Survey

  • Assessment begins at first sight

  • Therapeutic communication develops support and trust 

  • Non verbal body language; eye contact, posture, facial expressions, etc 

  • Watch for cues from the patient; verbal or non verbal for miscommunication 

  • Consider the emotional state of the patient 

  • Introduce yourself to the patient and ask for their name and date of birth 

  • Ask what they preferred to be called, pronouns, use the word partner  

  • General Inspection: physical/how they dress, season, culture, age group - hygiene/dental - body structure/movement - oder - mental status/behavior - visual inspection

  • Does a person stand promptly as his or her name is called and walk easily to meet you? Does a person look sick, rising slowly or with effort, with shoulders slumped and eyes without luster or downcast? Is a hospitalized patient conversing with visitors, involved in reading or television, or lying perfectly still? 

  • Objective, Direct Assessment; inspection, percussion, palpitation, auscultation

  • Subjective; what the patient tells you in response to your questions 

  • The data collected can tell you what clinical judgments to make, planning care or interventions 

  • Behavior Assessment; speech and mood  

  • Is speech articulate & have coherent thoughts, Is client cooperative & pleasant, Are facial expressions appropriate, Is client appropriately dressed & groomed

  • Indications of Abuse, neglect or human trafficking; patients afraid to respond, avoiding eye contact, nervous, how they dress, is the patient responding or someone else, old physical injuries, trouble walking 

  • Posture; standing straight, symmetry, hunched over, stiff spine, crunched over from pain 

  • Facial; symmetry, no swelling, lesions, swelling, twitching, facial expressions    

  • Emotional State; unexpected findings; Quiet, restless, grimacing (pain, anxiety, upset) Depression, distrust, anger, sadness (uncooperative, tearful, withdrawn)

  • Eye Contact; wondering eyes, confusion, nervous 






Levels of Orientation/Consciousness

Person

Knows their name and significant others

Person and Place

understands where they are 

Person, place and time

Date, day of the week, season

Person, place, time, situation

Can explain why they are at a healthcare facility 


Height and Weight

  • Stadiometer- standing scale; final height 18 - 20 years of age 

  • Every liter of fluid is an ↑ of 1 kg (2.2 pounds)

  • Unexpected >5lbs/day: fluid retention i.e.. CHF, Unintentional weight loss (5% in 1 month or 10 % in 6 months: fever, infection, malignancy, disease


  • Underweight Below 18.5 Normal 18.5 – 24.5 Overweight 25.0 – 29.9 Obesity  30.0 and greater


  • >30, greater risk DM, HTN, cancer, HD


Temperature

  • hypothalamus 

  • 96.8 - 100.4

  • Average 98.6, Fever 100.4 or greater 

  • Oral, axillary, rectal, tampanic 

Skin

  • Pallor - white

  • Cyanosis - blue tint

  • Jaundice - yellow ( liver issues)

  • Erythema - red 

Teeth

  • Gums are smooth and moist

  • Teeth are intact and aliens, color can vary 

  • Dry, cracked, dehydration, cold sore, scabs , bloody gums 

Build

  • Cachectic - can see ribs or bones

  • Expected weight and height for the age 

Range of Motion

  • Observe their walk, involuntary motions 

  • Stumbling, dragging the feets, immobility of a limb, unable to stop 

  • Paralysis

  • Crepitus - cracking sound 

  • Spasticity - alteration of muscle tone

  • Rigidity - resistance 

  • Myoclonus - sudden jerking

  • Tic - involuntary, neuro issues 

  • Tremors -  alteration of muscle groups

Assessment Checklist

  • Height, weight, BMI, vital signs, pain/Check for a baseline

Pulse

  • Radial is the most common

  • Dopplers are used if it is difficult to read 

  • Note the strength, rhythm, equality of the pulse; noted as 0-3

  • Listening with a stethoscope; aortic R, pulmonic/erbs UL, Apical/mitral LL

Pulse Ox 

  • Hypoxia - less than 90

  • normal  - 95 or above 

Respiratory Rate

  • Teen - 16 - 20

  • Adult - 12 - 20 \

  • Bradypnea - less than 12

  • Look for shallow breathing and the rhythm

BP

  • The force of blood against the arterial walls 

  • Normal - 120/80 0r less

  • Hypo - less than 90 systolic, hyper over 90

  • Stage 1 - 130-39/ 80-89

  • Stage 2 - greater 140/90

  • Cardiac/opioids can decrease BP

  • Vasoconstrictors can increase BP

  • Infant: 120-160 average 140 RR 30-60 BP Sy 60-90 dia 20-60

  • Adult: 60-100 average 70 RR 12-20 BP sy 110-139 dia 60-79

Pain

  • Ask region, radiation, severity, timing

  • Scale of 0-10

Head Circumference

  • At birth, 2-6 years 

  • Averaage at birth 32-38 cm

Ill

  • Distress, pain, short of breath, fainting feeling