Assessment Techniques + Vital Signs Flashcards
4 Moments of Hand Hygiene
- before initial patient/ patient environment contact
- before aseptic procedures
- after bodily fluid exposure risk
- after patient/ patient environment contact
Assessment Techniques
- Inspection
- Palpation
- Percussion
- Ausculation
Inspection
concentrated watching –> visual evaluation of the patient as a whole THEN individual systems
- performed first
Palpation
physical contact with/ manipulation of the target structure –> used to confirm points noted during the initial inspection
assesses:
- texture: rigidity, spasticity, crepitation
- temperature, moisture
- organ location and size
- potential swelling
- vibration, pulsation
- presence of lumps or masses
- tenderness, pain
Palpation: Steps
- Warm hands
- Select anatomy of focus, ensure adequate (but limited) exposure
- perform superficial palpation, then progress to deep palpation if necessary
- use intermittent pressure not continuous
- use the pads of your fingers
Superficial Palpation
surface level <1cm deep
uses 1-2 hands
Deep Palpation
3-4cm deep
usually uses two hands
Palpation Technique: Fingertips
- fine tactile discrimination - texture
Palpation Technique: Grasping of Fingers + Thumbs
- position
- shape
- size
- consistency
Palpation Technique: Back of Hands or Fingers
- temperature
- moisture
Palpation Techniques: Base of Fingers or Knuckles
- vibrations
Percussion
the tapping of skin with short, sharp strokes to assess underlying structures with sound
sound can indicate the: location, size, and density of underlying organs
Direct Percussion
the striking hand makes direct contact with the patient’s skin
- uses only one hand (striking)
Indirect Percussion
the striking hand makes indirect contact with the patient’s skin, striking the stationary hand instead
- uses two hands (stationary and
striking)
Percussion: Steps
- flex the non-dominant hand so that the middle finger is hyperextended downwards
- position the hyperextended middle finger on the patient’s skin on the location you want to percuss - ensure no other fingers touch the skin (dampen sounds)
- strike just below the nail bed of the stationary hand’s middle finger with the tip of the dominant hand’s middle finger
- strike each location twice before moving to a new location
Percussion Sounds: Dense Tissue
volume - dull thud
pitch - low, dense, muscular
duration - very short, solid, no echo
quality - description of sound
Percussion Sounds: Air-Filled Tissue
volume - loud, hollow
pitch - high, hollow
duration - long, echo (hollow space)
quality - description of sound
Ausculation
listening to sounds produced by parts of the body using a stethoscope
Artifacts to Avoid
- ensure direct contact with skin - clothing can create excess noise
- avoid your own artifact - ensure that your clothing, hair, or otherwise do not bump into the stethoscope to create additional sounds
- keep the room warm - cold rooms may cause the patient to shiver, creating addition noise (muscle contractions)
- unnecessary friction - wet hair (chest hair, etc) prior to auscultation to avoid artifacts from the friction
- ensure a private, quiet room - background noises can create a “roaring” in the stethoscope
Stethoscope: bell
deep, hollow, low-pitched sounds
- extra heart sounds
- murmurs
Stethoscope: diaphragm
high-pitched sounds
- bowel noises
- normal breath sounds
- manual blood pressure readings
Vital Signs (5)
- Temperature
- Pulse
- Respiratory Rate
- pulse Oximetry
- Blood Pressure
Additional Vital Signs (2)
- Pain (Assessment)
- Level of Consciousness
Normal Temperature
35.8 - 37.3 C
Temperature Locations
- Oral
- Axillary
- Tympanic Membrane
- Rectal
- Temporal
Temperature: Influencing Factors
- Diurnal Cycle - temp fluctuates 1.5C throughout the day (lowest in the morning, highest in the evening)
- Menstruation Cycle - increases temp (progesterone)
- Exercise + Stress - SNS stimulation increases temp temporarily
- Consumption -
- hot/ cold drinks changes the temp of
the mouth - chew gum moves the mandible which
