Patient+Assessment
Bedside Assessment of the Patient
Importance of Assessment
Assessing patients at the bedside is crucial for effective medical care.
4 Critical Life Functions
Ventilation: Movement of air in and out of the lungs.
Key indicators: Respiratory Rate (RR), chest movement, breath sounds, and partial pressure of arterial carbon dioxide (PaCO2).
Oxygenation: Process of getting oxygen into the blood.
Key indicators: Heart Rate (HR), skin color, level of consciousness (sensorium), and partial pressure of arterial oxygen (PaO2).
Circulation: Movement of blood through the body.
Key indicators: Pulse, heart rate and strength, cardiac output.
Perfusion: Delivery of blood and oxygen to tissues.
Key indicators: Blood pressure, sensorium, body temperature, urine output, and hemodynamics.
Monitoring Life Functions
Every part of the assessment is related to the four critical life functions.
Immediate action is required if there are signs of distress in any function:
Diaphoretic Patient: If a patient is diaphoretic during a breathing treatment, the treatment should be halted to assess.
Desaturation: If a patient shows signs of desaturation (low oxygen levels), stabilize the patient first with oxygen therapy before starting treatments.
Code Blue: If any life function is absent, a code blue must be called.
First Priority Steps:
Ventilation: Establish an open airway and ensure breathing.
Oxygenation: Increase the fraction of inspired oxygen (FIO2).
Circulation: Administer chest compressions, medications, etc.
Perfusion: Work to increase blood pressure.
Reviewing Patient’s Records
Key Components:
Admission Notes: Including admitting diagnosis, history of present illness, chief complaint, and past medical history.
Signs and Symptoms:
Signs: Objective information measurable or observable (e.g., color, pulse, edema).
Symptoms: Subjective information — what the patient communicates (e.g., dyspnea, pain).
Occupation History: Knowledge of employment history can provide context to the patient's health.
Allergies: Important to document allergies, particularly to medications and dyes.
Patient Evaluation
Records to Review:
Respiratory Orders: Type of treatment, frequency, and medications required.
Patient Progress Notes:
Document date, time (in 24-hour clock), and reaction observed in the patient.
Nursing notes for patient status.
Admission notes for pertinent data regarding the patient.
Physician notes, especially if any change in condition occurs.
Lab Reports: Check blood gases (ABG), complete blood count (CBC), blood urea nitrogen (BUN), creatinine, troponins, pulmonary function tests (PFT), imaging studies (x-rays, CT, MRI).
General Appearance Assessment
First step during the physical exam is to observe the patient’s appearance.
Goals: Create a holistic picture of the patient for documentation and understanding.
Aspects to note: Gender, ethnicity, age, height, weight, general state of health, and facial expressions.
Provides clues about the patient’s emotional state and nutritional status.
Observing Patient Characteristics
Consider the following questions:
Is the patient awake and responsive?
Is the patient relaxed or displaying anxiety/restlessness?
Position of patient (lying, sitting, etc.)?
Any signs of respiratory distress?
Ancillary equipment being used (e.g., oxygen)?
General health status of the patient.
Noting General Appearance
Important observations include:
The patient’s color (for signs of hypoxia or shock).
Excessive sweating and noting oxygen levels (SpO2) and oxygen therapy.
Cardiac monitoring equipment status (HR, rhythm).
Overall hair, skin, extremities, and head inspection.
Skin Assessment
Inspection of skin to identify color changes, edema, or diaphoresis which are vital signs.
Skin color should be consistent across individuals but noting deviations:
Pale and Cold: Often indicates shock/hypotension.
Angioedema: Swelling from allergic reactions affecting the face, tongue, and extremities.
Diaphoresis and Other Symptoms
Diaphoresis: Excessive sweating related to respiratory distress or cardiac illness.
Various possible causes include fever, anxiety, medications, and withdrawal from substances.
Example scenario: Athlete sweating during activity vs. patient in bed sweating may denote a problem.
Skin Color Analysis
Abnormal skin color assessments:
Pallor: Could suggest anemia or blood loss.
Jaundice: Indicates liver issues (yellow skin).
Erythema: Redness due to capillary congestion or infection.
Ecchymosis: Superficial bleeding under skin often seen in the elderly.
Cyanosis
Description: Bluish discoloration due to elevated desaturated hemoglobin (Hb).
Observation Areas: Lips, gums, nail beds.
Types of Cyanosis:
Central Cyanosis: Involves oral mucosa/trunk.
**Peripheral Cyan