SLO for Vital Signs and Health Assessment PDF

Student Learning Outcomes - SLO Vital Signs Discuss the physiological implications of vital signs. ◦ Vital signs provide data to determine a patient’s usual state of health (baseline data). Vital signs can reveal both sudden change in a patient’s condition and changes that occur progressively over t...

Student Learning Outcomes - SLO Vital Signs Discuss the physiological implications of vital signs. ◦ Vital signs provide data to determine a patient’s usual state of health (baseline data). Vital signs can reveal both sudden change in a patient’s condition and changes that occur progressively over time. Vital signs are a quick and e cient way of monitoring a patient’s condition or identifying - problems and evaluating their response to interventions. When you learn the physiological variables in uencing vital signs and recognize the relationship of their changes to one another and to other physical assessment ndings, you can make precise determinations about a patient’s health status and the need for medical or nursing interventions. Discuss the appropriate nursing care for alterations in vital signs. ◦ Any changes to the patient’s condition, you should collaborate with health care providers to decide the frequency of vital sign assessment. ◦ As a patient’s physical condition worsens, it is often necessary to monitor more frequently, such as every 5 to 10 minutes. ◦ Verify and communicate signi cant changes in vital signs. ◦ When vital signs appear abnormal, have another nurse or health care provider repeat the measurement to verify readings. ◦ Inform the charge nurse or health care provider immediately, document ndings in your patient’s record, and report changes to nurses during hand-o communication. Explain variations in techniques for obtaining vital signs. ◦ Taking temperature with a thermometer via oral, rectal, tympanic membrane, temporal artery, skin, axillary or even urinary bladder. ◦ Measuring Bp with a sphygmomanometer and a stethoscope ◦ Assessing pulse rate in the radial and apical locations are the most common sites for pulse rate assessment. The carotid artery site is recommended for quickly nding and assessing the pulse when a patient’s condition suddenly worsens and cardiac output declines signi cantly, peripheral pulses weaken and are di cult to palpate. ◦ Respiration i s me assured by observing patient’s breathing. Assess respirations immediately after measuring pulse rate, with your hand still on the patient’s wrist as it rests over the chest or abdomen. Observe a full inspiration and expiration when counting ventilation for a full minute. ◦ Measure oxygen saturation by using a pulse oximeter. A saturation greater than 95% is acceptable while a saturation of 75% or less is considered a critical value as the tissues are unable to extract enough oxygen to carry out vital functions. Selecting the appropriate pulse oximeter probe is important to reduce measurement error. For patients with decreased peripheral perfusion, apply an earlobe or forehead sensor. Identify ranges of acceptable vital sign values ◦ Discuss the evaluation of pulse sites. Select the correct pain assessment scale to use with a particular client ◦ There are three general categories for pain scale: ‣ Numerical rating scales (NRS): uses number to rate pain. ‣ Visual analog scales (VAS): asks you to select a picture that best matches your pain level. ‣ Categorical scales: primarily uses words, possibly along with numbers, colors, or location (s) on the body. ◦ The Numerical Rating Scale (NRS) is designed for anyone over age 9. It is one of the most commonly used pain scales in health care. ◦ The Wong-Baker FACES Pain Scale combines pictures and numbers for pain ratings. It can be used in adults and children over age 3. Six faces depict di erent expressions, ranging from happy to extremely upset. Each sin assigned a numerical rating between 0 (smiling) and 10 (crying) ◦ The FLACC Pain Scale is based on observations made by a healthcare provider. Originally created to evaluate young children, it can be used for anyone who cannot communicate. ‣ FLACC stands for: Facial expression Leg tension or relaxation Activity (still or squinting with pain) Crying Consolability (whether you can be comforted) ‣ Zero to two points are assigned for each of the ve categories. Then the overall score is tallied. ◦ The CRIES Pain Scale assesses: it’s often used for babies 6 month and younger. Used in NICU ‣ Crying ‣ Oxygenation ‣ Vital signs ‣ Facial expression ~ ‣ Sleeplessness Health Assessment/ Physical Exam Develop understanding of nurse’s role in Health Assessment. ◦ The nurse determine each patient’s current health status, distinguish variations from the norm, and recognize improvements or deterioration in the patient’s condition. Nurses apply clinical judgment when they recognize cues and interpret assessment nding related to each patient’s behavioral and physical presentation. ◦ Gather objective data though a head to toe body system review during physical examination, focusing on problem areas. ◦ Nurses make clinical judgments based on all the gathered data to create and individualized plan of care for each situation. ◦ With accurate data you create a patient-centered care plan, identifying the nursing diagnoses, desired patient outcomes, and nursing interventions. Di erentiate between subjective and objective data. ◦ Subjective data is information given from the viewpoint of the patient or someone in the patient’s life; it is a symptom ◦ Objective data is information directly observed by the healthcare worker; it is a sign ◦ Subjective data is what is said and objective data is what is observed. Identify the purpose, step, and procedures for Physical Examination. ◦ The purpose of the Physical Examination is to: ‣ gather baseline data about a patient’s health status ‣ Supplement, con rm, or refute subjective data obtained. ‣ Identify and con rm nursing diagnoses. ‣ Make clinical decisions about a patient’s changing health status and management ‣ Evaluate the outcomes of care. ◦ The step for Physical Examination is to: ‣ Perform daily head-to-toe physical assessment ‣ Perform a reassessment when a patient’s condition changes and as it improves or worsens. ◦ The considerable procedures for Physical Examinations are: ‣ Cultural aspects, infection control, preparation of the environment, patient