Health Assessment Week 1: Foundations of Health Assessment & Vital Signs

purpose of health assessment

• systematic method of collecting and analyzing data: following an organized step by step process rather than randomly collecting information

• informs a patient - centered plan of care: information nurses collect help create a plan of care specifically for that patient

nursing process

“ADPIE”

1. assessment

2. diagnosis

3. planning

4. implementation

5. evaluation

subjective data

• Reported by the patient

• Based on feelings, perceptions, experiences

• Cannot be measured directly

objective data

• Observed, measured, and verified

• Collected using senses or instruments

• Observable and quantifiable

data types

1. complete health database

2. focused / problem centered / episodic

3. follow up

4. emergency

complete health database

• Describes current and past health problems, provides baselines

• Think of a new patient appointment

• Electronic medical records such as EPIC/MyChart

focused / problem centered / episodic

• Gathering only data needed for a short-term problem

• Usually focused on a single problem or body system

follow up

Update status of current problems, should occur at regular intervals

emergency data

Rapid collection of data, usually associated with life saving measures

comprehensive health care

means providing care for the whole person, not just treating one illness or symptom.

It considers many parts of a patient's health, including their physical, mental/emotional, social, and preventive health needs.

types:

1. holistic care

2. social determinants of health

example of comprehensive care

if a patient has diabetes, comprehensive care may include checking blood sugar and medications, assessing diet and exercise, screening for complications, providing education, considering emotional well-being, and making sure the patient has the resources needed to manage diabetes at home.

social determinants of health

• factors that influence well being

• environment, access to health care, community. education, and economic stability

• impact of potential barriers

examples of social determinants of health

1. education access and quality

2. health care access and quality

3. economic stability

4. social and community context

5. neighborhood and built environment

assessment

“point of entry in and ongoing process”

• this is the first step of the nursing process

• collecting subjective data + objective data + patient’s record + laboratory studies form the patients database

• then info from this database allows the nurse to make a clinical judgment or diagnosis about the patients health state (nurse looks at data from database and identifies the patients actual or potential health problems)

diagnostic reasoning

process of analyzing health and data and drawing conclusions to identify diagnoses (looking at the patients information, connecting related findings and using reasoning to determine what health problem may be present)

• use clustering method

• cues

• combination of deductive, inductive, and abductive reasoning

clustering data

means putting findings that seem related together

• sort expected findings (normal) and unexpected findings (abnormal)

cue

a piece of important patient information that gives you a clue about what may be happening (then connect cues to determine what might be happening)

ex. patient says “im dizzy” or you check their blood pressure “BP = 82/50”

cue = clue

abductive reasoning

nurse has incomplete information, so you come up with a possible explanation (don’t have enough information to know exactly what’s happening yet but use abductive reasoning to produce an initial diagnosis)

ex.

• patient has SOB, chest pain, and low oxygen saturation

• so nurse thinks there could be a respiratory or cardiac problem

deductive reasoning

you use what you know about physiology and pathophysiology to predict findings

ex.

• you know pneumonia can cause inflammation and fluid in the lungs

• so nurse reasons that if this patient has pneumonia then patient might have fever, cough, abnormal lung sounds, and possibly decreased oxygen saturation

• then assess the patient for those specific findings

deductive = general knowledge = specific patient

inductive reasoning

looks at multiple specific signs and symptoms and use them to recognize a pattern

ex.

