Patient
Assessment
Objectives
• Students will:
– Identify normal and abnormal V/S measurements.
– Measure and record vital signs according to industry
standards.
– Measure and record height and weight according to
industry standards.
– Explain why urine, stool, and sputum specimens are
collected.
– Explain the rules for collecting different specimens
– Describe the seven warning signs of cancer
Vital Signs
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Are important indicators of health
Detect changes in normal body function
May signal life-threatening conditions
Provide information about responses to
treatment
Vital Signs
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Temperature
Pulse
Respirations
Blood Pressure
Vital Signs Are Measured:
– Upon admission
– As often as required by the person’s condition
– Before & after surgery and other procedures
– After a fall or accident
– When prescribed drugs that affect the respiratory
or circulatory system
– When there are complaints of pain, dizziness,
shortness of breath, chest pain
– As stated on the care plan
When Measuring Vital Signs
• Usually taken with the person sitting or lying
• The person is at rest
• Always report:
– A change from a previous measurement
– Vital signs above or below the normal range
– If you are unable to measure the vital signs
Temperature
• Measurement of balance between heat lost
and produced by the body.
– Heat is produced by:
• Metabolism of food
• Muscle and gland activity
– Heat may be lost through:
• Perspiration, Respiration, Excretion
• Measured with the Fahrenheit (F)
or Celsius or Centigrade (C) scales
Body Temperature
• Factors that  body
temperature
• Factors that  body
temperature
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Illness
Infection
Exercise
Excitement
High temperatures in the
environment
• Temperature is usually
higher in the evening
Starvation or fasting
Sleep
Decreased muscle activity
Exposure to cold in the
environment
Temperature Sites
• Oral - by mouth – most common method
– May be affected by hot or cold food, smoking,
oxygen, chewing gum
– Wait 15 minutes or use alternate site
• Rectal - in the rectum -most accurate site
– Do not use if patient has rectal surgery or bleeding
• Axillary - under arm – less reliable site
– Used when other sites are inaccessible
– Do not use immediately after bathing
Temperature Sites
• Tympanic or aural - in the ear
– Measures in 1 to 3 seconds
• Temporal Artery – temporal artery on the
forehead
• Record route temperature was taken
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O - Oral
R- Rectal
T – Tympanic
A – Axillary
Normal Body Temperature
Oral
98.6
Rectal
99.6
Axillary 97.6
Typmanic 98.6
Temporal 99.6
( 97.6 - 99.6)
(98.6 - 100.6)
(96.6 - 98.6)
(98.6 - 100.6)
(98.6 - 100.6)
Hypothermia – temperature below normal
Hyperthermia – temperature above normal
Types of Thermometers
• Clinical (glass) thermometer no longer contain
mercury.
– Come in oral and rectal.
– Disposable covers are usually used.
• Electronic can be used for oral, rectal, or axillary and
use disposable probe covers.
• Tympanic placed in auditory canal and uses
disposable cover.
• Strips that contain special chemicals or dots
that change colors can also be used.
Pulse
• The pressure of blood pushing against the wall
of an artery as the heart beats and rests.
• Measured for one minute while noting:
– rate - beats per minute
– rhythm - regular or irregular
– volume - strength or intensity - described as
strong, weak, thready, bounding
Pulse Sites
Most Commonly Used:
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Carotid – during CPR
Apical – use stethoscope
Brachial – for Blood Pressure
Radial - to count pulse
Femoral – assessment and
procedures
• Popliteal – assessment
• Dorsalis Pedis – assessment
Normal Ranges
Age
Birth to 1 year
2 years
6 years
10 years
12 years & older
Pulse per Minute
80-190
80-160
75-120
70-110
60-100
Bradycardia – Under 60 beats per minute
Tachycardia – Over 100 beats per minute
Factors that Affect Pulse
• Factors that  pulse
• Factors that  pulse
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Exercise
Stimulant drugs
Excitement
Fever
Shock
Nervous tension
Sleep
Depressant drugs
Heart disease
Coma
Respirations
• Process of breathing air into (inhalation) and
out of (exhalation) the lungs.
• Oxygen enters the lungs during inhalation.
• Carbon dioxide leaves the lungs during exhalation.
• The chest rises during inhalation and falls during
exhalation.
• Normal rate 12-20 breaths per minute
Assessing Respiration
• Respirations is measured when the person is
at rest.
• Rate may change is patient is aware that it is
being counted.
• To prevent this, count respirations right after
taking a pulse.
• Keep your fingers or stethoscope over the pulse site.
• To count respirations, watch the chest
rise and fall.
