Gen Survey & Vital Signs and Assessment Techniques.pptx

General Survey, Measurement, Vital Signs and Assessment Techniques B. Brewster RN, MSN Ed Objective Data  General survey is a study of the whole person  Obvious physical characteristics  Overall impression  Consider the four areas: ...

General Survey, Measurement, Vital Signs and Assessment Techniques B. Brewster RN, MSN Ed Objective Data  General survey is a study of the whole person  Obvious physical characteristics  Overall impression  Consider the four areas:  Physical appearance  Body Structure  Mobility  Behavior Copyright © Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 2  General Survey  Physical appearance  Body structure  Age  Stature  Sex  Nutrition  Level of consciousness  Symmetry  Skin color  Posture  Facial features  Position  Body build, contour 3 General Survey (cont’d)  Mobility  Behaviour  Gait  Facial expression  Range of motion  Mood and affect  Speech  Dress  Personal hygiene 4 Copyright © 2014 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 5 Copyright © 2014 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 6  Assessment Techniques and the Clinical Chapter 9 Setting Cultivating Your Senses  Skill of using senses of sight, smell, touch, and hearing to gather data  Develops over time with practice  Technical skills plus knowledge base  Skills of physical examination are inspection, palpation, percussion, and auscultation  Performed one at a time, in above order Copyright © Elsevier, Inc. Inspection  Concentrated watching, close/careful scrutiny  Compare patient’s right and left sides (symmetrical)  Use good lighting  Ensure adequate patient exposure  Will include instruments for specific body systems:  Otoscope  Ophthalmoscope  Specula: vaginal, nasal  Penlight Copyright © Elsevier, Inc. Palpation  Usingsense of touch can confirm points noted during inspection  Slow and systematic  Light versus deep palpation  Intermittent pressure  Bimanual palpation Copyright © Elsevier, Inc. Characteristics Assessed by Palpation  Texture  Rigidity or spasticity  Temperature  Crepitation  Moisture  Presence of lumps  Organ location and or masses size  Presence of  Swelling tenderness or pain  Vibration or pulsation Copyright © Elsevier, Inc. Palpation Techniques  Use particular parts of the hand:  Fingertips—best for fine tactile discrimination, for example, of skin texture, swelling, pulsation, and determining presence of lumps  A grasping action of the fingers and thumb—to detect the position, shape, and consistency of an organ or mass  The dorsa (backs) of hands and fingers—best for determining temperature because the skin is thinner here than on the palms  Base of fingers (metacarpophalangeal joints) or ulnar surface of the hand—best for detecting vibration Copyright © Elsevier, Inc. Percussion  Tappingskin with short, sharp strokes to assess underlying structures  Yields palpable vibration and characteristic sounds:  Location, size, density of underlying organ  Direct percussion:  Striking hand contacts body wall directly  Indirect percussion:  Stationary hand  Striking hand Copyright © Elsevier, Inc. Percussion Technique Textbook Explanation  As the textbook reads: “Why learn percussion when an x-ray study is so much more accurate? Because your percussing hands are always available, are easily portable, and give instant feedback.” Copyright © Elsevier, Inc. Information Obtained From Percussion  Characteristics of  Variation of percussion percussion notes: noted in:  Resonant  Amplitude  Hyperresonant  Pitch  Tympany  Dull  Quality  Flat  Duration Copyright © Elsevier, Inc. Auscultation Technique and Procedure Use sense of hearing for detecting sounds produced by heart, blood vessels, lungs, and abdomen, channelled through a stethoscope Fit and quality of stethoscope:  Diaphragm and bell endpieces Eliminate confusing artifacts Learning begins with comfort in identifying normal sounds (vs. abnormal and extra sounds) Copyright © Elsevier, Inc. Types of Equipment  Platform scale with height  Pocket vision screener attachment  Skin-marking pen  Sphygmomanometer  Stethoscope with  Flexible tape measure diaphragm and bell and ruler  Thermometer  Reflex hammer  Pulse oximeter (in  Sharp object (split hospital/clinic setting) tongue blade)  Flashlight or penlight  Cotton balls  Otoscope/ ophthalmoscope  Clean gloves  Nasal speculum  Lubricant  Tongue depressor Copyright © Elsevier, Inc. A Clean Field  Stethoscope common vehicle for transmission of infection  Always cleanse stethoscope with alcohol swab between patients  Clean versus used area for handling equipment used in physical examination  All equipment that is carried from patient to patient should be cleaned with alcohol Copyright © Elsevier, Inc. A Safer Environment  Hazards of nosocomial (hospital-acquired) infections  Proper handwashing practice  Gloves, masks, gowns, and protective eyewear  Public Health Agency of Canada (2012) guidelines for reducing transmission of bloodborne and other infections in hospitals  Routine practices  Transmission-based precautions Copyright © Elsevier, Inc. The Clinical Setting  General approach:  Patient’s and examiner’s emotional state  Value of laboratory practice  Hands-on practice with a patient:  Height, weight, and vital signs  Assessment of hands  Concentrate on one step at a time  Examination sequence  Brief health teaching  When findings are complicated  Summarize findings for person Copyright © Elsevier, Inc. Developmental Considerations - Children  Incorporating knowledge Preschoolers: limited body  of developmental image; allow play with principles and approaches equipment; use games; is key in physical compliment on cooperation examination  School-age: desire approval;  Infants: need for parental sense of modesty; presence; use of demonstrate equipment; distraction; perform least interest in how body works distressing aspects first  Adolescents: self-conscious and introspective; body  Toddlers: on parent’s lap; image and body comparison use of security objects; (need feedback that body is enhance autonomy; healthy and normal); demonstrate procedures idealistic and amenable to on parent first health teaching; wish not to be treated as a child Copyright © Elsevier, Inc. Developmental Considerations Older Adults  Pace of examination may need to be slowed  Physical touch is important if hearing and vision are diminished  Be alert to distinction between effects of visual or hearing impairments and confusion  Impact on health of losses related to body changes, energy, retirement, financial security, longtime home, spouse and/or friends Copyright © Elsevier, Inc. Waist - Hip Ratio  Waist circumference - Stand up straight and breathe out. Use a tape measure to check the distance around the smallest part of your waist, below the rib cage and just above the iliac crest  Hip circumference - The distance around the largest part of your hips — the widest part of your buttocks.  Calculate your WHR by dividing your waist circumference by your hip circumference.  Measuring fat distribution 23 Temperature  Temperature  Hypothalamus as thermostat mechanism  Influences on temperature  Diurnal cycle  Menstrual cycle  Exercise  Age  Routes of temperature measurement: Core vs surface temperature  Tympanic, Temporal artery, rectal  Oral; Axillary; Skin Measuring Body Temperature  Goal: to obtain a representative average temperature of core body tissues or surface  Normal range: 35.8 – 37.3 Celsius Copyright © Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 30 Special Considerations  Teaching  Maintaining body temperature  Risk factors for hypothermia, frostbite, and heatstroke  Taking antibiotics as directed  Pediatric  Physiologic differences  Swaddling  Gerontologic  Lower normal temperature (greater risk for hypothermia)  Physiologic differences  Home care  Environmental conditions that influence temperature  Mercury-in-glass thermometers Pulse  Pulse  Stroke volume  Technique of measurement  Rate adult 60-100  Bradycardia under 60  Tachycardia over 100  Normal rate for age group  Rhythm  Sinus arrhythmia  Regular or even  Force – 0, +1, +2 , +3  Equality - = bilateral  Assessing Radial Pulse  Goal: to assess the integrity of the cardiovascular system  Radial and carotid arteries commonly used  If irregularity noticed, count for 1 minute  Inspiration can cause fluxuations Respirations  Respirations  Adult Rate 10-20  Technique of measurement  Normal rate for age group  Ratio of pulse rate to respiratory rate should be approximately 4:1  Rhythm: regular, silent, smooth, relaxed automatic  Depth: shallow vs normal Depth =1 inch, deep Assessing Respirations  Respiration: the exchange of oxygen (O2) and carbon dioxide (CO2)  Assess ventilation by observing rate, depth, and rhythm of respiratory movements  Relaxed, regular, automatic, and silent  1 cycle = a complete rise and fall of the chest  Special Considerations  Teaching  Deep breathing and coughing exercises  Pediatric  Assess respiratory rates first, before other vital signs  Be aware of physiologic differences  Gerontologic  Restricted chest expansion  Reduced depth of respirations  Change in lung function  Dependence on accessory muscles  Home care  Assess for environmental factors that influence patient respiratory rate Copyright © 2014 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 37  Quick Quiz! The nurse receiving the report is told that her patient is having Cheyne- Stokes respirations. What will the nurse expect to find when assessing this patient? A. Slow but normal breathing rate B. Increased depth of respirations C. Alternating periods of apnea and hyperventilation D. Cessation of respirations for several seconds Blood Pressure  Blood pressure = the force of blood pushing against the side of the vessel wall.  Systolic pressure - is the maximum pressure felt on the artery during left ventricular contraction.  Diastolic pressure - is the resting pressure that the blood exerts constantly between each contraction  Pulse pressure = The difference between the systolic and diastolic pressures S-D = PP  Mean arterial pressure Evidence-Based Practice  Automatic blood pressure machines Do not give the same results as manual methods (stethoscope/sphygmomanometer) Systolic and diastolic values are lower INFLUENCES ON BLOOD PRESSURE  Age  Gender  Ethnocultural background  Diurnal rhythm  Weight  Exercise  Emotions  Stress Physiological factors controlling blood pressure  Cardiac output  Peripheral vascular resistance  Volume of circulating blood  Viscosity  Elasticity of vessel walls Factors Controlling Blood Pressure Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. Blood pressure measurement  Sphygmomanometer  Cuff width and size  Blood pressure measurement in the arm  Position of person  Palpate brachial artery  Proper inflation and deflation technique  Korotkoff’s sounds include  I: systolic pressure  IV: muffling of sounds  V: diastolic pressure BP Cuff sizing  Cuff bladder length should be 80% of the arm circumference.  