect are part of this. Speech observation: Look for fluency , pace ,and articulation. 6/32 ● Is the client able to speak their primary language easily and appropriately? ● Does the client speak with ease ? or a struggle ? ● Clients' speech clear and evenly paced ? or slurred , garbled , or without any expression ? Unexpected : can be indicative of a disorder. ● If the client can only whisper / horse voice ; laryngeal disease ● Dysarthria , if word choice is appropriate but sounds are unclear. ● Form of aphasia; struggles to find words or express ideas. ● Word choice unusual; indication if thought princess abnormality; echolalia. The client's speech also shows how the client is feeling. Rate , tone , volume , and pauses all have meaning. a. Clients can have sarcastic , unbelieving, hostile tones. b. Client pace and volume may be fast and loud ; indicates anxiety. c. Quiet voice ay be to fear and shyness d. Pauses before answering a straightforward question ; indication the client did not hear the question or that they are developing an answer that might not be completely truthful. e. Depressed ; may take a long time to answer , and speech may be quiet and monotonous. Monotonous; dull ,tedious , and repetitive.; lacks variety and interest. Mood State of emotion. Observe clients emotions that are expressed. Can ask directly “ how are you feeling” to assess clients moo Aect is the physical expression of their mood. - How it appears to others. Usually nervousness and crying = understandable A client that is pleasant / cooperative is expected . 7/32 Unexpected ; a client that is laughing and smiling talking about a dicult situation ; inappropriate Face remains expressionless ; flat aect ; indicates depression. PErsonal hygiene Also assessed. ● Client grooming , body and breath colors , and expecting dental hygiene. ● Begins with greeting clients; further assess with weighting and performing vital signs. - This involves close contact - Frequency of bathing , shaving , and use of deodorants vary among cultures, socioeconomic classes, and occupations. Grooming ; clients clothing , hair , and nails Determine if the clothing and hair are appropriate, clean , and fitting to weather. Expected : clean clothing that fits well. Facial hair is well maintained ; nails trimmed and clean A patient's clothing mismatched / unbuttoned correctly and hair is dirty or not combed may be depressed , have a cognitive disorder , or be abused if dependent on a caregiver. ● Clothes too loose or tight ; weight loss or weight gain ● Wearing long sleeves on a hot day might have a problem with metabolism or hide injuries / needle marks. Odor Breath and body odor. Expected ; neutral / pleasant odors Unexpected : Halitosis / bad breath ; indicative of poor oral hygiene. Specific odors ; alcohol, fruity breath ; indication of diabetes , malnutrition, or dehydration , ammonia→ relation to kidney disease. Musty body odor/ breath ; liver disease. Fetid odeon ; dental respiratory infection ( fetid : smelling extremely unpleasant) Fecal breathe odeon; indication of vomiting due to a problem with bowels. DEntal hygiene Observation of lips , gums, and teeth, Expected ; lips smooth and moist Color ; pink to brown , or even darker than the surrounding skin. 8/32 Gums /gingiva ; should be intact , moist , firmly attached to teeth and scalloped shape. Color of gums vary from pale / coral pink in lighter skin tones ro brown / darker skin tones Dark skin tone ; dark line along the gum margin Teeth ; intact , aligned , and smooth. Color varies ; white - pale yellow and can appear gray in some individuals. Unexpected findings: Dry and cracked lips ; dehydration / excessive licking of lips Presence of lesions / cold sores or scabbed areas .. can indicate infection of disease processes. Gums that are bleeding , swollen , overgrown , spongy , retracted , discolored. Teeth that are missing , misaligned , broken. Teeth that are brown/ dark yellow can indicate infection of medication side eects , smoking , poor dental hygiene , excessive fluoridation in the wantal , dental caries. Also, brown discoloration of teeth can indicate excessive fluoride , and yellow can indicate tobacco use, Look for missing / broken teeth. Body structure and mobility Assessed during the initial survey. Clients' posture and overbuild are included. Gait ; mobility status Posture ; how the client positions himself while standing and sitting. Also , observe symmetrical positioning of hips and shoulders. Expected findings; standing/ sitting upright with ease, arms relaxed at the