Assessing Respiration
• Character and quality of respirations is also assessed:
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Deep
Shallow
Labored or difficult
Noises – wheezing, stertorous (a heavy, snoring type of sound)
Moist or rattling sounds
• Dyspnea – difficult or labored breathing
• Apnea – absence of respirations
• Cheyne-Stokes – periods of dyspnea followed by periods of apnea;
often noted in the dying patient
• Rales – bubbling or noisy sounds caused by fluids or mucus in
the air passages
Blood Pressure
• Measure of the pressure blood exerts on the walls
of arteries
• Blood pressure is controlled by:
– The force of heart contractions
• weakened heart  drop in BP
– The amount of blood pumped with each heartbeat
• loss of blood  drop in BP
– How easily the blood flows through the
blood vessels
• Narrowing of vessels  increase in BP
• Dilatation of vessels  decrease in BP
Factors that Affect Blood Pressure
Factors that  blood
pressure
• Excitement, anxiety,
nervous tension
• Stimulant drugs
• Exercise and eating
Factors that  blood
pressure
• Rest or sleep
• Depressant drugs
• Shock
• Excessive loss of blood
Measuring BP
• A sphygmomanometer is used to measure BP
– Aneroid – has a round dial and needle
– Mercury – has a column of mercury
– Electronic – automated device
• BP is measured in millimeters (mm) of
mercury (Hg).
• The systolic pressure is recorded over the
diastolic pressure.
Normal Range of Blood Pressure
• Systolic: Pressure on the walls of arteries when the heart is
contracting.
Normal range – less than 120 mm Hg
• Diastolic: Constant pressure when heart is at rest
Normal range – less than 80 mm Hg
• Hypertension—BP that remains above a systolic
of 140 mm Hg or a diastolic of 90 mm Hg
• Hypotension—Systolic below 90 mm Hg and/or
a diastolic below60 mm Hg
Measuring Height and Weight
• Used to determine if patient is underweight or
overweight
• Height and weight charts are used as averages
• Weight greater or less than 20% considered normal
• BMI or Body Mass Index a statistical measure of
body weight based on a person's weight and height.
• BMI from 18.5 to 24.9 is considered normal
Measuring Height and Weight
General Guidelines:
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Use the same scale every day
Make sure the scale is balanced before use
Weigh the patient at the same time each day
Remove jacket, robe, and shoes before weighing
OBSERVE SAFETY PRECAUTIONS!
Prevent injury from falls and the protruding height lever.
Some people are weight conscious.
Make only positive comments when weighing patients
Types of Scales
• Clinical scales contain a balance beam and
measuring rod
• Bed scales or Chair scales are used for patients
unable to stand
• Infant scales come in balanced, aneroid, or digital
– When weighing an infant…keep one hand slightly over but
not touching the infant
– A tape measure is used to measure infant height.
Urine Specimens
• Can provide valuable information about the
patients state of health
• Urine is commonly tested for:
– Bacteria, pus, or blood as found in bladder and
kidney infection
– Sugar and acetone as found in diabetes
– Hormones as found in pregnancy
– Drugs
Common Types of Specimens
• Random urine specimen
– Collected for a routine urinalysis.
– No special measures are needed.
• Midstream specimen (clean-voided or clean-catch)
– The perineal area is cleaned before collecting the
specimen.
– Sterile gloves and container are needed.
• Double voided
– Patient voids and the specimen is discarded
– After 30 minutes, patient voids again and
specimen is collected for testing
Testing Urine
• Urine pH measures if urine is acidic or alkaline.
– Normal pH is 4.6 to 8.0.
• Testing for glucose and ketones
– These tests are usually done 30 minutes before each meal
and at bedtime.
– Information used to make drug and diet decisions.
– Double-voided specimens are best for these tests.
• Testing for blood
– Sometimes blood is seen in the urine.
– At other times it is unseen (occult).
– A routine urine specimen is needed.
Testing Urine
• Using reagent strips
– Universal Precautions must be used at all times
– Dip the strip into urine.
– Compare the strip with the color chart on the
bottle at the required time interval.
– Record and report results
Stool Specimen
• Stool, or feces, may be tested for:
– Blood
– Fat
– Microbes
– Worms
– Other abnormal contents
• The stool specimen must not be
contaminated with urine.
Sputum Specimen
• Sputum specimens may be tested for blood,
microbes, and abnormal cells.
• The person coughs up sputum from the
bronchi and trachea.
– It is easier to collect a specimen in the morning.
Other Types of Specimens
• Specimens may be obtained from other body
tissue and fluid.
• A biopsy is done by removing a small piece of
tissue for further examination.