Cuff width should equal 40% of the arm circumference.  Cuff width should equal 2/3 of the upper arm length Copyright © Elsevier Canada, a division of Reed Elsevier Canada, Ltd. Copyright © Elsevier Canada, a division of Reed Elsevier Canada, Ltd. Inflate Until Pulse Disappears, Continue up to 20 to 30mmHg Copyright © 2014 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 48 Copyright © Elsevier Canada, a division of Reed Elsevier Canada, Ltd. Common errors in blood pressure measurement  Related to patient status  Positioning  Cuff size  Cuff inflation errors  Observer error Special Considerations  Teaching  Risks for hypertension  Time and position to take blood pressure  Pediatric  Not routine for children younger than 3 years old  Risk of anxiety  Korotkoff sounds difficult to hear  Gerontologic Susceptible to cuff pressure injury Increased systolic pressure Fall in blood pressure after eating Postural hypotension  Home care Equipment/environment recommendations Copyright © 2014 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 53  Oxygen Saturation (pulse oximetry)  Measurement of oxygen saturation  Pulse oximetry  Sensor compares ratio of light emitted to light absorbed by hemoglobin and converts into a percentage of SpO2  Normal range: 97%–98% Probes can be applied to the earlobe, finger, toe, bridge of nose, or forehead Documenting  Results of TPR BP should be in the EMR or paper chart with date, time (24 hr clock), signature/initial.  BP size of cuff if different then regular  Temperature route  If abnormal results – comment in the nurses notes should occur.  Abnormalities should be reported to Primary/ Charge nurse. Copyright © 2014 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 56 Questions: 1. Significant elevation in blood pressure measurements from one day to the next could be attributed to which of the following? A. a decrease in cuff size. B. an increase in cuff size. C. new onset of pain or anxiety. D. both A & C. 2. The nurse is assessing a patient with a heart rate of 55 beats per minute. Which of the following patients would be most likely to have this rate? A. A 70-year-old cell phone salesman who is dehydrated B. A 20-year-old runner who had surgery 4 days ago for a fractured leg C. A 67-year-old who presented with an exacerbation of his COPD D. An infant who has a temperature of 37.8°C Copyright © Elsevier, Inc. Answers to Chapter 10 Questions  1. Correct answer: D Either of these factors could increase the numbers obtained when blood pressure is taken. Option A describes an artificial elevation, in which the actual value may not have changed. Option C would entail a true elevation of the value being measured.  2. Correct answer: B Athletes who train for endurance are likely to have a low resting heart rate because of a high cardiac output. Copyright © Elsevier, Inc. Chapter 9 Questions Assessment Techniques and the Clinical Setting Copyright © Elsevier, Inc. 1. Your physical examination of the patient should begin with the hands because: A. they are easy to reach from any position. B. they reveal a great deal about the patient. C. they will always be clean and dry. D. they are a place people are accustomed to being touched by strangers. Copyright © Elsevier, Inc. 2. Which of the following characteristics is not evaluated via palpation? A. Temperature B. Resilience C. Density D. Crepitation Copyright © 2019 Elsevier, Inc. Answers to Chapter 9 Questions  1. Correct answer: D There is no prominent clinical reason that the hands should be assessed first. Rather, it is important to begin in a way that is nonthreatening for the patient.  2. Correct answer: C Density is evaluated via the technique of percussion, rather than palpation. Copyright © Elsevier, Inc. 1. The nurse is performing an assessment of the abdominal region. What is the appropriate sequence for this examination? A. Palpation, percussion, inspection, auscultation B. Inspection, palpation, auscultation, percussion C. Auscultation, percussion, inspection, palpation D. Inspection, auscultation, percussion, palpation Copyright © Elsevier, Inc. 2. The nurse is preparing to do a physical assessment on a patient who is end-stage HIV-positive. What should the nurse do for self-protection? A. Wash hands and don gloves, a gown, and a protective face shield. B. Don gloves and wash hands after examination; no other protective equipment is necessary. C. Wash hands and don two pairs of gloves and a gown. D. Wash hands, don gloves, and wash hands after examination; no other protective equipment is necessary. Answers to ARQ Questions  1. The correct answer is D. The appropriate sequence for an abdominal examination is inspection, auscultation, percussion, and palpation. Palpation is performed last in the sequence to avoid eliciting pain or an abdominal spasm.  2. The correct answer is D. The nurse should always wash his or her hands prior to the examination. This patient should be treated using routine practices. Gloves are necessary with all patients, regardless of HIV status. Answer A is incorrect because a gown and face shield are not necessary for use with patients who have HIV infection. Answer B is incorrect because hands should be washed prior to the physical examination. Answer C is incorrect because double-gloving is not necessary. Copyright © Elsevier, Inc.. 67