side. Standing ; straight vertical line through outer ear, shoulder , hip, patella , and ankle, Older adults ; hunched older as kyphosis. Unexpected : Slumped / rigid posture and fidgeting Sti neck and spine moves as one unit ; indication of immobility or pain → arthritis 9/32 Slumped shoulders , erect , and rigdi position , bent posture ; indication of emotional distress Diculty breathing and leaning forward with arms resting on knees ; tripod position Clients with abdominal pain will often lie curled up in the fetal position / guard their abdomen with crossed arms. Overall body build: Make sure height is within reference range. Expect extremities for bilateral symmetry and observe if they are proportionate to their body size. Add overall impression of the client's nutritional status. ( does the client appear well nourished , anorexic , or obese ) Expected ; weight evenly distributed for height range. Uneven distribution of weight face, neck , and tunk ; endocrine disorder Unexpected : height above / below expected range. Asymmetry of a body part / elongated or shortened limbs compared to rest of the body. Mobility Observation of gait , range , motion , and involuntary movement Gait ; look for coordination of movements and distance between feet. Observe arm movement and symmetry. Expected : smooth, steady movements / feet and shoulder width apart Arms should move freely and evenly Able to rise / sit into a chair without the use of arms to push um from the chair / lower oneself to a seated position Expected ; use of assistive devices for ambulation. Unexpected : wide stance , stumbling , shuing , dragging , limping , immobility of leg , guarding , diculty coming to a stop, Inability to rise from seated position / to go from a standing seated position without placing hands on the arms of the chair. Range of motion Examine full nobility of the joint and compare opposite sides for symmetry. 10/32 Expected ; movements that are conscious , controlled ,coordinated, symmetrical between bright and left sides Unexpected : Limited range of motion Pain with movement Immobility due to paralysis or injury jerky/ uncoordinated movements Hesitancy with movement Asymmetry between left and right joints Crepitus / crackling sound made when bone surfaces rub against each other . Involuntary movements Relation to alterations in muscle tone or muscle movement ( both are unexpected ) 1. Spasticity 2. Rigidity 3. fasciculation 4. Myoclonus 5. Tic 6. Tremors. Spasticity; alteration in muscle tone manifested ; increased tonicity Ex. increased resistance when attempting to passively extend a joint. Rigidity; alteration in muscle tone ; resistance to any manipulation of the joint. Fasciculation; alteration in muscle movement ; continuous , rapid twitching of a muscle at rest Myoclonus; alteration in muscle movement that is sudden jerking of muscle. Ex. hiccups , seizure activity , single myoclonic jerk of the arm/ leg when falling asleep. Tic ; alteration in muscle movement ; involuntary, repetitive movement of a muscle group Relation to neurologic / psychogenic causes. Ex. grimaces, winks , and shoulder shrugs. 11/32 Tremors ; Alteration in ,muscle movement; opposing muscle groups that results in rhythmic movement of one or two joints. Tremors can occur at rest / attempting voluntary and purposeful movement. Measurement During initial survey ; height , weight , body mass index, and waist circumference - Baseline measurements comprare tehri current measurements Height: Stadiometer ; measures height. Found as a measuring pole apart from an adult balance scale ; wall mounted device. - Pull up the measuring pole and extend the headpiece before measuring. - Removal of sutures required. Client should hold head up and look straight ahead. Adult height ; inches and centimeters. Clients that are unable to stand ; measured by placing clients in supine position on a firm surface. Remove their shoes ,and use a tape measure to determine their height by measuring from the tip of the head to the bottom of the heel to foot. Weight: Balance / electronic scale Measured ; kilograms or pounds Removal of shoes and outerwear. Weight automatically calculated. Balance scale has a : larger weight that is moved from 50 1b(22.7kg) increments and a smaller weight ; nearest 0.25 lb (0.1kg) Calibration is needed ; 0 12/32 Instruct the client to stand in the center of the scale platform and then adjust the large and s,a;l wighs to balanced weight. When weights need to be monitored closely; weigh the client at the same time each day , and have the client