CH 17 & 19
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Assesment is the systematic gathering of information related to the physical, mental, spirtual, socioeconomic, and cultural status of the individula, group or community
What are Vital Signs?
- suggests assessment of vital or critical physiiological functions. Veriations in temps, pulse, resp, B/P
- Indicators of e person's state of health/function of body system's
When VS should be taken?
- On admission to the hospital
- At the beginning of a shift
- Before/after surgery
- To monitor effet of med/s
- Change in patient condition
- Timeframe depend on: HC setting and Nursing judjement
What is Temperature?
- Degree of heat maintained by the body
- Difference between heat produced and heat lost
- Produced by metabolism and skeletal muscle movement, and nonshivering thermogenesis in infants by metabolizing brown fat to produce heat.
- Regulated by Thermoregulaton
- Channels: Temporal artery (lob), Rectal, Oral, axillary, tympanic.
- Normal: oral 98 F(36.7 C) Rectal 98.6 F(37)
- Normal range for core temp: 97-100.8 F (36.1 - 38.2 C)
- Converting F to C: (F - 32)x5/9
- Convertin C to F: (C x 9/5) + 32
What Factors affect Temperature?
- Developmental level
- Environmental temperature
- Circadian rhythm - cyclic repetition of certain physiological processes like morning temp is lower then evening temp.
What is Pulse?
- Rhytmic expansion of artery
- Produces when heart contracts/moves a bolus of blood
- Rhythm and quality reflects the patients cardiac output
- The strength of the pulse reflects the volume of blood that is ejected against the arterial wall with each contraction of the heart
- An innregular or weak pulse indicates dicreased cardia output
- A bounding pulse indicates increased cardiac output
- Access rate(fast or slow), rhythm(regular or irregular), quality, compare bilaterally
- Sites: Apical and Peripheral - radial, brachial, carotid, femoral, popliteal, dorsalis pedis, posterior tibial
- Normal range: 60 - 100 beats/min
- Avarage 80 beats/min
What Factors influencing Pulse?
- exercies/position changes
- Blood Loss
slow hear rate(pulse)
Fast heart rate (pulse)
Pulse Quality (volume)
- ammount of force produced by the blood pusling through the arteries
- assesed on the skel 0-3
- 1- Weak or thready:pulse is beraly felt and can be easily obliterated by ressing with fingers
- 2- Normal quality: Pulse is easily palpated, not weak or bouding
- 3- Bouding or full: Pulse is easily felt with little pressure: not easily obliterated
What is Respiration?
- exchange of oxygen and carbon dioxide in the body
- Pulmonary ventilation/breathing
- Active movement of air in and out
- Invloves contraction.relaxation of thracic muscles and diaphgragm, changes in air pressure
- Assess: rate, rhythm, depth(deep, shallow, nomrmal), rhythm(normal or abnormal), effort(dyspnea-labored breathing or orthopnea is difficulty or inability to breath)
- Abnormal sounds: rhonchi; grackles; strider; stertor
- Normal Range: 12-20 breaths/min
Factors influencing Respiration
- Fever/pulse rate
Inadequate cellular oxygenation
occures when rapid and deep breathing reslut in excess loss CO2.
when the rate and depth of respirations are decreased and CO2 is retained or alvolar ventilation is compramised
Arterial oxygen saturation
- measures the amounts of oxygen and carbond dioxide present in the blood.
- Called pulse oximetry - monitors resp. status with a devise that measures oxygen saturatio - and inidcation of the oxygen being carried by hemoglobin in the arterial blood.
- well oxyginated hemoglbin absorbes a lot of light that transmits in to the device
- Normal range: 95-100
What factors affets oxygen saturation?
- High levels of carboxyhemoglob in patients who smoke can produce false highs.
- Reduces cardia output states, impared arterial or peripheral circulation, use of vasoconstrictors, conditions such as chock, hypothermia, or thrombosis, carbon monoxide poisoning, edema, thickened nails
- Impared circulation
What is blood pressure?
- Idicator of overall cardiovasculra health, is the pressure of the blood as it s forced against arterial walls during cardiac contraction
- Normal Range: 100/60 - 119/79
- Systolic: peak pressure, ventricular contraction/ejection
- Diastolic: minium pressure, between contraction(resting)
what factors affecting B/P?
- just smoked
- cuff too small or too big
- never use arm with AV fistula, mastectomy, IV line, flaccid limb
- Family history
- Diurnal variations (sutochnie izmeneniya)
- The pulse that can be palpated to determine heart rate is due to the difference between the systolic and diastolic pressures . This difference is known as the pulse pressure.
- Ex in bp 120/80 pulse pressure is 40.
- It should not begreater than 1/3 of the systolic pressure.
Blood Pressure Cuff size
- Cuff width should cover 2/3 of a length of the upper arm.
- Length of the bladder should encircle 80% of the arm in adults.
