Assessment Techniques & General Survey & Vital Signs

Question 1

What are the components of general assessment?

Answer 1

• physical appearance
  
  • age - should be consistent with physical appearance and gender
  • sex - development should be consistent with gender and age
  • level of consciousness - alert and oriented
  • facial features - symmetrical with movement
  • age, sex, facial features, level of consciousness, skin colour
• body structure
  
  • stature - ht should be consistent with age and genetic heritage
  • nutrition - wt should be in normal range for height and body build
  • symmetry - body parts should be equal bilaterally
  • posture - comfortably erect as appropriate for age
  • position - sitting comfortably in a chai, on the bed, or on the examination table; arms relaxed at sides, head turned to examiner
  • body build, contour - ht = arm span; length from crown to pubis should be equal to length from pubis to sole
• mobility
  
  • gait (A person’s manner of walking) - base should be about shoulder width; steps are smooth, even; foot placement accurate; arm swing should be symmetrical
  • ROM
• behaviour
  
  • facial expression
  • mood and affect
  • speech - clear and fluid? makes sense?
  • dress - neat and clean?
  • personal hygiene - can indicate self-care behaviours

Question 2

What are the normal range for T, P, R, BP, and O2 sat?

Answer 2

• T - 36-38 degrees
• P - 60-100 bpm
• R - 10-20 breaths/min
• BP - normal → 120-130/80-85
  
  • high normal → 130-139/85-89
• O2 sat - 92-100%

Question 3

What assessment or questions you should do before taking temp?

Answer 3

• Did you do any exercise prior to our meeting?

if oral route:

• assess if it’s safe for pt to get their temp taken orally (can pt hold thermometer in their mouth? will pt bite down on probe?)
• have you had a smoke? hot or cold food or drink? chewed a gum?
  
  • wait for 2 minutes if pt smoked, 20 minutes if they ate or drank something hot or cold, and 5 minutes if they chewed a gum.

if axillary route:

• check for lesions and excessive perspiration
• assess if pt had a bath; wait for 15 minutes after bath

Question 4

Steps on doing an Axillary temp

Answer 4

1. Remove thermometer pack from charging unit. Ensure that oral probe (blue tip) is attached to thermometer unit. Grasp top of probe stem; be careful not to press the ejection button.
2. Slide disposable plastic probe cover over thermometer probe until it locks in place.
3. Raise patient’s arm away from torso, and inspect for skin lesions and excessive perspiration. Insert probe into centre of patient’s axilla, lower arm over probe, and place arm across chest.
4. Hold probe in place until audible signal occurs and temperature appears on digital display.
5. Remove probe from patient’s axilla.
6. Push ejection button on thermometer stem to discard plastic probe cover into appropriate receptacle.
7. Return thermometer stem to storage well of recording unit.
8. Assist patient to assume a comfortable position, and move linen or gown back over patient’s shoulder.
9. Perform hand hygiene.
10. Return thermometer to charger.

Question 5

What is the difference between taking an oral temp and axillary temp?

Answer 5

axillary temp is about 0.5 degrees lower than oral

Question 6

What to ask and do before taking the pulse/BP?

Answer 6

ask patient:

• have you consumed any caffeine in the past half hour?
  
  • wait for 60 minutes after
• have you had any nicotine recently? at what time?
  
  • wait for 60 minutes if pt smoked a cigarette
• did you exercise before I went in?
  
  • wait 30 minutes if pt did exercise
• do you have hypertension/hypotension?
• do you take any cardiovascular medications?
  
  • make sure pt took their meds before taking BP

observe:

• make sure pt is rested for 5 minutes before taking pulse or BP
• is pt is crossing their legs?
• if patient: has a cast, an IV infusion, had a mastectomy on one side of the body, an arteriovenous shunt or fistula, or an injured arm; use the other arm if these things are present

Question 7

Proper position of the body for BP

Answer 7

• arms should be at heart level; use pillows prn
• feet should be flat on the floor and not crossed

Question 8

Steps on Taking Blood pressure? (Based on the slides)

Answer 8

1. Rest the patient for at least 5 minutes
2. Tell the patient to sit supportedly, feet flat on the floor or lay on the bed
3. Have the arm at the same level of the heart, palm upward make sure the arm is free from any IV
4. Put the cuff on the arm about 2.5 cm above the brachial artery
5. Palpate radial (or brachial) artery and inflate cuff until pulse disappears then add 20-30 mmHg higher
6. Use a stethoscope place it the over brachial artery
7. Deflate cuff slowly, 2 mm Hg per beat
8. Note when sound starts and when sound stops

Question 9

Steps on taking Blood pressure?

Answer 9

1. Make sure patient is relaxed and rested; allow a 5-minute rest before measuring BP
2. Hand hygiene
3. With patient sitting or lying, position patient’s forearm at heart level, position patient’s thigh flat (provide support as needed). To measure at patient’s arm, turn palm up. If patient is sitting, their legs should not be crossed and feet should be touching the floor.
4. Expose patient’s extremity arm or sometimes the leg in certain medical situations by fully by removing constricting clothing.
5. Palpate patient’s brachial artery (arm) or popliteal artery (leg). With cuff fully deflated, apply bladder of cuff above artery by centring cuff over artery. If no centre arrows appear on the cuff, estimate the centre of the bladder and place this centre over artery. Position cuff 2.5 cm above site of pulsation (antecubital or popliteal space). Wrap cuff evenly and snugly around. Do not place blood pressure cuff over clothing.
6. Position aneroid manometer gauge no farther than 1 metre away.
7. Measure blood pressure: Two-step method:
   