wear the same type of clothing. Unbeqarin weight client; beds and chairs with built in electronic scales are available in hospitals and other facilities. Identify if the client is in expected reference weright range, underweiight , overweight, obese. Use the weight charts based on the clients age and sex. Do not pass judgement or alarm to overwight and obese clients. Expected ; body weight influenced by genetics , exercise , diet , and fluid volume. Genetics determine bone structure and body mass. Unexpected ; Unintentional weight change alerts you to an underlying condition Unintentional weight gain ; 5 lb a day. - Indication; fluid retention and heart failure. Unintentional weight loss ( 5%) of body weight in a month; 10% in 6 months ; indication of disease process ; fever , infection , malignancy , endocrine disease. BMI ; calculated on ll clients Used to assess healthy weight and is a preferred method of identifying body fat over assessing body weight alone. BMI; weight ( lb)/height (in)2 x 703 BMI classification ( adult ● Underweight; less than 18.5 kg/m ● Healthy weight 18.5 to 24.9 kg/m ● Overweight 25-29.9 kg/m ● Obesity 30 and above BMI ; greater than 30 = increases risk for hypertension , diabetes mellitus, cardiovascular disease , and cancers. Adolescent growth curve 13/32 Height and weight obtained every visit. Routine until the client is finished growing between 18-20. Recorded on a growth chart. Clients height and weight are compared with growth curves of general population of adolescents with the same age and sex. Continuously occurs throughout ; timing of growth spurts are inconsistent. Height/ weight older adults Experience a decrease in height by the time they reach their 80’s. Reason; thinning in vertebral disks , shortening of vertebrae, kyphosis, and mild flexion of the knees and hips. Since long bones don't decrease in size ; the older adult client will have a shorter trunk relative to extremities. Body weight also decreases. 80’s-90’s - Due to loss of muscle mass and subcutaneous fat. Fat is redistributed with loss in the face and extremities and gain in the abdomen and hips. Case study Preparing to calculate BMI ; 89 year old ; cachectic and weak. Weight 45.5 kg 173.3 cm tall Assess measurement data; According to the chart ; BMI is 14. Considered underweight Older adult height / weight : monitored along with dietary habits to assess risk factors. Poor nutrition increases the risk for infection and delayed wound healing. Secondary eects ; undernutrition extended hospital stays and increased hospital costs. Characteristics ; underweight , 89 years old , and weak ; important to assess the client's nutritional status and dietary habits. Therapeutic communication is used; a helpful opening statement “ your weight is below the healthy normal range , for someone your height” tells me about the foods you eat on a regular basis. During this conversation , you would ask open ended questions to determine the following: Questions : 14/32 a. b. c. d. e. f. g. h. i. j. k. Does the client need assistance with purchasing groceries? Need help with preparing meals ? Is the client able to eat meals independently ? Does the client skip meals on a regular basis? Any family or friends that live close by and available to assist with client needs? Does the client take nutritional supplements? Is the client on a special diet , food allergies , or food intolerances? Have diculty swallowing / chewing? How is the client's appetite ? Is the client eating from the 5 food groups ? Does the client receive financial assistance with purchasing groceries ? Vital signs During survey ; routinely measure Obtained for baseline of client health status Helps assess the eectiveness of clients' circulatory , neurological, endocrine , and respiratory systems. Includes ; temperature , pulse , respiration s blood pressure , pulse oximetry. A pain rating is included; subjective. - It also monitors the client's condition evaluating eectiveness of nursing and prescribed interventions. - Frequency ; stability of client - Monitored closely ; procedure / treatment places the client at risk for a change in condition. Can be delegated if the client is stable and baseline measurements have been obtained. External factors can aect vitals. ( room temp, physical activity, recent oral intake of warm/cold fluids , and noise level 15/32 Avoidance of these factors = better eectiveness. temperature : Regulated through heat production conservation , loss. Tissues / cell function best ; 36-38 C ( 96.8 and 100.4 F) Dierent parts of the