Week 2 General Survey and VS - DAR PDF

General Survey, Vital Signs and Documentation Today’s Objectives u Learnabout vital signs - how to take them and interpreting results u Pain assessment techniques u Documenting findings u Reviewfocused assessment for integumentary General Survey u Physical Appearance...

General Survey, Vital Signs and Documentation Today’s Objectives u Learnabout vital signs - how to take them and interpreting results u Pain assessment techniques u Documenting findings u Reviewfocused assessment for integumentary General Survey u Physical Appearance u Body structure u Note the age and sex of the u Stature, build and contour patient u Nutrition u LOC, skin colour and facial u Symmetry features u Posture u Facial expression u Chosen body position u Mood and affect u Gait u Speech u Range of motion u Dress u Personal hygiene 5 Vital Signs (well maybe 6) Blood Pressure Heart Rate Respiration Rate Temperature Oxygen Saturation Pain Blood Pressure BLOOD SYSTOLIC mm DIASTOLIC mm Hg PRESSURE Hg (upper (lower CATEGORY number) and/or number) NORMAL LESS THAN and LESS THAN 80 uWhat are we measuring? 120 ELEVATED 120 – 129 and LESS THAN 80 u The pressure on your arteries HIGH BLOOD 130 – 139 or 80 – 89 when your heart pumps (systolic PRESSURE pressure) and when it is at rest (HYPERTENSI ON) STAGE 1 (diastolic pressure) HIGH BLOOD 140 OR or 90 OR u A reflection of the PRESSURE HIGHER HIGHER (HYPERTENSI relationship between cardiac ON) STAGE 2 output, peripheral HYPERTENSIV HIGHER THAN and/or HIGHER THAN E 180 120 resistance, blood volume and CRISIS (consul viscosity, and the elasticity t your doctor of the heart muscle immediately) American Heart and Stroke foundation Taking a blood pressure u Set the Stage u Have the patient sit quietly and comfortably with back supported Always ask if they and feet flat take their own Blood u Ensure you can get arm to level of Pressure at home heart u Ask about caffeine intake, nicotine use or exercise/exertion in the last 30 minutes u S elect the appropriate cuff u Select the appropriate arm  u Find the brachial artery Taking a blood Brachial artery should be at heart pressure u height u If the patient is lying, use the higher arm u Place the cuff on the arm with centre of bladder over the artery and 2.5cm or a two finger widths above the creasew u Palpate the radial pulse and then inflate the bladder until it is obliterated u Deflate the bladder and allow a rest Taking a blood pressure uInflate again this time 30mmhg higher than the number that obliterated the radial pulse. uInflate rapidly then slowly deflate with bell of stethoscope over the brachial artery uPhase 1 = SBP uPhase 5 = DBP uDiscrepancies between arms should not exceed 5-10mmhg uTo hear the sounds https://youtu.be/5gn8cbY9rkc uWait one minute and then repeat Interpreting a blood pressure u Normal Blood Pressure u Hypertension u < 120/80 u Stage 1 BP greater than 130- 80 u Hypotension u Discrepancies of > 5-10mmhg between arms u Orthostatic hypotension u Requires further evaluation u Difference in SBP of >20mmhg of DBP of 10mmhg from supine to standing within a 3 minutes span Heart Rate u What are we measuring? u Using the radial pulse u Rate u Rhythm u Quality u Normal rate u Palpate for 30 seconds counting u 60-100 bpm the beats, multiply by 2 for beats/minute u Rhythm u Quality u Should be basically regular u Are all the pulses the same? u May vary with breathing (regularly irregular) u Are they strong or weak or bounding? u Irregular requires investigation Respiratory Rate u What are we measuring? u Either visually assess and count u Rate respirations for a minute or listen over the trachea and count the u Rhythm number of breaths/min u Quality u Normal Rate u Assess for increased work of u 12-20 breaths/minute breathing u Normal Rhythm u Use of accessory muscles u Occasional sighs are normal, u Tachypnea otherwise regular rhythm u Tripod position to breath u Normal Quality u Prolonged expiration u Calm and quiet breathing Taking a temperature Normal is approximately 370C u Oral u Oral u Common lower u Make sure no hot or cold liquids in prior 10-15minutes u Lower than core body u No smoking in prior 10-15 minutes u Lower than rectal u Insert thermometer under the tongue, u Axillary close the mouth and wait u lower than oral by 10C u Take 5-10 minutes to measure u Rectal u Tympanic Membrane u Lie on side with hips flexed u More variable than rectal or oral u Make sure it is a rectal thermometer J u Temporal Artery u Using lubricant u Closest to the pulmonary artery u Insert 3-4cm into the anal canal and temperature along with oral wait u Rectal Taking a Temperature Continued u Axillary u Tympanic u Put thermometer deep into the u Make sure ear canal is cerumen axillar and wait free u Can take 5-10 minutes u Pull ear back and position probe so that the infrared beam is aimed at u Takes time even with a digital tympanic membrane thermometer u Usually takes 2-3 seconds u Temporal artery u Start at centre of forehead, depress button and sweep device across forehead and down cheek to below the earlobe Measuring SpO2 u What are we measuring? u When hemoglobin is low u Ration of light emitted to light u This number is misleading absorbed and converts to a u Measure saturation of hemoglobin percentage not absolute hemoglobin u Presented in percentage u Is only part of the picture of u Normal SpO2 oxygenation u Anything above 96% is normal u Anything above 92% is healthy u COPD normally aim for 88-92%  uThe Sixth Vital Sign uO – onset uL - location Pain uD – duration uC - characteristics Assessment uA – alleviating/aggravating/associated symptoms uR - radiating uT – Timing and Treatment uS – Severity/Scale uU - Understanding Pain Scales Stinging Cramping Grinding Pressure Squeezing Scalding Burning Piercing Shooting Pulsing Numbing Pounding Throbbing Sickening Stabbing Boring Itching Pressing Aching nauseating Documentation - https://www.bccnm.ca/RPN/PracticeStandar ds/Pages/documentation.aspx u Facilitates communication u Document only the care you provide u Promotes safe and appropriate care u Include your decision-making processes u Promotes continuity of care u Use client quotes to illustrate u Meets professional and legal objective observations standards u Document in a timely way u Use SN to identify your status as a student The DAR Note u D – Data u Subjective data - what did the patient tell you, what are their symptoms u Objective data – what did you see, smell, hear, touch or measure, test results u Interpretation - What is currently happening with my patient and why do I need to intervene u Action – What did you do u Detail your interventions u Think what did I do to address the the information documented above and how did it help my patient u Response – What was the outcome of your action, did the action result in the desired outcome? Charting your Assessment Data u Chart by system – even though you conduct it head to toe u Chart subjective and objective data in each section u Identify normal vs. abnormal findings u DAR charting for interventions related to abnormal findings. u Be concise