- If cuff is too narrow in width - reading too high
- If cufss is too wide - reading too low
isaBP reading of 120 to 139 systolic or 80-89 diastolic, obtained with two readings taken 6 minutes apart, with the patient sitting.
- is a persistently higher than normal BP. BP above 140 systolic or above 90 Diastolic.
- Not a nursing diagnosis by medical diagnosis.
Stage I Hypertension
- systolic 140-159
- Diastolic 90-99
Stage II Hypertension
- systolic 160 and above
- Diastolic 100 and above
is diagnosed when ther eis no known cause for the BP elevation. 90% of all cuases. Although no single cuase is identified, family history, age, race, obesity, diet, heavy alcohol concumption, smoking hiostory, high cholesterol levels, and stress all contribute to the development of primary hypertension
occurs when there is a clearly identified couse for the persistant rise in BP. A variety of renal and endocrine disorders, drugs, oral contraceptives, decongestants,
5th Vital Sign
- quality of the pain
- Is it preproducible
- when does it occur
- how long does it last
What are the changes in vital signs with aging?
- Temp: older adults usually have a lower temp, reulagory mechanism less effiecient therfore at greater risk of hypothermia and /or hyperthermia. Also less likely to develope a fever even with an infection.
- Pulse: rhythm may be irregular, radial artery may be less compliant, more rigid and stiff.
- Respirations: decrease in vital capacity and in reserve valume, may breathe more shallowly and more rapidly.
- Blood PRessure: blood vessels less supple(gibkie)
- Bell(small piece) hear low-frequency(pitched) sounds, such as extra heart sounds(murmurs) or turbulent blood frlow =, known as bruits. Apply lightley
- Diaphragm (big) - assess high-frequency sounds. high-pitched that normally occur int he heart, lungs, and abdomen. Press heard enough to produce ring
Minimum standards for registered nurses include the following
Assessment and Analysis: the RN initiates data collection and analysis that includes pertient objective and subjective data regarding the health status of the clients. The RN is responsible for ongoing client assessment, cluding assimilation of data gathered from licensed practical nurses and other members of the health care team.
- overt(yavnii) - signs
- are the signs - physical assessments (VS, lung sounds), diagnostic results (lab resolts.)
- what you(RN) see, hear, feel, read
- patient is pale
- patin has clurred speech
- the urine test is psotive
- Covert (skritii) - symptoms
- symptoms -priznoki bolezni
- how the person feels about his condition, how they are discribing heir pain
- Can make them objective by giving it a number 0-10
- what the patient says
- I ache all over
- M head hurst
- Iam nauseated
- I think I am dying
Nursing assesment vs. Medical assesment
- Nursing assessment: focuses on the client's functional abilitites and physical responses to illness and other stressors.
- Medical assess: focus on disease and pathology
What are the different types of assessments?
- Spacial Needs: nutritional, functional, pain, cultural, spritual, pshychosocial.
- Includes health history interview
- Physical examination (objective data)- head to toe of every body system
- This data provides guidance for planning care determine the needs for further assessment.
- May contain subjective data as well
Focused physical assessment
- the assessor is focused on treating or assessing one particular condtion.
- ex. patient having a chest pain, I am focused on his chest pain rightnow, not his last flu vaccine
- obain data about an actual, potential, or possible problem that has been identified. IT pertains to a particula, topic, body part, or functional ability ratehr than overall health status, and it adds to the database created by the comprehensive assessment.
is performed as needs, after the initial databse is completed, and, ideally, at every interaction with the patient. Or in any change in the condition of the patient.
Five assessment techniques
- The use of sight to gather data. icluding what you see with the otoscope or ophalmoscope
- What do I see? this, obese, yong, old, infant?
- Smiling, crying, depressed, scared?
- is the use of light touch to gather data
- depress 1-2 cm in a rotating motion
- assess: temp of skin,moisuture, anatomical landmarks, edema, masses, areas of tenderness.
- tapping of fingers on the skin using short strokes producing different vibrations and sounds depending on what is under the area tapped
- dull sound over fluid filled bladder, mass or organs
- Tympany: (musical/high) sound over gastric air/distention
- Inderect percussion - requires two hands
- Direct: Listening with the unaided ear for sounds made by the cleint
- Indirect: listening using a stethoscope
- use sence of smell to gather info.
- ex. patient has slurred speach but smell of alcohol.
subjective and objective data obtained from the client: what the client says or what you observe.
- obtained "second hadn" from example from medical record or from another caregiver.
- ex. a clients' hsuband may say, "she seems more confused than usual. Or NAP may reportheart rate was 100 beat but if you count the heart rate yourself, though, it is primary data.
Cultural considiration in completing health assesment.
health disparities exist amoin racial and ethnic groups. YOu nedds a good understanding of culture and ethnicit not ony for providing direct care, but also for teaching, supervising, and role-moleding culturally competent care for other care providers.
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