body have dierent temps. Ex. core of the body ( rectal thermometer, invasive catheters inserted into arteries or urinary bladder)--> 0.5 C higher than the temp on the skin's surface; also aected by environmental temperatures. Thermoregulation; process to maintain core temp with optimal range. Involves physiological and behavioral mechanisms. Thermoregulation ; negative feedback. ( may malfunction ) When they're ill , or have a nervous function disorder. Metabolism , physical activity , and shivering provide thermoregulation. Metabolism ; chemical reactions; produces heat. Core temp decreased ; vasoconstriction / narrow vessels Aids by preserving temp and preventing heat loss. Vasodilation ; allos loss of heat through ; evaporation , radiation , conduction , and convection. Factors that aect temperature ; Consider their age , hormonal changes , stress level, and diurnal rhythms . Older adults ; lower core temp; increased metabolism , decreased in subcutaneous fat , diminished control of vasoconstriction/vasodilation ,, and reduced sweating. Body's temp has a diurnal rhythm of highs and lows based on the time of day. Temperature at its lowest ; early in the morning 1-4 am. Rises steadily ; peaking in the late afternoon ( 4pm) - This varies depending on the client's sleep routine. Tool used : Thermometers. Electronic and disposable, tympanic , and temporal artery. Electronics have 2 probes. a. One blue probe = oral use , b. red probe ; rectal; use. 16/32 Electronic is preferred because it oers greater accuracy and a quicker reading. Disposable thermometer; client in ; the readings aren't always accurate. Tympanic Temporal They are used to measure fahrenheit and celsius. For conversions between the 2 ; use formulas. Routes : Oral , rectal ,temporal , axillary , tympanic.. 17/32 Advantages and disadvantages for all. Make sure to select the safest ; most accurate route for the client. Use the same route when comparing measurement to baseline. Regardless of route used; observe infection procedures using a protective probe cover for the thermometer and cleansing thermometer between each client. Temperature ranges dier according to the dierent routes. Oral : ● Expected 36-38 C ( 96.8 - 1004.f) ● Average 37C ( 98.6F) ● Older adults 35-36.1 C ( 95-97 F) ; because of their less body fat. Rectal : 0.5 C ; 0.9 F higher than oral Temporal : nearly 0.5 C and 1F higher than oral Axillary : 0.5 C and 0.9 F lower than oral. Tympanic ; consistent with oral Oral : Before assessment ; make sure the client did not smoke or any oral intake. - This can alter the temp reading ; wait 10 mins to take their temp. Rectal: Provides the most accurate reading of core temp. Used less frequently ; invasive and more time consuming , increased risk of transmission of infection , and be uncomfortable. Route chosen for a client who cannot open or close their mouth ; comatose. Not used for ; clients rectal bleeding , diarrhea, rectal disorders ,, rectal surgery. Temporal : Accurate temp when combined forehead and behind ear readings are obtained.hold probe against the center of the forehead and move it across the forehead and then behind the ear. Axillary: Less accurate ; used less in adults. 18/32 Tympanic : Easily access; reflects core temp. Can be aected if the client has been lying on their side , cerumen is present in the ear canal , pathologic variances exist, infection of the ear is present. Unexpected findings: hyperthermia ; elevated body temp ( fever ) caused by infection , tissue break down, neurological condition. Flushed warm skin , diaphoresis, dry skin , and mucous membranes , change in mental status , possible seizures. Hypothermia ; low body temperature caused by prolonged exposure to a cold environment. Cool pale skin cyanotic in color, sluggish capillary refill, shivering and change in mental status. Pulse : About circulatory and cardiac status. Pulse ; palpable pulsation ; contractions from the heart and resultant blood flow through peripheral arterial systems. Determines ; heart rate, rhythms , and strength of contractions. By comparing arterial pulse sites on the right and left sides of the body, determines equality of pulses. Radial is located on the thumb side of the inner wrist . frequently used. Easy access. Apical / carotid pulse ; used if the client is unstable or has poor cardiac output. Pulse sites ; Temporal Carotid Brachial Radial 19/32 Femoral Popliteal; knees Posterior tibial Pedal ; feet Tools ; watch/clock Stethoscope ; for auscultation of apical pulse if necessary Apical pulse ; left center of chest , below the nipple. Dicult to assess radial pulse for obese clients, diminshed blood flow, weak heart contractions. Dicult pulses to locate /palpate; tuse of an electric doppler, ultrasound. Doppler detects sound ways and amplifies sounds of blood flow through the radial artery → handheld transducer and used to auscultate circulation. Palpation Palpation of pulse site ; apply pressure over artery with finger pads of index and middle fingers Press firm. Identify rhythm for regularity. Regular pulse ; count for 30 seconds and multiply by 2 = pulse rate. Irregular ; pulsations for 60 seconds.. During palpation ; note the rate , rhythm , strength , and equality of pulse. ( included upon completion of assessment) Pulse qualities : Rate and rhythm ; determine rate and pulsations in 1 minute. After counting ; decided if in the expected range based on their age. Average adult ; resting heart rate of 60-2mm / min. Adolescent; slightly slower 50-90 / min Bradycardia is expected in physically active adults Their hearts work eciently allowing for lower heart rate than expected reference range. 20/32 Unexpected ; a pulse rate less than 60/ min in an adult at rest. Bradycardia occurrence in certain med. Conditions ; hypothyroidism or hypothermia ( eects of some medications) - Assess the apical pulse rate and check the clients medication list. Tachycardia ; resting client heart rate greater than 100/min ● Temporary condition ; related to pain ● Adverse addicts from medications ● Anxiety ● Exercise ● Infection with fever The heart rate increases to compensate for the body's demand for oxygenated blood. ● Irregular rhythm; unexpected finding. ; dysrhythmia / arrhythmia Determine if consistent , pulse skipping every 4th beat ( documented as regularly irregular). ● Or no consistency to the rhythm( irregularly regular). Detection ; auscultate the client's heart for a more comprehensive assessment of dysrhythmia. Strength ; assess / amplitude of pulse during palpation. - It reflects - the force of heart contractions , - volume of blood ejected - And flow of blood to the pulse site. Measured on a scale of 0-4+ 0= absent ; impalpable pulse +1= weak; thready , diminished +2; normal , brisk pulse ( expected finding) +3; increased ; strong +4; bounding ; full volume pulse Normal pulse ; easily palpated ; not forceful or weak. Diminished pulse ; indication of a weakened heart muscle , hemorrhaging , poor vascular flow to pulse site. 21/32 Strong / bounding ; anxiety , increased activity , abnormal condition cause increased heart contractility and / increased blood pressure. Important assessment of peripheral vascular system ; bilateral equality / symmetry of pulse Assessed by palpating the same location of the pulse Ex. radial pulse on right and left side at the same time. ( compare rate , rhythm and strength) of the two. Usually they both will have equal characteristics. Unexpected ; diminished impalpable pulse on one side; indication of imapired blood flow due to a blood clot / malposition of the artery. Pulse oximetry (SPO)2 - Measured with pulse oximeter - Light wavelengths to detect the amount of oxygen bound to hemoglobin. - Readings ; percentages of saturation and estimates the client's arterial oxygen status - Measurement of oxygen saturation is included with other vital signs and provides information regarding the client's respiratory status. Tools; sensor that attaches to client ; nail polish remover if needed. \ Sites in sensory ; finger , nose , forehead, earlobe , and foot. Probes ; earlobe , forehead; faster and more reliable results for a client with poor peripheral flow. Not reliable if the oxygen is less than 70%. Factors that aect pulse oximetry readings Certain factors can alter transmission of LED light. a. Carbon monoxide poisoning , jaundice , painted / thickened nails , recent injecting of dyes into the circulatory system. And dark skin tone. b. Client movements; interference with external light sources 22/32 c. Impaired circulation ex. Peripheral vascular disease , hypothermia vasoconstriction, hypotension , and peripheral edema Assess for changes in oxygen saturation : ● Insect skin ● Nail beds ● & lips for cyanosis. ● Observation of breathing for normal rate , rhythm , depth , sounds. ● Behaviors ; irritability , restlessness, confusion ; signs of hypoxia. ● Note conditions that may alter readings ; use of oxygen therapy , bronchodilators , and low hemoglobin level. Expected : 95%-100% Unexpected : less than 90%. Abnormal and considered an emergency.