patient assessment and vital signs

patient centered care

individualized care, patient involvement, provider collaberation

effective communication

consider patient condition, adjust environment factors

aidet communication tool

acknowledge, introduce, duration, explanation, thank

teach back method

have patient explain it to you

stages of clinical incounter

chart review, introductory, initial assessment, treatment/monitoring, follow up

HIPAA Health Insurance Portability and accountability act

legal and moral obligation to keep a patient's information private info to the strictest confidence

PHI protected health info

must ensure only approved personnel have access to PHI

CUS

concerned, uncomfortable, stop

vital signs

establish a baseline, observe trends

types of vital signs

pulse HR, respiratory rate RR, blood pressure

frequency of vital signs

routine signs are every 4-6 hours

trends

more important than one single measurement, series of measurements

Temperature

normal 37c and 98.6f. can be taken from temporal, oral, rectal, and ear.

pulse

Heart beats per minute

Measured by palpating

counting beats for 15 seconds x4

Normal: 60- 100 bpm

blood pressure

measurement of the force exerted against the wall of arteries.

bp= systolic/diastolic

systolic = first noise you hear

diastolic = last noise you hear

normal bp 120/80

respiratory rate

breaths per minute

count 30 × 2

watch chest or stomach

adults 12-20

physical examination of thorax and lungs

inspection palpation percussion auscultation