BSN211 Clinical Health Assessment - Theory Lecture 2 PDF

BSN211 Clinical Health Assessment - Theory General Survey, Measurement, Vital signs, Pain Assessment, and Documentation 2024/2025 Week 2 1  Learning Objectives By the end of t...

BSN211 Clinical Health Assessment - Theory General Survey, Measurement, Vital signs, Pain Assessment, and Documentation 2024/2025 Week 2 1  Learning Objectives By the end of this lecture the students will be able to: 1. Recognize the aim of the initial assessment, identify the different components of general survey and vital signs measurements. 2. Identify the five assessments of vital signs. Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 2  Learning Objectives 3. Apply knowledge of physiological processes to explain the normal range of v/s findings in adults. 4. Identify the factors that might affect vital signs reading and explain the nurse’s responsibilities. 5. Give nursing diagnosis examples for selected abnormalities. 6. Follow the professional nursing documentation guidelines. Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 3  Introduction According to the JCI Hospital Standards, all patients must have an initial assessment that includes a health history and a physical examination. The initial assessment provides information to: Understand the care the patient is seeking. Form a nursing diagnosis and select the best care setting for patient. Understand the patient’s response to any previous care Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 4  General Survey and Measurements The General Survey What’s your first impression? First encounter- obvious physical characteristics It is an introduction to prepare for the physical assessment Gives an overall impression Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 5  General Survey and Measurements The General Survey Comprises: 1. Physical appearance Age, gender, level of consciousness, skin color, facial features, overall appearance. 2. Body structure Stature, nutrition, symmetry, posture, position, body built, contour, obvious deformities. 3. Mobility Gait and range of motion. 4. Behavior Mood, facial expression, speech, dress, personal hygiene. Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 6  General Survey and Measurements Measurement Weight Instruct person to remove his shoes and heavy outer clothes before standing on the scale Record the weight in kg. Height Use a wall-mounted device or the measuring pole on the balance scale. Align the head piece with the top of the head. Person should be shoeless & standing straight. Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 7  General Survey and Measurements Body Mass Index BMI: Weight (in Kilograms) Height (in meters)2 BMI is a practical marker of optimal healthy weight for height and an indicator of obesity or malnutrition Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 8  Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB 9  Abnormalities in Body Height and Proportion Hypopituitary Dwarfism: deficiency in growth hormone results in retardation of growth, delay puberty, hypothyroidism. Achondroplastic Dwarfism: genetic disorders in converting cartilage to bone results in short arms, legs and stature. Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 10  Abnormalities in Body Height and Proportion Gigantism: excessive secretion of growth hormone resulting in overgrowth of body. Acromegaly (Hyperpituitarism): excessive secretion of growth hormone in adulthood, causes overgrowth of bone in face, head, hands & feet. Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 11  Vital Signs: Definitions Temperature, Pulse, Blood Pressure, Respiratory Rate Indicate the effectiveness of circulatory, respiratory, neural and endocrine body functions. These measures referred to vital signs because of their importance as indicators of body’s physiological status. Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 12  Vital Signs: Definitions Any difference between normal baseline measurement and present may indicate the need for nursing and medical interventions. Pain is considered to be the 5th vital sign. (Potter & perry,2010). Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 13  Vital Signs: Temperature Cellular metabolism requires stable core or deep body temperature of a mean of 37.2 C The body maintains a steady temperature through a feedback mechanism regulated in the hypothalamus of the brain. The thermostat balances heat production with heat loss. What are the sources of heat production? What are the methods of heat loss? 14 Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier.  Vital Signs: Temperature Heat is produced from: Metabolism Exercise Food digestion External factors Heat is lost through: Radiation Conduction Convection Vaporization 15 Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier.  