   • Relocate patient’s brachial or popliteal pulse. Palpate the artery distal to the cuff with fingertips of nondominant hand while inflating cuff rapidly to pressure 30 mm Hg above the point at which the pulse disappears. Slowly deflate cuff, and note reading when pulse reappears. Deflate cuff fully, and wait 1 minute.
   • Place stethoscope earpieces in ears, and be sure sounds are clear, not muffled.
   • Relocate patient’s brachial or popliteal pulse, and place bell or diaphragm chest piece of stethoscope over it. Do not allow chest piece to touch cuff or clothing.
   • Close valve of pressure bulb clockwise until tight.
   • Rapidly inflate cuff to 30 mm Hg above previously palpated systolic pressure.
   • Slowly release pressure bulb valve, and allow needle of manometer gauge to fall at rate of 2 to 3 mm Hg per second. Make sure no extraneous sounds are audible.
   • Note point on manometer when first clear sound is heard. The sound will slowly increase in intensity.
   • Continue to deflate cuff, noting point at which muffled or dampened.
   • Continue to deflate cuff gradually, noting point at which sound disappears in adults. Listen for 10 to 20 mm Hg after the last sound, then allow remaining air to escape quickly.
   • Remove cuff from patient’s extremity unless measurement must be repeated. If this is the first assessment of the patient, repeat procedure on the other extremity.
8. Remove cuff from extremity unless measurement must be repeated. If patient’s blood pressure is being assessed for the first time, repeat blood pressure assessment on other extremity.
9. Assist patient in returning to a comfortable position, and cover patient’s upper arm if it was previously clothed.
10. Wipe the blood pressure cuff with disinfectant or, if disposable, keep in patient’s room until no longer needed; then dispose of the cuff according to agency policy.
11. Discuss findings with patient as needed.
12. Perform hand hygiene.
13. Compare reading with previous baseline value, or acceptable value of BP for patient’s age group (or both).
14. Correlate BP with data obtained from pulse assessment and other related cardiovascular signs and symptoms.
15. Inform patient of value of and need for periodic reassessment of BP.

Question 10

Steps on taking the radial pulse?

Answer 10

1. Assist patient to assume a supine or sitting position.
2. If patient is supine, place patient’s forearm straight alongside the body, across lower chest or upper abdomen with wrist extended straight. If patient is sitting, bend patient’s elbow 90 degrees and support his or her lower arm on a chair or on your arm. Slightly flex patient’s wrist, with palm down.
3. Place tips of first two or middle three fingers over groove along radial or thumb side of patient’s inner wrist.
4. Lightly compress your fingertips against patient’s radius, obliterate pulse initially, and then relax pressure so that pulse becomes easily palpable.
5. Determine strength of pulse. Note whether thrust of vessel against your fingertips is bounding (+4), strong (+3), weak (+2), thready (+1), or absent (0).
6. After you can feel a regular pulse, look at watch and begin to count pulse rate when second hand reaches a number on watch dial; start counting pulse with “one” then “two” and so on.
7. If pulse is regular, count rate for 30 seconds and multiply total by 2.
8. If pulse is irregular, count rate for 1 minute (60 seconds). Assess frequency and pattern of irregularity. Compare bilateral radial pulses

Question 11

Steps on taking apical pulse?

Answer 11

1. locate the PMI (point of maximal impulse) in the left midclavicular line of the 5th intercostal space
2. place diaphragm of stethoscope on this spot
3. listen for the heart beat and count the number of contractions for 30 seconds if regular, 60 if irregular
4. not if pt’s heart rate is greater than 100 (tachycardia) or less than 60 (bradycardia)

Question 12

Characteristics of a normal pulse

Answer 12

• strength of 2+
• rate should be between 60-100 bpm
• regular rhythm
• pulse in both arms should be equal

Question 13

How to take respirations?

Answer 13

• After taking the BP, start counting but do not tell the patient that you are doing it
• count respirations for 30 seconds if regular (60 seconds if irregular) after taking pulse without telling the pt
• take note of the rate, depth, and rhythm of respirations
  
  • a patient’s breathing is relaxed, regular, automatic, and silent
  • ratio of pulse to respirations is usually 4:1

Question 14

What to assess for before taking O2 sat?

Answer 14

• Check for capillary refill (should be less than 3 seconds)
• check for nail polish on fingernail
• check if pt’s hands have tremors, if so, use earlobe as site

Question 15

what is the OPQRSTUV Assessment? (Pain Assessment)

Answer 15

• onset (When did it started)
• provocative/palliative
  
  • aggravated by activity? alleviated by rest?
• quality of the pain
  
  • throbbing? sharp?
  • how would you describe the pain?
• region/radiation
  
  • does the pain move to other areas?
• severity
  
  • on a scale of 1-10?
• treatment/timing
  
  • what treatments have worked for you in the past? is it constant? intermittent?
• understanding of pain
  
  • what pt believes is causing pain
• values
  
  • What is your acceptable level for this pain? Is there anything else that you would like to say about your pain?
    Are there any other symptoms related to the pain?

Question 16

What are the four assessment techniques?

Answer 16

Inspection
Palpation
Percussion
Auscultation

Question 17

What are the four assessment techniques when dealing with abdominal assessment?

Answer 17

Inspection
Auscultation
Percussion
Palpation

We do Auscultation first because we don’t want to alter the frequency of bowel sounds