Begins when first meet client Physical appearance Mental Status Mobility Behavior Attention to detail - clues to problems

for further assessment

 General

appearance: healthy, obvious conditions Age: close to stated age Skin: color (variations), lesions Hygiene: cleanliness, grooming, odors Stature: height appropriate for age Nutritional status: well nourished, cachectic, obese Symmetry: R/L sides similar

While client is responding to questions and giving information about history

Affect and mood Level of anxiety Orientation to person, place & time Speech

Body movement Gait Posture Range of Motion

Dress and Grooming Body odors Facial expression Mood and affect Ability to make eye contact Level of anxiety

Ask client first before getting measurements Helps establish baseline data and helps determine health status Medication dosage calculation Adult height attained between 18 and 20 years

Baseline indicators of a clients health status A change can indicate a change in physiological function Vital Signs: T = Temperature P = Pulse R = Respiratory Rate BP = Blood Pressure O2 sat = Oxygen Saturation Pain

Nurses responsibility/delegation Knowledge of equipment Knowledge of clients range Knowledge of clients history and current status Environmental factors Systematic approach Approach with the client Frequency of assessment Assessment for medications Analysis and verification of results Communication of results

Regulated by hypothalamus: heat gain vs. heat loss 96.4 to 99.1 F (36.8 to 37.3 C) 98.6 F (37 C) core temp Cellular metabolism most efficient Stays relatively constant despite environmental changes and physical activity

Age Diurnal variations: Lowest in early morning (0100-0400), higher in late afternoon/evening (max @ 1800) Menstrual cycle: temp and persists until ovulation (due to progesterone ) Exercise also increases temp ( metabolism) Stress temperature

Oral: glass, paper, or electronic thermometer (normal 98.6F/37C) Axillary: glass or electronic thermometer (normal 97.6F/36.3C) Rectal or "core: glass or electronic thermometer (normal 99.6F/37.7C) Tympanic: electronic thermometer (normal 99.6F/37.7C) Of these, axillary is the least and rectal is the most accurate.

Normal 97 99.9F Delay 10 minutes if ingested hot/cold liquids Electronic thermometer (sheathed): under tongue, place in either right or left posterior sublingual pocket (15-30 seconds) Safe for children/confused adults Dont take oral temp if had oral surgery or lesions

Normal 99.6F/37.7C Probe covered, placed in external ear canal; in contact with all sides of canal (23 seconds) Questionable reliability in children (direction of beam) Less than 3 years: pull down Over 3 years: pull up Adults: pull up and back

Normal 97.6F/36.3C Common site for infants and children Not close to major blood vessels Low sensitivity to detect fever (febrile patients) Electronic: middle of axilla with arms folded Alternative site for those with oral inflammation, wired jaws, oral surgery, mouth breathers (nasal surgery)

Normal 99.6F/37.7C (.7 to .8o higher) Used less frequently with newer methods Used more common in comatose or seizing clients Do not use if client had rectal surgery, hemorrhoids or lower GI disorders Adults: less comfortable, more time, increased risk of infection
Sims position 1.5 inches into rectum (electronic)

Children: last resort

1 inch

Newborns, Infants: risk of rectal perforation

inch

Shake down, verify Insert cover, position properly Wait 2-3 minutes Read correctly 2 opportunities

Pat the axilla dry if moist Bulb is placed in the middle of the axilla Wait 6-9 minutes Compare reading to oral (one degree less than oral)

Wear gloves, water soluble lubricant Position in Sims or lateral Insert to 1 inches depending on age ( infant; 1 child; 1-1 adult) Wait 2-3 minutes Compare reading to oral (one degree higher than oral)

Know how to document on flow sheet Terminology: Hyperthermia: very high fever Febrile: fever Hypothermia: low fever Afebrile: no fever Factors Affecting Temperature: Diurnal variation Menstrual cycle Exercises Stress

Valuable information about cardiovascular system Information regarding strength of the pulse and perfusion of blood to various parts of the body Indirect reflection of heart contraction

Measure:
Rate: beats per minute Rhythm: regularity (time between beats) Strength: volume of blood ejected with each beat Equality: comparison of same pulse in opposite extremities by taking simultaneously

 Rhythm: Regular rhythm Evenly spaced beats; 30 x 2; 15 x 4 Irregular rhythm Full minute Regularly irregular: regular pattern overall with skipped beats Irregularly irregular: chaotic, no real pattern, very difficult to measure rate accurately Strength: Bounding, strong, weak or thready

