BSN211_General survey, Measurement, Vital signs,Pain Assessment, & Documentation.docx

BSN211 Clinical Health Assessment - Theory 2024/2025 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...

BSN211 Clinical Health Assessment - Theory 2024/2025 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. 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.  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 - Understand the patient's response to any previous care General Survey and Measurements =============================== ### The General Survey - #### First encounter- obvious physical characteristics - It is an introduction to prepare for the physical assessment - Gives an overall impression ### What's your first General Survey and Measurements ==================================================== The General Survey 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. General Survey and Measurements =============================== Measurement - **Weight** - Instruct person to remove his shoes and heavy outer clothes before - 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. 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  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. 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. 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  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). 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?**  Vital Signs: Temperature ======================== - Heat is produced from: - Metabolism - Exercise - Food digestion - External factors - **Heat is lost through:** - Radiation - Conduction - Convection - Vaporization  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. Vital Signs: Temperature ======================== The factors that affecting normal temperature: - Age: Low temperature in older adult. Wide normal temp - Exercises increases body Temp.  Temperature Measurement Sites =============================  +-----------------------+-----------------------+-----------------------+ | | | | +-----------------------+-----------------------+-----------------------+ | | | | +-----------------------+-----------------------+-----------------------+ | | | | +-----------------------+-----------------------+-----------------------+ | J | | nt (7th ed.). | | | | Philadelphia: WB | | | | Saunders Elsevier. 19 | +-----------------------+-----------------------+-----------------------+ Mercury - Glass or plastic - Safe disposal is required. - Have been replaced with electronic one due to environmental concern of **mercury pollution** \ Electronic - Reading in 20-30 - Disposable probe covers. - Different models - Must be fully charged \ Chemical disposable thermometers - Sensitive patch applied on forehead. \ Infrared - Senses the infrared emissions in eardrum. - Non- Vital Signs: Temperature ======================== - #### Report temperature in degrees Celsius unless your agency uses the Fahrenheit scale.  Vital Signs: Temperature ========================  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. 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 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 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? 28 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. 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. Nursing Diagnosis Examples ========================== - Decreased cardiac output *related to* altered heart rate *as evidenced by* arrhythmias, palpitations, electrocardiographic changes Vital Signs: Respiration ============================================= - Normal person's breathing is relaxed, - 1 respiration comprises: 1 inspiration (Inhalation) and eexpiration (Exhalation) - Unaware process: Do not mention that you will be counting the respiration, awareness may alter the normal pattern Vital Signs: Respiration ======================== - ###### Maintain your position of counting the radial pulse and unobtrusively count the respiration: - Count for 30 seconds and multiply by 2. - Count for a full minute if you suspect - Avoid the 15 seconds interval.  Vital Signs: Respiration ======================== Factors affecting respirations - Exercise - Acute pain - Anxiety - Smoking - Medications - Brain stem / spinal cord injury - Hemoglobin function Components of Respiratory Assessment ========================================================== Rate - Tachypnea, bradypnea, apnea - Hyperventilation & hypoventilation - Regular or irregular expirations & inspirations. - Normal, effortless , silent breathing - Labored with abnormal sounds 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 SpO~2~ of 97%to 100% Nursing Diagnosis Examples ========================== - #### Ineffective airway clearance related to allergic airways *as evidenced by d*iminished breath sounds. - Impaired gas exchange *related to* alveolar-capillary membrane changes *as evidenced by* abnormal respiratory rate, rhythm, and depth 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. Vital Signs: Blood Pressure =========================== Vital Signs: Blood Pressure ================================================ ### BP Measurement - Equipment: Types of sphygmomanometers: ---------------------------  43 Vital Signs: Blood Pressure =========================== - Non invasive BP can be measured from the arm and/or thigh - 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. Vital Signs: Blood Pressure ================================================ - Korotkoff sounds: are the component of a BP Classification of Blood Pressure ===================================================== - #### Hypotension: abnormally low BP - Hypertension: abnormally high BP Vital Signs: Blood Pressure =========================== Orthostatic Hypotension: - Drop in systolic pressure of more than 20 mmHg, with a 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 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 d*ecreased blood pressure; less than normal limits 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 Types of Pain ================================== 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) 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) - ###### Ask patient questions about the pain - Do you have pain? - ###### Where is your pain? - When did your pain start? - ###### What does your pain feel like? - How much pain do you have? - ###### What makes your pain better or worse? - How does pain limit your function or activities? - ###### How do you usually react when you are in pain? - What does this pain mean to you? - ###### Use **PQRST** table 10-1, page 167 Pain Assessment Tools ========================================== Pain Assessment Tools =====================  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  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** 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".  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) 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  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 - Joint commission International Accreditation and Standards for Hospitals (2014) (5th ed.). - https://[www.nursetogether.com/](http://www.nursetogether.com/) Additional Readings =================== - tCD\_EBA-GOC - Recognizing & responding to clinical deterioration -- Australian Commission on Safety & Quality in Healthcare - The Oxford University Pain internet site - Clinical Practice/Hypertension/Pages/default.aspx Australian Heart Foundation facts & recommendations -