Vital Signs: Temperature The factors that affecting normal temperature: Diurnal cycle of 1F to 1.5 F with trough occurring in the early morning hours and peak occurring in late afternoon to early evening. Highest between 4-6pm, lowest between 4am-6am (Kozier, Berman, Snyder, Abdarhman, Abu-Mogli, Saleh, 2012). The menstruation cycle, progesterone secretion at mid- cycle increases a 0.5  F to1 F in temperature. Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 16  Vital Signs: Temperature The factors that affecting normal temperature: Age: Low temperature in older adult. Wide normal temp variation in infant and young children. Why? Exercises increases body Temp. Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 17  Temperature Measurement Sites Orally Axillary Rectally Tympanic membrane Temporal artery Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 18  Temperature Measurement Sites Site Advantages Limitation Oral Accurate & convenient. Normal Delay in measurement if patient temperature is 370C Range of ingested hot, cold fluids or smoked 35.8C-37.3C Should not be used with infants or confused patient Rectal Most accurate- Source of embarrassment, anxiety & BUT weigh the risks and benefits- discomfort use only if needed Impacted stool influences reading. It measures 0.5C higher then Not for patients with diarrhea oral Axillary Safe, used with newborn and Long time, requires continuous unconscious patients positioning, affected by exposure to environment, underestimates core temperature Tympanic Accessible site, accurate core Requires disposable cover, cerumen membrane reading* and very rapid. Used in impaction can distort readings newborns. 19 Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier.  Types of Thermometers Mercury Electronic Chemical Infrared thermometer. thermometer disposable thermometer Glass or plastic Reading in 20-30 thermometers Senses the Safe disposal is sec. Sensitive patch infrared required. Disposable applied on emissions in Have been probe covers. forehead. eardrum. replaced with Different models Non- electronic one due for oral & rectal. traumatic, to environmental Must be fully extremely concern of mercury charged quick and pollution efficient 20 Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier.  Vital Signs: Temperature Report temperature in degrees Celsius unless your agency uses the Fahrenheit scale. 9 5 F = C x 5 + 32 C = (F – 32) x 9 9 5 F = 37 x 5 + 32 98.6 C = (98.6 – 32) x 9 37 Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 21  Vital Signs: Temperature Hyperthermia or Fever Hypothermia is usually caused by pyrogens due to accidental, secreted by toxic bacteria during infection or from prolonged exposure to tissue breakdown. cold Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 22  Vital Signs: Temperature Afebrile: Pt. who is not febrile. Febrile : Pt. has fever. Pyrexia : Temp. above normal but below 41 C. Hyperpyrexia: Very high Temp. (41 C) and above. 23 Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier.  Nursing Diagnosis Examples Hyperthermia related to exposure to hot environment as evidenced by flushed warm skin. Hypothermia related to decreased metabolic rate as evidenced by body temperature below normal range Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 24  Vital Signs: Pulse Pulse: The adult heart pumps about 70 ml of blood with every beat (stroke volume) The force flares the arterial walls & generates a pressure wave, which is felt in the periphery as the heart rate- pulse Palpating peripheral pulse gives the rate, rhythm and force of the heartbeat Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 25 Vital Signs – Characteristics of Pulse Rate Rhythm Force Normal HR= 50- Pattern of Strength of the 95 (beats per beats & interval heart’s stroke minute= bpm) between the volume (force Rate varies with beats of blood with age & gender Irregular each beat. HR over 95 or rhythm is Absent: 0 100/min is arrhythmia or tachycardia Weak or dysrhythmia. thready:1+ (with anxiety, fever exercise) Heart rate may Normal force: HR less than 50 vary with the 2+ bpm is respiratory cycle especially Full or bradycardia bounding: 3+ (HR 50 normal in children and with athletes) young adult. 26  Vital Signs: Pulse Pulse: Use the pad of the first 3 fingers Palpate/ identify the pulse If the beat is regular: Count the beats for 30 second multiply by 2 Although the 15 seconds interval is practiced it might lead to mistakes If the beat is irregular: Count the beats for a full minute Where can we find a pulse? Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 27  Vital Signs – Peripheral Pulses Radial Popliteal Brachial carotid pulse Femoral pulse 28 Posterior tibial Dorsalis pedis  Vital Signs: Pulse Age: As age increases pulse rate decreases Gender: After puberty male pulse rate is lower than females. Exercise: Pulse rate increases with activity. Fever: PR increases due to increased BMR. Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 29  Vital Signs: Pulse Medications: Some medication increases pulse rate & some decrease it. Hypovolemia: Loss of blood increases pulse rate. Stress: Increases the pulse rate and the force. Position changes: Pooling of blood decreases venous return, which might reduces blood pressure and increase pulse rate. Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 30  Nursing Diagnosis Examples Decreased cardiac output related to altered heart rate as evidenced by arrhythmias, palpitations, electrocardiographic changes Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 31  Vital Signs: Respiration Age Breaths/ Normal person’s breathing is relaxed, minutes regular, automatic and silent. Neonate 30-40 1 respiration comprises: 1 inspiration 1 yr 20-40 2 yr 25-32 (Inhalation) and eexpiration (Exhalation) 8-10 yr 20-26 Unaware process: Do not mention that 12-14 yr 18-22 you will be counting the respiration, awareness may alter the normal pattern 16 yr 12-20 Adult 10-20 Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 32  Vital Signs: Respiration Age Breaths/ Maintain your position of counting the minutes Neonate 30-40 radial pulse and unobtrusively count 1 yr 20-40 the respiration: 2 yr 25-32 Count for 30 seconds and multiply by 2. 8-10 yr 20-26 Count for a full minute if you suspect 12-14 yr 18-22 abnormality. 16 yr 12-20 Avoid the 15 seconds interval. Adult 10-20 Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 33  Vital Signs: Respiration Factors affecting respirations Exercise Acute pain Anxiety Smoking Medications Brain stem / spinal cord injury Hemoglobin function Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 34  Components of Respiratory Assessment Tachypnea, bradypnea, Rate apnea Depth Hyperventilation & (Volume) hypoventilation Regular or irregular Rhythm expirations & inspirations. Normal, effortless , silent Quality (Ease breathing or Effort) Labored with abnormal sounds Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 35  Measurement of Oxygen Saturation Pulse Oximeter: is a noninvasive method to assess arterial oxygen saturation (SpO2). Sensor attached to person’s finger or earlobe has a diode that emits light and a detector that measures the amount of light absorbed by oxyhemoglobin and un- oxygenated hemoglobin. Healthy person has an SpO2 of 97%to 100% Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 36  Nursing Diagnosis Examples Ineffective airway clearance related to allergic airways as evidenced by diminished breath sounds. Impaired gas exchange related to alveolar-capillary membrane changes as evidenced by abnormal respiratory rate, rhythm, and depth Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 37  Vital Signs: Blood Pressure Blood Pressure (BP) is the force of the blood pushing against the vessel wall. The systolic pressure is the maximum pressure felt on the artery during left ventricular contraction, or systole. The diastolic pressure is the elastic recoil or resting pressure that blood exerts constantly between each contraction. Pulse pressure is the different between systolic & diastolic pressures, it reflects the stroke volume. Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 38  Vital Signs: Blood Pressure Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 39  Vital Signs: Blood Pressure Overall Factors Affecting BP: Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 40  Vital Signs: Blood Pressure BP Measurement - Equipment: Bladder/ Sphygmomanometer Stethoscope Bulb with valve Cuff Cuffs include six sizes that fit newborn infants to extra large adult 42  Vital Signs: Blood Pressure Types of sphygmomanometers: Mercury Aneroid Digital 43  Vital Signs: Blood Pressure Non invasive BP can be measured from the arm and/or thigh Thigh Pressure: Used if BP cannot be measure in the arm or for comparison reason Consider that normally the systolic value is 10-40/mmHg higher in the thigh than in the arm. Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 44  Vital Signs: Blood Pressure (Nikolai Korotkov 1905) Korotkoff sounds: are the component of a BP reading Phase 1: is the systolic pressure. As the cuff pressure lowers, the artery opens and blood first spurts into artery Phase 5: the last audible sound (marking the disappearance of sounds) is diastolic pressure Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 45  Classification of Blood Pressure Hypotension: abnormally low BP Hypertension: abnormally high BP Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 46  Vital Signs: Blood Pressure Orthostatic Hypotension: Drop in systolic pressure of more than 20 mmHg, with a quick change to a standing position How to assess? Take a baseline pulse & BP when person rest supine, then repeat measurements with person sitting then standing For patients who cannot stand, assess while he is sitting and legs dangling Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 47  Nursing Diagnosis Examples Hypertension Decreased cardiac output related to high blood viscosity as evidenced by exertional dyspnea. Hypotension Decreased cardiac output related to diminished blood volume as evidenced by decreased blood pressure; less than normal limits Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 48  Pain Assessment Pain is an unpleasant sensory & emotional experience associated with actual or potential tissue damage It is whatever the experiencing person says it is It exists whenever he/she says it does Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 49  Types of Pain Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 50  Pain Assessment Tools Pain is multidimensional- many tools have been developed Select the appropriate one- teach the patient how to use it, enlarge the print if needed and use it consistently. 