Pulse assessment sites: Temporal Carotid Apical Brachial Radial Femoral Popliteal Posterior tibial Pedal

WHAT IS A NORMAL PULSE? Adult: 60 to 100 Newborn: 120-170 1 year: 80-160 3 years: 80-120 6 years: 75-115 10 years: 70-110

Average Pulse and Blood Pressure in Normal Children

Age

Birth

6mo

1yr

2yr

6yr

8yr

10yr

Pulse

140

130

115

110

103

100

95

Systolic BP

70

90

90

92

95

100

105

Most frequently measured Arm is supported on a bed, chair or nurses arm Wrist is extended (not bent) Lightly compress tips of first 2 fingers against radius, obliterate pulse initially, and then relax pressure so pulse becomes easily palpable For a regular pulse count for 30 seconds and multiply by 2 Irregular pulse: count for a full 60 seconds

Apical pulse: Auscultate for 1 minute 5th intercostal space midclavicular line Use stethoscope when assessing Measure rate and rhythm

Brachial: located in groove between the triceps and biceps muscle medial to the biceps tendon in the antecubital fossa

Carotid: located along the medial edge of the sternocleidomastoid muscle in the lower third of the neck

Radial: Accurate count Apical: 60 seconds Apical/Radial: 60 seconds 2 opportunities for each

 Know how to document on flow sheet Factors affecting pulse: with exercise, fever, stress with males, age, athletes Terminology: Pulse sites Rate: beats per minute Rhythm: regularity (time between beats) Pulse deficit: difference between radial and apical Bradycardia: < 60 bpm Tachycardia: > 100 bpm

Exchange of O2 and CO2: oxygen reaches body cells and carbon dioxide is removed from the cells Respiration involves:
Ventilation: the movement of gases in and out of the lungs Diffusion: the movement of oxygen and carbon dioxide between the alveoli and the red blood cells Perfusion: distribution of red blood cells to and from the pulmonary capillaries

 Best done immediately after taking the patient's pulse. Do not announce that you are measuring respirations. Without letting go of the patients wrist begin to observe the patient's breathing. Is it normal or labored? Count breaths for 30 seconds and multiply this number by 2 to yield the breaths per minute. In adults, normal resting respiratory rate is between 14-20 breaths/minute.

Note the rate, rhythm, depth and effort of breathing Rate = number of ventilatory cycles (inhalation and exhalation) per minute Males: diaphragmatic (abdominal) Females: thoracic Rhythm = regularity of breathing (equal space between breaths) Regular or irregular

Depth = observation of excursion (movement) of chest wall Deep (large amount of air) Normal Shallow (small amount of air) Effort: even, quiet, effortless

Accurate count (best for 30 sec.) 2 opportunities Document on flow sheet Factors affecting respiration: with exercise, fever, stress, altitude Varies with age

 Terminology: Rate: number of ventilatory cycles (inh + exh) Rhythm: regularity of breathing (reg or irreg) Depth: observation of excursion (movement of chest wall) deep or shallow Effort: even, quiet effortless Tachypnea: fast Bradypnea: slow Apnea: no breathing Dyspnea: difficulty breathing Orthopnea: diff lying Retractions: intercostals or substernal

Force of blood against arterial wall Relationship between cardiac output and peripheral resistance BP dependent on blood volume, velocity, vessel elasticity Measured in mm Hg: height of mercury column from blood pressure Systolic: maximum pressure on arteries during ventricular contraction (ejection) Diastolic: minimum pressure on arteries during ventricular relaxation

BP = CO x R BP= blood pressure CO=cardiac output (heart rate x stroke vol) R = Peripheral vascular resistance Resistance refers to the resistance to blood flow determined by the tone of vascular musculature and diameter of blood vessels As resistance rises, arterial BP rises As vessels dilate and resistance falls, BP decreases

Recorded = systolic/diastolic (not a fraction) Pulse pressure: difference between systolic and diastolic pressure 120/80=40 (usually 30- 40 mm Hg) Direct: arterial catheterization Indirect measurement Sphygmomanometer and stethoscope (auscultation) NIBPM: electronic sensing of vibrations, not Korotkoff sounds

Factors that affect BP measurements:

Age: gradual rise Gender: females males after puberty; females males after menopause; Race: HTN 2x higher in African Amer Diurnal variations: in early am; highest in late afternoon or early evening Emotions: anxiety, stress or anger can Pain: acute pain can Personal habits: caffeine and smoking within 30 minutes before taking may Weight: obese have Medications

 Upper arm most common site; thigh alternate site (10-40 mm higher) Blood flow occluded by inflated cuff Cuff deflated until sounds of pulsing blood return (1st Korotkoff sound); systolic pressure Clear, rhythmic, thumping sound, increasing intensity 2nd, 3rd, 4th Korotkoff sounds swishing/thump/muffled-low pitch sound Pressure at which no sound heard indicates artery completely open (5th Korotkoff sound); diastolic pressure

Phase 1: sharp thuds, start at systolic blood pressure Phase 2: blowing sound; may disappear entirely (the auscultatory gap ) Phase 3: crisp thud, a bit quieter than phase 1 Phase 4: sounds become muffled Phase 5: end of sounds -- ends at diastolic blood pressure

Common errors in BP measurement Accuracy affected by technique Research finds that providers incorrect technique results from lack of knowledge False high/low measurements Many errors due to wrong cuff size

False-high BP measurement: Arm above level of heart Cuff too narrow Cuff too loose Deflating cuff too slowly Reinflating cuff without completely deflating Not waiting 1-2 minutes before repeat measure

False-low BP measurement: Arm below level of heart Manometer higher than heart Cuff too wide Not inflating cuff enough Deflating too rapidly Pressing diaphragm too firmly on brachial artery

Normal: <120/<80 Prehypertensive: 120-139/80-89 Stage 1 hypertension: 140-159/90-99 Stage 2 hypertension: >160/>100

 Position the patient's arm so the antecubital fold is level with the heart. Support the patient's arm with your arm or a bedside table. Center the bladder of the cuff over the brachial artery approximately 2 cm above the antecubital fold. Proper cuff size is essential to obtain an accurate reading. Be sure the index line falls between the size marks when you apply the cuff. Position the patient's arm so it is slightly flexed at the elbow. Palpate the brachial or radial pulse and inflate the cuff until the pulse disappears. Inflate an additional 20 mmHg higher and release cuff until you can again feel the pulse. This is a rough estimate of the systolic pressure.

 Place the stethoscope over the brachial artery. Inflate the cuff to 30 mmHg above the estimated systolic pressure. Release the pressure slowly, no greater than 5 mmHg per second. The level at which you consistently hear beats is the systolic pressure. Continue to lower the pressure until the sounds muffle and disappear. This is the diastolic pressure. Record the blood pressure as systolic over diastolic ("120/70" for example).

 With fingers palpating radial or brachial artery, inflate cuff rapidly until you can't feel the pulse, then 20 mm higher Release cuff at 2 to 3 mm Hg per second until you again feel the pulse; this is the palpable systolic pressure Wait 30 seconds before measuring blood pressure Measuring palpable pressure first avoids risk of seriously underestimating blood pressure

 Wash hands, clean stethoscope Position patient Obtain correct size BP cuff (40% width or 2/3 (80%) length) Palpate brachial artery Center bladder over artery Wrap cuff securely, 1 inch above AC Inflate cuff 30 above last heard or palpated systolic Release valve slowly Correct interpret readings (2 chances) within 4mmHg Document on flow sheet

 Factors affecting BP: with age, after menopause, African Amer, in the PM, emotions, pain, caffeine, smoking, weight after puberty and in the AM Cuff size, medications, choice of arm Terminology: Systolic: top # (ventricle contracting) Diastolic: bottom # (ventricle filling) Pulse pressure: difference between systolic and diastolic Orthostatic hypotension: drop in BP as you stand

 When and why to avoid a certain arm: Mastectomy IV fluids or blood infusing Burns AV Grafts Signs and symptoms of hypertension: HA Flushing Ringing in the ears Nose bleed Signs and symptoms of hypotension: Increased heart rate Dizziness Cool Clammy

Included with vital signs Pulse oximetry: oxygen saturation of hemoglobin Probe on fingertip (other sites) Digital readout Saturation levels less than 90% necessitate further evaluation Caregivers knowledge deficiency in measurement and interpretation reported

COLDSPAT Character Onset Location Duration (constant or intermittent) Severity (On 0-10 scale) Precipitating Factors Alleviating Factors Treatment