• patient has fever + productive cough + crackles + increased WBC

• these signs and symptoms together create a pattern that may be consistent with infection such as pneumonia

inductive = specific findings = bigger pattern

clinical judgment model

structure nursing education to enhance clinical judgment skills for novice nurses

priority problems level

1. first level

2. second level

3. third level

4. interdisciplinary approach

first level priority

emergent, life threatening, and immediate (problems like airway, breathing, and circulation = ABC’s)

ex. A 48 year old male presenting with chest pain

second level priority

next in urgency, requiring attention to avoid further deterioration (problems that include mental status changes, acute pain, infection risk, abnormal laboratory values, and elimination problems)

ex. A 68 year old male who had a ground level fall (GLF)

third level priority

important to patient’s health but can be addressed after more urgent problems are addressed (have problems such as lack of knowledge, mobility problems, and family coping)

(triage)

ex. a 19 year old female who has frequent headaches with stable vital signs

interdisciplinary approach

to improve outcomes for complex care problems

airway, breathing, circulation

ABC’s

principles of setting priorities

• complete a health history, including allergies, medications, current medical problems, and reasons for visit

• determine whether any problems are related and set priorities (priority setting evolves over time with changes in priority depending on the relationships between and severity of problems

types of assessments

1. inspection (I)

2. palpation (P)

3. percussion (P)

4. auscultation (A)

key note

for the abdomen you inspect (I) then auscultate (A) then percuss (P) then palpate (P)

(look, listen, tap, feel)

inspection

assessing patient without touching or listening, just looking at the patient and looking at skin, body, movements, color, breathing pattern, facial expressions, wounds, or rashes

palpation

exploring the body further by laying hands on the patient (assess tenderness or pain, swelling, masses/lumps, pulses, texture)

• light and deep palpation

percussion

tapping on the patient body and listening to the sounds produced; sound gives you information about what is underneath the area you’re tapping like air, fluid, or solid tissue

auscultation

listening to the sounds produced by the body, usually with a stethoscope

assessment setting

• comfortable, quiet, private, well lit

• lighting: natural day light preferred

• exam table instead of bed

• arrange assessment so your equipment is easily reachable, patient not having to move much

sphygmomanometer

blood pressure cuff

assessment equipment

1. sphygmomanometer - measures blood pressure

2. stethoscope - listens to heart, lungs, bowel sounds

3. thermometer - measures body temp

4. pulse oximeter - measures oxygen saturation and pulse rate

5. telemetry leads - continuously monitors the hearts electrical activity, rhythm and rate

6. penlight - measures pupil reaction and pupil size

7. otoscope - looks inside the ear canal and at the eardrum

8. tuning forks - used for hearing tests

9. reflex hammers - tests deep tendon reflexes like knee / patellar reflex

approach

introduce yourself . AIDET (Acknowledge the patient, Introduce yourself and your role, give an estimated Duration, Explain what you’ll be doing, and Thank the patient)

• ask for pronouns

• talk patient through it

• assess from least invasive to most invasive

assessing infants

• Allow caregiver to hold if possible

  • Infants can sit around 6 months; 9-12 months are interactive but lack object permanence

• Ideally assess 1-2 hours after feeding

• Listen to “quiet” items first to most distressing last

• Stranger Danger

  • Remove white coats, anything that might be scary looking

assessing toddlers and preschool aged

• Interactive

• May allow child to play with equipment or demonstrate on caregiver or toy

• Give the toddler choices when possible

• Likes independence and to be involved

• Use short, simple explanations

• Games are a fun way to complete assessment

• Demonstrate on a toy, let them “assess” themself

assessing school age to adolescents

• Caregivers and siblings present until puberty, then let child decide who should stay

• Consider a chaperone

• Talk about family, school, friends, music, sports, hobbies to build rapport

• Can now proceed with the exam head to toe as with adults

• Provide physical privacy as much as possible

assessing older adults

• Consider patient safety and comfort in positioning

• May need to break exam into parts or slow down to allow for rest periods

• Do not confuse decreased vision or hearing for confusion

  • May use physical touch for reassurance

• Special focus on psychosocial aspects of care including loss, loneliness, and financial security

extremities

are the arms and legs—the parts of the body that extend from the trunk.