position, age of the patient, equipment, and explanation of assessment procedures. ‣ Never leave a patient who is confused or combative alone during an examination ◦ Follow a systematic routine when you perform a physical examination to avoid missing important ndings. A head-to-toe approach includes all body systems, and the examiner recalls and performs each step in a predetermined order. For an adult, the examination begins with an assessment of the head and neck and progresses methodically down the body to incorporate all body systems. Describe the appropriate use of inspection, auscultation, palpation, and percussion and recognize normal ndings. ◦ Inspection: occurs when interacting with a patient, watching for nonverbal expressions of emotional and mental status, and assessing physical movements and structural components. ‣ Make sure that adequate lighting is available. ‣ Use a direct lighting source (ex. Pen light or lamp) to inspect body cavities. ‣ Inspect each area for size, shape, color, symmetry, position, and abnormality. ‣ Position and expose body parts as needed so that all surfaces can be viewed but privacy can be maintained. ‣ Check for side-to-side symmetry by comparing each area with its match on the opposite side of the body. ‣ Validate nding with the patient. ◦ Palpation: involves using the sense of touch to gather information. Through touch, you make judgments about expected and unexpected ndings of the skin or underlying tissue, muscle, and bones.. ‣ Use di erent parts of the hand to detect di erent characteristics: Palmar surface of the hand and nger pad is more sensitive than the ngertips and is used to determine position, texture, size, consistency, masses, uid, crepitus. Assess body temperature by using the dorsal surface of the hand and ngers. Vibration is best felt on the palmar surface of the hand and ngers. ‣ There are two types of palpation, light and deep. Perform light palpation by placing the hand on the body being examined; it also involves pressing inward about 1 cm (1/2 inch) Use deep palpation to examine the condition of organs such as those in the abdomen by depressing the area approximately 4 cm (2 inches), using one or both hands. ◦ Auscultation: involves listening to sounds the body makes to detect variations from normal. A Stethoscope is necessary to hear internal body sounds. ‣ Sounds you hear while using a stethoscope: Frequency indicates the number of sound wave cycles generated per second by a vibrating object. The higher the frequency, the higher the pitch of a sound, and vice versa. Loudness refers to the amplitude of a sound wave. Auscultated sound range from soft to loud. Quality refers to sounds of similar frequency and loudness from di erent sources. Terms such as blowing, or gurgling describe the quality of sound. Duration means the length of time that sound vibrations last. The duration of sound is short, medium, or long. Layers of soft tissue and dampen the duration of sounds from deep internal organs. ◦ Percussion: involves tapping the skin with the ngertips to vibrate underlying tissue and organs. The vibration travels through body tissues, and the character of the resulting sound re ects the density of the underlying tissue. The denser the tissue, the quieter is the sound. Analyze the concepts of physical safety within the health care setting. ◦ Physical safety if very important for both the patient and health care providers. ‣ Safety for patients who are confused should be a priority; never leave a patient who is confused or combative alone during an examination. ‣ Special examination tables make positioning easier and body areas more easily accessible for the patient. This also prevent injuries to the healthcare providers by making it more ergonomic. ‣ Injury can be avoided if you help patients on and o examination tables. ‣ Clean equipment before and after patient use to prevent infection. ‣ Identify and learn skills related to ADLs ◦ ADLs: Activities of daily living are activities related to personal care. ◦ ADLs are those skills required to manage one’s basic physical needs, including personal hygiene (includes bathing and showering) or grooming, dressing, toileting, transferring or ambulating, and eating. Discuss hygiene care of the adult/geriatric client. ◦ Hygiene includes cleaning and grooming activities that maintain personal body cleanliness and appearance. ◦ A variety of personal, emotional, social, economic, environmental, and cultural factors in uence hygiene practices. ◦ When providing hygiene, integrate other nursing activities: ‣ Ex: perform ongoing patient assessment or interventions such as range of motion exercises, application of dressings, observation of pressure injuries, or inspections and care of intravenous (IV) sites. ◦ Ensure privacy, convey respect, and foster a patient’s independence, safety, and comfort. Utilize the nursing process to assess, identify nursing diagnosis, plan implement and evaluate care of a client requiring assistance with ADLs. ◦ Knowledge of pathophysiology assists you to provide preventative hygiene care. ‣ Ex: you can recognize disease states that create changes in the integument, oral cavity, and sensory organs. ◦ In the presence of any conditions, use clinical judgement to adapt hygiene practices to minimize injury. ◦ Use your time with patients as an additional opportunity to completely assess for and identify skin and musculoskeletal abnormalities and any self-care de cits related to hygiene. ◦ By taking the time to identify any abnormalities during hygiene, you will have su cient information to establish a plan of care to individualize hygiene interventions designed to prevent further injury to sensitive tissues. Di erentiate between ADLs with IADLs. ◦ IADLs (Instrumental activities of daily living): are things you do everyday to take care of yourself and your home. ‣ IADLs aren’t considered to be necessary for human survival, but they do support a high quality of life. ex: managing nances, home maintenance, communication, medication management, etc. ◦ ADLs (Activites of daily living): ‣ ADLs relates to self-care that is more connected to health and survival and are essential aspects of daily life. They consist of a minimum of tasks treat must be completed in order for an individual to be healthy and have their basic needs met. Ex: mobility, eating, drinking, bathing, dressing, using the toilet, grooming