• A culture and sensitivity is done by swabbing
a body surface and testing
for the presence of microbes
Seven Warning Signs of
Cancer
Warning Sign
Unusual bleeding
or discharge
What to Look For
• Blood in urine or stool
• Discharge from any parts
of your body, for
example nipples, penis,
etc
Warning Sign
What to Look For
A sore that
does not heal
• Sores that:
• don't seem to be getting
better over time
• are getting bigger
• getting more painful
• are starting to bleed
Warning Sign
What to Look For
Change in bowel
or bladder
habits
• Changes in the color,
consistency, size, or
shape of stools.
(diarrhea, constipated)
• Blood present in urine
or stool
Warning Sign
What to Look For
• Any lump found in the
Lump in breast or breast when doing a self
other part of
examination.
the body
• Any lump in the scrotum
when doing a self exam.
• Other lumps found on the
body.
Warning Sign
Nagging cough
What to Look For
• Change in
voice/hoarseness
• Cough that does not go
away
• Sputum with blood
Warning Sign
What to Look For
• Use the ABCD RULE
Obvious
change in moles
• Asymmetry: Does the mole look the
same in all parts or are there
differences?
• Border: Are the borders sharp or
ragged?
• Color: What are the colors seen in the
mole?
• Diameter: Is the mole bigger
than a pencil eraser (6 mm)?
Warning Sign What to Look For
Difficulty in
swallowing
• Feeling of pressure in
throat or chest which
makes swallowing
uncomfortable
• Feeling full without food
or with a small amount
of food
CAUTION
(Cancer’s Warning Signs)
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C Change in bowel or bladder habits
A A sore that does not heal
U Unusual bleeding or discharge
T Thickening or lump in breast or body part
I Indigestion or difficulty in swallowing
O Obvious change in a wart or mole
N Nagging cough or hoarseness
Nursing Assistants as Medical Scouts
• As the primary caregiver, your observations can be the
difference between a resident who receives early and
effective treatment, and a resident who becomes
gravely ill
• A recent study by Kenneth Boockvar MD, Assistant
Professor in the Department of Geriatrics at Mount Sinai
School of Medicine found:
– That nursing assistants almost always saw that a
resident was becoming ill earlier than anything noted
in the chart
– Illnesses that were detected early were:
• UTI’s, Pneumonia, CHF, Gastroenteritis,
Arrhythmias and Dehydration
The 5 Early Warning Signs of Illness
1. Weakness – sudden onset TIA, pneumonia,
dehydration, CHF, infection, liver failure
2. A sudden change in greeting
– severe hearing loss, depression confusion
3. Nervousness or Agitation –
being emotionally off can signal physical illness
4. Loss of appetite
5. A resident complains
ABC’s of Observation
• Appearance
• Behavior – actions, conduct, pain
• Communication
Signs and Symptoms
• Signs
• Symptoms
Objective data are seen, heard,
felt, smelled. You can see
urine, hear a cough, feel a pulse
and smell a foul odor.
Subjective data are thing a
person tells you about that you
cannot observe through your
senses. Examples include
nausea, pain and dizziness.
Observations by Body
Systems
Using sight, touch, hearing, and smell
Integumentary System
• Color – flushed, pale, ashen, icteric,
cyanotic, (don’t forget nails)
• Temperature – warm, hot cool
• Moisture – dry, moist, perspiring
• Abnormalities – rashes, bruises, wounds
Musculoskeletal System
• Posture – stooped, fetal position,
straight
• Mobility – in bed, balance, ambulation
• Range of Motion – performance of
ADL’s
Circulatory System
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Pulse – strength, regularity, rate
Blood Pressure
Skin color
Extremities – edema
Respiratory System
• Respirations – rate, regularity, depth,
dyspnea, SOB (exertion, at rest),
stertorous
• Cough – frequency, dry, productive
• Sputum – color, consistency
Nervous System
• Mental state – orientation
• Ability to communicate
• Senses
– Eyes – pupils equal, reddened, drainage
– Ears – drainage, hearing
– Nose – drainage, bleeding
Urinary System
• Frequency, amount, color, dysuria
• Clarity, blood or sediment, incontinent
• Pain or burning upon urination
Digestive System
• Appetite – amount of solids/liquids
consumed, belching, burping, intolerance to
foods
• Eating – difficulty chewing or swallowing
• Nausea/Vomiting
• Bowel elimination – frequency, amount,
consistency, color, diarrhea, constipation,
flatus
Reproductive System
• Female
– Breasts – drainage from nipples,
discoloration, lumps
– Vagina – discharge, amount, color,
character
• Male
– Testes – lumps
– Penis – drainage, amount and character