• Upper extremities = shoulders, arms, elbows, wrists, hands, and fingers

• Lower extremities = hips, thighs, knees, lower legs, ankles, feet, and toes

assessing the sick patient

• Focused exam

• Consider if patient in distress

• Examine “well” areas before “sick” areas

• Compare bilaterally: eyes, ears, extremities

• If unconscious – continue to talk to your patient and tell them what you are doing!

Vital Signs

1. Heart rate (HR)

2. Temp (T)

3. Respiratory rate (RR)

4. Blood pressure (BP)

5. Pulse oximetry (SpO@)

6. Pain

Heart rate

auscultation of heart or telemetry monitoring

• rate 60-100 in adult

• rhythm: regular or irregular

• force:

  • 3+: full, bounding

  • 2+: Normal

  • 1+: weak, thready

  • 0: absent

pulse

palpation of an artery

• rate 60-100 in adult

• rhythm: regular or irregular

• force:

  • 3+: full, bounding

  • 2+: Normal

  • 1+: weak, thready

  • 0: absent

bradycardia

low resting HR

less than 60 bpm

tachycardia

high resting HR

greater than 100 bpm

apical pulse

is heard with a stethoscope over the heart, typically at the 5th intercostal space at the left midclavicular line in an adult (listening over the app of the heart)

count for 30 - 60 secs

rate: 60-100

The apical pulse is a way of measuring the heart rate by listening directly to the heartbeat with a stethoscope.

pulse sites

1. radial artery (radial pulse)

2. carotid artery

3. femoral artery

4. dorsalis pedic artery

5. tibial artery

6. brachial artery

7. popliteal artery

pulse assessment

pulse tells you about the heart rate and circulation. When assessing a pulse, evaluate the rate, rhythm, and strength

radial pulse

felt on the wrist on the thumb side

normal rate: 60-100bpm

temperature assessment

core body temp average = 37 degrees Celsius or 98.6 degrees F

• variations in temperature related to diurnal cycle, menstrual cycle, exercise, age

• Hyperthermia

• Hypothermia

rate for pulse and heart beat

60-100bpm

temp average

37 degrees C or 98.6 degrees F

hyperthermia

37.8 degrees CC or 100.4 degrees F aka febrile

hypothermia

less than 36 degrees C or 96.8 degrees F

diurnal cycle

of 1° F to 1.5° F, with trough occurring in early morning hours and peak occurring in late afternoon to early evening

menstruation cycle

progesterone secretion, occurring with ovulation at mid cycle, causes a 0.5° F to 1.0° F rise in temperature that continues until menses

exercise

moderate to hard exercise increases body temperature

age

wider normal variations occur in infant and young child due to less effective heat control mechanisms; in older adults, temperature usually lower than in other age groups, with a mean of 36.2° C (97.2° F) via oral route

respirations

range: 10-20 breaths per minute

• tachypnea

• bradypnea

• apnea

• effort or work of breathing (WOB)

• rhythm

When assessing respirations, look at: Rate + rhythm + depth + effort

range of respiratory rate

10-20 breaths per minute

tachypnea

greater than 25 breaths per minute (rapid breathing)

bradypnea

less than 10 breaths per minute (slowing breathing)

apnea

absence of breathing

blood pressure

measures the force of blood against the walls of the arteries

measures systolic and diastolic

• average rate is 120/80 mmHg

• pulse pressure: difference between systolic and diastolic

• mean arterial pressure (MAP): calculated via formula

  • greater than or equal to 60 mmHg needed to maintain organ perfusion

• korotkoff sounds

systolic

maximum pressure during LV heart contraction (systole),

rate is 120

diastolic

pressure during resting or filling (diastole), when the heart relaxes

rate is 80

hypotension

abnormally low blood pressure, less than 90/60

hypertension

elevated BP

120-129 (systolic) and less than 80 for diastolic

Stage 2 HTN

systolic (greater than or equal to 140) diastolic (greater than or equal to 90)