1. Initial pain assessment: Asks patient to answer 8 questions. 2. The brief pain inventory: Ask patient to rate pain within the past 24 hours using gradual scales (0-10) Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 51  Pain Assessment Tools 3. Numeric rating scale: ask patient to choose number that rates the level of pain for each painful site. Can be determined verbally or visually along line 4. Descriptive scale: list words that describe different level of pain intensity. 5. Faces pain scale: for who can’t understand the numeric scale (children, elderly, cognitive impairment) Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 52  Initial Pain Assessment Ask patient questions How does pain limit your about the pain function or activities? Do you have pain? How do you usually react Where is your pain? when you are in pain? When did your pain What does this pain start? mean to you? What does your pain feel Use PQRST table 10-1, like? page 167 How much pain do you have? What makes your pain better or worse? Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 53  Pain Assessment Tools Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 54  Pain Assessment Tools Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 55  Nursing Diagnosis Examples Acute pain related to tissue destruction as evidenced by expression of pain (such as moaning or crying). Chronic pain related to chronic physical disability as evidenced by altered ability to continue usual activity Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 56  Documentation – Why do we do it? Improves quality of patient care: Creates a plan of care Enables evaluation of patient progress against measurable goals Promotes communication between health care team Ensures a historical record of care episode Encourages accountability Health care documentation is legal documentation Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 57  Documentation of Data Record of the entire nursing process. Provides clear data for all the health care team. Protects the wellbeing of patients. Electronic and/or paper based. “if you didn’t document it, it didn’t happen”. Thorough and accurate documentation is vital to ensure valid conclusions are made when the data are analyzed. Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 58  Documentation Guidelines Current: made at the time or shortly after an event* Factual: objective & subjective Accurate: use of exact measurements Legible: black ink (per local policy) Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 59  Documentation Guidelines Concise, clear and easy to understand data. Use abbreviation carefully. Complete: Information must contains appropriate and essential information Organized: communicate information in a logical orders. Applying critical thinking skills Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 60  References Jarvis, C (2016). Physical Examination and Health Assessment (7th ed.). Philadelphia: W.B. Saunders, USA. Perry, A. & Potter, P.(2010). Clinical nursing skills & techniques. (7th ed.). Mosby, Elsevier. Kozier, B., Erb,G., Berman, A., Snyder. S., Abdarhman. M., Abu-Mogli, F., Saleh, M. (2012). Fundamentals of nursing, concept, process, & practice. The Arab world edition. (1sted).Edinburgh: Pearson Education Limited. Holtzclaw, b. (2014). Monitoring Body Temperature in Critical and Acute –care Settings. Safe Practices in patient care. Retrieved from www.safe-practices.org Joint commission International Accreditation and Standards for Hospitals (2014) (5th ed.). Retrieved on December, 2014 from http://www.jointcommissioninternational.org https://www.nursetogether.com/ Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 61  Additional Readings http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/content/RaR tCD_EBA-GOC Recognizing & responding to clinical deterioration – Australian Commission on Safety & Quality in Healthcare http://www.medicine.ox.ac.uk/bandolier/booth/painpag/index2.html The Oxford University Pain internet site http://www.heartfoundation.org.au/ProfessionalInformation Clinical Practice/Hypertension/Pages/default.aspx Australian Heart Foundation facts & recommendations http://video.about.com/highbloodpressure/Blood-Pressure.htm Jarvis, C. (2016). Physical examination and health assessment (7th ed.). Philadelphia: WB Saunders Elsevier. 62