Week 1 Health History, Infection Control, Vital Signs, Assessments

4 major elements of health assessment

1. general survey

2. health history

3. vital signs

4. physical assessment

WIPES

W - wash hands

I - introduce yourself, identify patient

P - privacy

E - environment, explain

S - safety

SOLER

S - sit

O - open posture

L - lean forward

E - eye contact

R - relax

Physical presence of general survey

stated vs apparent age, gait, posture, motor activity, speech, skin, odors, LOC (person, place, time, situation)

Psychological presence of general survey

dress, grooming, hygeine, mood, affect, speech, expressions

Distress of general survey

labored breathing, wheezing, cough, painful expression, emotional distress - FOCUS HERE IF NOTICE

7 parts of health history

1. demographics/source of info (family, form, patient)

2. “chief complaint”

3. present health - HPI

4. past history

5. family history

6. review of systems

7. health patterns

HPI / present health - OLD CART

O - onset/setting

L - location

D - duration, frequency

C - character or quality (ache, burn, stab)

A - associated manifestations

R - relieving or aggravating factors

T - treatment

Components of infection cycle

-agent

-reservoir

-portal of exit

-means of transmission

-portal of entry

-susceptible host

Vascular phase of inflammatory respones

vasodilation increases blood flow (redness and heat), histamine released causes permeability of vessels and protein-rich fluid to get to site of injury (swelling, pain, loss of function)

Cellular phase of inflammatory responses

leukocytes/neutrophils consume debris, damaged cells repaired

Medical asepsis

clean technique; hand hygeine/wearing gloves

Surgical asepsis

sterile technique; inserting indwelling catheter or IV

Lab data indicating infection

-elevated white blood cell count (5,000 - 10,000 / mm3 normal)

-increase in specific white blood cells
-elevated erythrocyte sedimentation rate

-presence of pathogen in urine, blood, sputum, cultures

Airborne precautions

bacteria released when patient talks, coughs, sneezes, need N-95 mask, gloves (e.g. TB, measles, pox, shingles), negative-pressure

Droplet precautions

respiratory secretions when coughing or sneezing, need mask, gloves (e.g. flu, pertussis, mumps, meningitis)

Contact precautions

skin to skin contact, contact with objects in room, need gown, gloves, face shield/goggles if needed (e.g. MRSA, VRE)

How do enteric precautions differ?

hand sanitizer not enough for hand hygiene, must wash hands with soap and water, need gown, gloves (e.g. C.diff)

Neuropenic precautions

protecting patient from OUR bacteria, for patients immunocompromised (cancer, transplant) need mask, gloves, gown if needed, no fresh fruits/veggies, flowers, postive-pressure

Donning order

gown, mask, goggles, gloves

Doffing order

gloves, gown, goggles, mask

Oral temp range

96.4 - 100.0

Axillary temp range

95.8 - 99.0

Rectal temp range

97.3 - 101.0 MOST ACCURATE

Tympanic temp

range same as oral or rectal scales, for adult pull UP and back for child pull DOWN and back

Temporal temp range

97.4 - 100.1

No touch thermometer

not as accurate, temp, room, hats, etc can influence reading, can read really low

True or false: Normal pulse rate decreases as you age.

TRUE - newborns normal is 100-170 while adults is 60-100

8 peripheral pulses

radial, dorsalis pedis, posterior tibialis, popliteal, femoral, brachial, carotid, temporal

True or false: The apical pulse is the most direct.

TRUE - S1 lub S2 dub, 5th intercostal space

True or false: As we age our normal respiration rate slows down.

TRUE - infant 30-40/min while adult 12-20 per min

Errors that result in false high BP

cuff too small, cuff too loose, arm below heart, arm not supported, inflating or deflating cuff too slowly (high diastolic), deflating cuff too quickly (low systolic high diastolic)

Errors that result in false low BP

cuff too large, pressing stethescope too tightly, arm above heart, repeating too quickly, inaccurate inflation

Normal BP

systolic < 120, diastolic < 80

Prehypertension BP

systolic 120-139, diastolic 80-89

Hypertension stage I BP

systolic 140-159, diastolic 90-99

Hypertension stage II BP

systolic > 160, diastolic > 100

Orthostatic hypotension

drop in BP when patient moves from laying to standing

True or false: normal BP values increase with age.

TRUE - newborn 80/46, adult 120/80, elderly 130/80

True or false: The "ideal" O2 saturation value for a COPD patient is 85% and up.