--> further assessment Respirations : Exchange of oxygen and carbon dioxide - Ventilation - Diusion - & perfusion. - Involuntarily regulated by brain stem Very little equipment needed. Need a watch / clock with a second hand. They do not need to be aware you are counting their breath. They will slow them down , and try to count them also. Assessed by rate , depth , and rhythm, Rate : Expected ; varies between adolescents and adults. Teens; 16-20 a min Adults ; 12-20 min Unexpected : bradypnea ; rate less than 12 Tachypnea ; greater than 20 23/32 Depth : measured by an even , quiet , and regular breathing pattern. Expected : movies in and out ; easily observable. Occasional deep breaths are normal. Unexpected : shallow depth ; with minimal chest expansion during respirations. - Close observation needed ; assess respiratory rate when client has shallow respirations. Deep respirations ; Client uses full expansion for each breath. Term; labored breathing. The client is attempting to draw in as much as possible with each breath. Rhythm: Observe the rate / number of ventilatory ( inspiration / expiration ) in 1 min. Observe depth of movement of chest wall. - Description ; shallow , normal , deep. - Observe as regular or irregular, Expected ; regular rhythm, steady even rate. Depth : not deep or shallow. Unexpected :irregular respirations ; fluctuations with depth and rate. Irregular rhythm; counted for a full minute for accuracy. Factors that aect respirations 1. Exercise 2. Pain 3. Anxiety 4. Smoking 5. Body position 6. Medications 7. Neurological injury / alterations in hemoglobin Exercise ; alter respiratory pattern ; faster / deeper Causes rate & depth to increase for more oxygen , rid of carbon dioxide. 24/32 Pain ; chest / abdominal area; shallow breaths to minimize movement of chest / abdominal wall. Medication used ; can have adverse eects of slowing the clients rate of breathing → shallow Anxiety; increase due to stimulation of sympathetic nervous system Smoking; tobacco changes lining of airways in lungs ; inhibiting airflow and making breathing faster Body position ; sitting / standing straight allows fuller chest expansion. ● Slumped over inhibits full expansion ● Lying down ; prevents chest rise Medications: cause breathing alterations. Meds for relieving pain/ narcotics ; slow the respiratory rate by depressing the central nervous system. Stimulants ( amphetamines) breathe faster and deeper. Neurological injury / alterations in hemoglobin : Brain injury ; inhibit rate of rhythm & breathing Less hemoglobin: less oxygen and causes faster breathing Sickle cell blood cells; malformations that reduce oxygen carrying ability.--> increased respiratory rate and depth. Blood pressure: The force of pulsing blood on the walls of an artery ; good indicator of cardiovascular health. Peak of maximum pressure in arteries occurs when heart contracts and pushes blood into the vascular system ( systolic ) Minimum pressure ; ventricles relax and blood enters ( diastolic) Tools ; sphygmomanometer , stethoscope. 25/32 Electronic blood pressure ; useful when a client requires blood pressure assessments, invasive procedures during cardiac medications or when they're critically ill. Required equipment ; electronic blood pressure device with appropriate cu. Should not be used ; client has hypertension , hypotension, with a systolic less than 90 mm Hg, dysrhythmias, seizures , or experienced trauma ; the readings will not be accurate. Appropriate sized cu ; more accurate. Should cover at least 80% of the circumference of the limb being used. Width of cu approximately 40% of the limb. Expected for adult ; systolic is less than 120 mm Hg Diastolic less than 80 mm Hg Unexpected : Hypotension; systolic less than 90 mm Hg Diastolic pressure ; less than 60 mm Hg. Elevated blood pressure is a systolic pressure from 120-129 mm Hg, and a diastolic pressure less than 80 mm Hg. Hypertension is divided into 2 stages Stage 1 ; systolic pressure of 130-139 mm Hg ; diastolic 80-89 mm Stage 2 ; hypertension ; systolic pressure ; greater than or equal to 140 mm Hg ; diastolic pressure greater than 90 mmHg Alternative cu replacement Injuries , casts, ivs , dressings ; require placement on the forearm , or thigh. Use the same measurement guide as referred with the upper arm.\lower extremity blood pressure ; position client in a prone position; have the client flex their knee. Place blood pressure cu 2.5 cm ( 1 in ) above the location where the popliteal artery can be palpated. 