Stage 1 HTN

systolic (130-139) diastolic (80-89)

normal BP

systolic (less than 120) diastolic (less than 80)

elevated BP

systolic (120-129) diastolic (less than 80)

level of BP determined by five factors

1. cardiac output

2. peripheral vascular resistance

3. volume of circulating blood

4. viscosity

5. elasticity of vessel walls

cardiac output

increase in CO leads to increase in BP whereas decrease in CO leads to decrease in BP

peripheral vascular resistance

increased resistance (vasoconstriction) leads to increase in BP whereas decrease in resistance(vasodilation) leads to decrease in BP

volume of circulating blood

fluid retention leads to increased BP whereas hemorrhages leads to decreased BP

viscosity

increase associated with increase in BP

elasticity of vessel walls

increasing rigidity associated with increase in BP

blood pressure factors

average BP varies normally with many factors

1. age

2. sex

3. race

4. social determinants

5. diurnal rhythms

6. weight

7. exercise

8. emotions

9. stress

age

gradual rise through childhood and into adult years

sex

after puberty, females show a lower BP than males; after menopause, females higher than males

race

Differences exist relative to combination of genetics and environment

social determinants

effects of environment & social factors lead to increased risk of HTN

diurnal rhythm

Daily peak and trough levels r/t timing cycles

weight

Obesity increases blood pressure as compared to normal weight recorded measurements of same age

exercise

Will cause a transitory increase in blood pressure

emotions

Will increase in response to sympathetic nervous system response

stress

Will increase in response to increased stress and tension

leads to high readings

• Taking when physiologically active, following activity, or emotionally labile

• Narrow cuff size and/or applied too loose

• Reinflating during procedure

leads to low readings

• Decreased inflation

• Too large cuff size

orthostatic vital signs

assess how blood pressure and pulse change when a person changes position, particularly from lying to standing

• Used when suspect volume depletion, concerns related to blood pressure medications, dizziness, or syncope

• Rest supine for at least 3 minutes  take baseline BP and pulse

• Sit patient up  take BP and pulse

• Stand patient up  take BP and pulse

• Wait 3 minutes (with patient still standing)  retake BP and pulse

• Orthostatic hypotension: drop in systolic pressure ≥20 or diastolic pressure ≥10

orthostatic hypotension

is commonly defined as a drop within 3 minutes of standing of:

Systolic BP ↓ ≥20 mmHg

OR

Diastolic BP ↓ ≥10 mmHg

For example:

Lying: 130/80
Standing: 105/68

Systolic dropped 25 mmHg → significant orthostatic drop.

The patient may experience dizziness, weakness, lightheadedness, or fainting

pulse oximeter

• used to noninvasively measure arterial oxygen saturation (SpO2)

  • Sensor emits light to detect oxygen molecules saturating hemoglobin

• Normal, healthy adult: >95% on Room Air

  • Need to report in relation to oxygen, ex: 97% on RA, 94% on 2L NC

• Ensure that it is a valid reading before documenting

  • Challenges: poor circulation, cold extremities, dark nail polish

types of documentation

• HR 98 regular rhythm, + 2 radial pulse

• Temp 99.5°F rectally

• RR 18 easy, unlabored

• BP 124/78 RUE sitting

• SpO2 98% on RA

• HR 64, irregular rhythm apical

• Temp 97.8°F oral

• RR 12 easy, unlabored

• BP 118/78 LUE supine

• SpO2 95% on RA

temperature changes due to aging

• changes in body’s temperature regulatory mechanism leave aging person less likely to have fever but at greater risk for hypothermia

  • temperature is less reliable index of older

    person’s true health state; sweat gland activity is

    also diminished

pulse changes due to age

normal range of heart rate is 50 to 95 bpm, but rhythm may be slightly irregular

• Radial artery may feel stiff, rigid, and tortuous in older person, although does not necessarily imply vascular disease in heart or brain.

• Increasingly rigid arterial wall needs faster upstroke of blood, so pulse is easier to palpate.