FALSE - 90% and up, 95% for non COPD

Ecchymosis definition

bruising

Erythema definition

inflammation

Patticae definition

small pinpoint red dots under skin

Unexpected skin texture/moisture findings

velvety skin, roughness, dryness, flakiness, diaphoresis (sweating)

Unexpected skin integrity findings

skin lesions (moles), ABCDE rule

A - asymmetry

B - borders, uneven

C - color

D - diameter (larger than 6 mm concerning)

E - evolving

Unexpected skin mobility/turgor findings

tenting, edema

Unexpected nail findings

weird colors, clubbed, jagged, delayed capillary refill

Parathesias definition

pins and needles

Dyesthesias definition

aching/burning to touch

Tremors definition

involuntary movements: trembling, shakiness

a. resting

b. postural (action) - when trying to do something (finger to finger)

c. intention - during movement

d. oral-facial

e. tics - facial twitching

f. dystonia - stiff muscles/ remain contracted

g. athetosis - ringing of hands

h. chorea - fluttering/flapping of hands

Important areas to examine during neuro

-mental status (A/O by 1, 2, 3, 4)

-cranial nerves

-motor system: coordination, gait, stance, posture

-sensory system: pain, temp, light touch, discrimination

-reflexes

Pupil examination

PERRLA

P - pupils

E - equal

R - round

R - reactive

L - to light

A - accommodation (6 movements)

normal pupil about 3-4 mm in diameter

Nystagmus in eyes

bouncing from side to side, can be due to alcohol intoxication

Glasgow coma scale

based on eye opening, motor response, verbal response, 3-no response, 3-8 comatose, 15-fully alert

Cranial nerve I - 1

olfactory - smell

Cranial nerve II - 2

optic - visual activity

Cranial nerve III - 3

oculomotor - pupillary reactions

Cranial nerve IV - 4

trochlear - inferior and lateral movement of eye (down and out)

Cranial nerve V - 5

trigeminal - motor in face, clench teeth, move jaw side to side, corneal reflex (blink)

Cranial nerve VI - 6

abducens - lateral movement of eye

Cranial nerve VII - 7

facial - expressions, raising eyebrows, smiling/frowing

Cranial nerve VIII - 8

acoustic - hearing sounds/vibrations, whisper test

Cranial nerve IX - 9

glossopharyngeal - sensory input (taste), motor input (swallowing, saliva production)

Cranial nerve X - 10

vagus - controls rest and digest, heart rate, reflexes like swallowing and coughing (gag reflex), uvula movement

Cranial nerve XI - 11

spinal accessory - trapezius, shrugging, turning head side to side

Cranial nerve XII - 12

hypoglossal - tongue movement, articulation, tongue position in mouth

Spastic hemiparesis

dragging foot "zombie"

Scissors gait

knee crosses midline

Steppage gait

overexaggerated step, going "up stairs"

Parkinsonian gait

hunched, stiff

Cerebellar ataxia

damage to cerebellum causes loss of muscle coordination

Sensory ataxia

loss of muscle coordination due to impaired proprioceptive or sensory feedback from the lower extremities (don't know affected side exists)

Musculoskeletal system

bones, joints (fibrous, cartilaginous, synovial), ligaments, tendons, muscles (skeletal, smooth, cardiac)

Expected findings during musculoskeletal assessment

symmetry, alignment, equal movements

True or false: Jaw clicking is an expected variation during a head and neck assessment.

TRUE

True or false: Noticing nodules on the elbows upon palpation is an expected finding.

FALSE - olecranon process normal but nodules not

True or false: Calluses are an example of an expected variation in the feet.

FALSE - only arch variations expected

What 2 vitamins are recommended to support the musculoskeletal system? a. calcium and potassium

b. calcium and vitamin D

c. vitamin C and vitamin D

B. calcium and vitamin D

Head to toe components

general survey, vital signs, skin hair nails, HEENT: head ears eyes nose throat, respiratory, cardio, peripheral vascular, GI/GU, musculoskeletal, neuro

IPPA

inspect, palpate, percuss, ausculate

Part of head to toe assessment where IPPA differs and why

ABDOMEN - palpating and percussing before auscultating might disrupt bowel sounds

Light palpation

-finger pads or back of hands

-superficial, delicate, gentle

-skin texture, moisture, temp, superficial pulsations, tenderness

Moderate palpation

-finger pads

-1 cm depression

-skin texture, moisture, masses, fluid, guarding, pulsations, tenderness

Deep palpation

-hands

-4-5 cm depressions

-position of organs, masses (size, shape, mobility, consistency)

-abdominal and reproductive structures

Common body parts percussed during HTT

abdomen and thorax

Percussion uses

-elicit pain: sign of inflammation

-location size and shape of organs

-density - fluid, solid, air filled

-abnormal masses

-reflex assessment

3 percussion techniques

1. direct - touching patient directly

2. indirect - finger over finger

3. blunt - fist over hand