26/32 Systolic in lower extremity ; 10-49 mm Hg higher than brachial artery. Factors that aect blood pressure 1. Smoking 2. Sex 3. Ethnicity 4. Diurnal volume 5. Medications 6. Obesity 7. History / hypertension or hypotension 8. Orthostatic blood pressure Smoking ; causes blood vessels to constrict Result ; higher pressures Sex; no stirct rules. Males in puberty and females past menopause may experience high pressures tha nolder adults. Ethnicity Whites are less likely to have hypertension than African americans. African Americans have among one of the highest incidence of hypertension ; experiences severe hypertension early in life. Increased risk for stroke , heart attack ,and death. Diurnal volume: increases during the day. Late afternoon ; decreases. Medications: can aect . Cardiac and antihypersensitive lower blood pressure. Opioid analgesics results in hypotension. Increasing ; vasoconstrictors and amphetamines. Obesity: plays a role in hypertension. 27/32 Overweight people tend to have higher pressures. History / hypertension or hypotension Helps determine the high/low readings is the baseline or if there is a significant change from baseline that requires intervention. Orthostatic blood pressure Taking multiple blood pressure readings in supine, standing , and sitting positions. Start with supine position. Rests for 3 minutes before blood pressure reading. Keep it in place and then sit the client up. Wait 1-3 min before reading. Then stand the client up and wait 1-3 min; a drop if 20 mm Hg in the systolic / decreased of at least 10 mmHg in diastolic pressure between positions indication orthostatic hypotension Pain scale 28/32 0. 1. 2. 3. 4. 5. 6. 7. 8. Pain free Very mid Discomforting Tolerable Distressing Very distressing Intense Horrible 29/32 9. Unbearable 10. Unspeakable Pain assessment is a vital sign ; individualized for each client. - Subjective ; perception of pain - Caused by ; physical / emotional cognitive issue Client rates pain. And describes what helps / worsen the pain. General pain assessment ; focus → physical pain , types , and collection data. Sources of pain Visceral , somatic , and referred ● Visceral: beings in large internal organs. ● Deep cramping , squeezing , dull pain Ex. appendicitis ( inflammation of appendix) , cholecystitis ( inflammation of gallbladder) and colitis ( inflammation of colon) This pain travels along the autonomic nervous system (ANS) Presence of pain ; nausea, sweating , and vomiting. Types of pain Acute & chronic pain 1. ● ● ● ● ● Acute: Acute ; transient pain. Short duration Related to injury / illness Does not last more than 6m Usually follows a pattern of healing and will resolve one the identifiable cause has been addressed. 2. Chronic: ● Last longer than 6m 30/32 ● Can last 20 years or more ● Recurring ; reach severe level ; may originate in an unidentifiable area. ● Clients may never feel total relief. ● 2 types of chronic pain 1. Malignant ( related to cancer) 2. non,malignant. Non malignant pain can be because of : musculoskeletal conditions ( arthritis , low-back pain) & nerve disorders ( fibromyalgia , peripheral neuropathy) Collecting subjective data Subjective ; and only described by the patient Better the client responds ; more able to treat Questions to ask : 1. Do you have pain ? 2. Where is your pain ? 3. When did it start ? 4. Describe the quality of your pain > 5. How much pain are you in now ? PQRST method ; asks questions that will extract more information for specific answers. ● provocation/palliation ; what were you doing when the pain started ? What makes it better or worse? Triggers ? Relieves it ? ● Quality: describe the pain ? is it dull/sharp? Stabbing , throbbing , or cramping ? ● Region: WHERE IS the pain > does it radiate ? or localized ? 31/32 ● Severity: how severe ? Does it interfere with any activities ? How long does it last? ● Timing: what time did it start ? How long does the episode last? Is it sudden / gradual onset ? Numeric scale To determine severity 0-10. Ask ; where are you on that scale? Where is the pain when treated at home ? What level of pain can you remain functional ? Not all information will be subjective. Some are objective too. ● Swelling , bruising , inflammation. ● Clients with increases heart rate / blood pressure ● Facial grimaces , guarding with movement ,clenching teeth, frowning. ● Look for restlessness / inability to pay attention or stay still. Physical findings do not always support the client's report of pain. Especially for chronic pain ; I learned how to adapt to continual presence of pain. Pain cues ; may be more subtle. ( messaging , sighing and decreased activity. 32/32