Lecture 4: Assessment Techniques and Safety in the Clinical Setting

steps to complete before examining a patient

gather equipment, wash hands + glove, assess the scene, let the patient know what is happening

the single most important step to decrease microorganism transmission

washing your hands

inspection

first step of examination - close scrutiny of the individual: as a whole, then the body system, begins right away

palpation

second step of examination - using sense of touch to assess

when to palpate with fingertips

fine tactile discrimination of skin texture, swelling, pulsation, lumps

when to palpate with fingers and thumb

detection of position, shape, and consistency of an organ/mass

when to palpate with dorsa of hand

temperature → thinner skin

when to palpate with base of fingers / ulnar surface

vibration

percussion

using short, sharp strokes and listening to sounds to assess underlying structures

what kind of percussion sounds should normal lungs produce

resonant

what kind of percussion sounds should lungs with stuff in them produce

flat

auscultation

listening to sounds produced by the body, channeled with a stethoscope to block out extraneous sounds

when do we wear gloves

when you contact body fluids (all the time)

assessment order for the abdominal region

inspection, auscultation, percussion, palpation

assessment order for most of the body

inspection, palpation, percussion, auscultation

examination for a sick person

alter position for comfort, full assessment isn’t always feasible, return for complete assessment after distress has been resolved

how to document assessment

vital signs, general overview, ROS

what are the parts of a nursing report

age, gender, chief complain, subjective, objective

initial objective data

objective data collected right the start - includes vital signs and general survey

general survey

gestalt perception of the person: considers physical appearance, body structure, mobility, and behavior

items included in physical appearance

age, sex, LOC, skin color, facial features, AAOx3

items included in body structure

stature, nutrition, symmetry, posture (consider toddler lordosis or older adult’s kyphosis), position, body build, deformities

items included in motility

gait - foot placement, ROM, involuntary movements

items included in behavior

facial expression, mood and affect, speech, dress, personal hygiene

how do we measure weight

kilograms ideally, aim for the same time of day and same type of clothing, compare to previous visits, show person how their weight matches to their height

how do we measure height

person should be shoeless, looking forward, feet and shoulders touching the wall

how to calculate BMI

kg / m² or 703 x lb/in²

what regulates body temp?

hypothalamus (remember the 5 H’s from psych)

when is your body temperature lowest

4:00 AM

how does menstruation affect body temp

increase 0.5-1.0 degrees F

how is body temp different in children?

wide variation

(for future reference) how to convert fahrenheit to celsius

5/9(F-32)

normal range oral sublingual temp

96.4 → 99.1

normal range for rectal temp

0.7-1.0 higher than sublingual

how do you take temp on a mercury thermometer

shake to 96, leave 3-4 minutes afebrile 8 minutes febrile, spend this time taking vital signs

how long to wait to take patient’s temp

15 after drinking hot/cold liquids, 2 minutes after smoking

tympanic membrane thermometer (TMT)

reads internal carotid artery temp, quick and efficient (2-3 seconds), good for unconscious, critically ill, or labor

stroke volume

the amount of blood every heart beat pumps into the aorta, about 70 ml in adults

how to take pulse

count for 30 seconds, 2x. unless irregular: full minute

normal heart rate range

60-100

how does heart rate change as you age?

decreases

sinus arrhythmia

arrythmia commonly found in children and young adults - heart rate varies with respiratory cycle, speeding up at inspiration

how is pulse force scaled

3+, 2+, 1+, 0

What are the characteristics of normal breathing?

relaxed, regular, automatic, silent

tachypnea

>20 respirations/minute

respiratory depression

<10 respiration/minute

what does blood pressure measure

the force of blood pushing against the vessel

systolic pressure

pressure felt during left ventricular contraction (aka systole)

diastolic pressure

elastic recoil, pressure that exerts between each contraction

pulse pressure

systolic - diastolic, reflects stroke volume

normal BP range

90-120/60-80

stage 1 HTN

120-140/80-90

stage 2 HTN

140-160/90-100, needs attention but not urgent

stage 3 HTN

160-180/100-110 notify

stage 4 HTN

>180/110 urgent, call within an hour

orthostatic BP

decrease in systolic occurs from going supine → standing

pulse oximeter

noninvasive method to assess SpO2, detects amount of light absorbed by oxyhemoglobin

O2 value of hypoxia

<90%