increases oral temp - smoking dilates vessels increasing oral
temp
- hot/ cold drinks changes the temp of
- Age - decreases with age
Oral Temperature
place covered probe (blue cover) under the tongue in one of the two sublingual pockets - close mouth and wait
- ensure thermometer is set to adult
oral and is in C
- dispose of cover immediately after
When NOT to take an oral temperature
- when the patient is unable to close their mouth (child, intubated)
- when the patient cannot follow instructions
- when the patient is unconscious
Axillary Temperature
place covered probe (blue cover) into the axillary pocket and close arm - wait for reading
- ensure the thermometer is set to adult
axillary and in C
- dispose cover immediately after
- do NOT use for adults
Rectal Temperature
- patient positioned on their left side with knees pulled up to their chest
- hand hygiene, don gloves, and place red probe cover on thermometer
- lubricate thermometer probe and insert in the direction of the umbilicus NO MORE than 1inch (2-3 cm) - hold and wait for reading
- dispose of probe immediately
When to take a rectal temperature
To be used when other routes are not practical
- when the patient is unconscious (coma)
- when the patient cannot follow instruction
- the patient cannot close their mouth (children, intubation)
Tympanic Membrane Temperature
pull the helix of the ear up and back to straighten ear cannal, place cover on thermometer, and place probe into the ear in the direction of the nose
- ensure the thermometer is set to C
- look inside the ear canal for ear wax
that could interfere with reading
Temporal Temperature
place the thermometer in the middle of the patient’s forehead, slide along the hairline to one side, and finish behind th ear
- less accurate
- should be used as an additional
reading, but not on its own
Hyperthermia
> 38 C
Hypothermia
<35 C
9 Pulse Points
- Temporal
- Carotid
- Apical Impulse
- Brachial
- Radial
- Femoral
- Popliteal
- Anterior tibialis
- Dorsalis Pedis
Normal Heart Rate
50-95 bpm
Tachycardia
> 95 bpm
Bradycardia
< 50 bpm
Pulse Assessment
a. Rate - within, above, or below normal
range
b. Rhythm - regular or irregular
c. Force - 0, 1+, 2+, 3+
d. Equality - bilateral, equal
Normal Respiratory Rate
10 - 20 breaths per minute
Tachypnea
> 20 breaths per minute
Bradypnea
< 10 breaths per minute
Respiratory Assessment`
a. Rate
b. Effort
c. Rhythm
d. Depth
e. sound
Pulse Oximetry (definition)
amount of oxygen reaching the tissues
Normal Pulse Oximetry
> 95%
Normal Blood Pressure
(<) 120 / 80
(5) Factors Determining Blood Pressure
- Cardiac Output
- Vascular Resistance
- Blood Volume
- Blood Viscosity
- Elasticity of Vessel Walls
Factors Affecting BP: Physiology
Factors Affecting BP: Situational
Korotkoff’s Sounds
Phase 1 - appearance of a thumping sound = systolic value
Phase 4 - muffling of the thumping sound
Phase 5 - thumping sound disappears, complete silence = diastolic value
Orthostatic Hypotenison
an extreme change in blood pressure that occurs when the patient changes position
- dehydration
- hypertension + new htn meds
- history of syncope
Abnormal Changes:
systolic dec > 20
diastolic dec > 10
pulse inc > 20
Hypotension
< 90/60 mmHg
- vasodilation (dec resistance)
- hemorrhage (dec blood volume)
- acute MI (occlusions, heart muscle
dies)
Symptoms:
- pallor, dizziness, confusion - low
perfusion (esp. to brain)
- tachycardia - compensation for low BP
Hypertension
> 130/ 90 mmHg
- arteriosclerosis
increases risk for strokes
Elevated Blood Pressure Value
120-129/80 mmHg
Hypertension Stage I Value
130/ 80-89 mmHg
Hypertension Stage II Value
> 140/ 90 mmHg
Blood Pressure Errors
- Activation of the SNS (emotion, stress, exercise)
- <1-2 mins between readings
- incorrect arm position
- incorrect cuff size
- incorrect deflation of the cuff
BP Error: Incorrect Cuff Size
too big = inc BP
too small = inc BP
BP Error: <2mins between readings
inc diastolic BP - some blood will still be flowing and get trapped, leading to an artificially high diastolic reading
BP Errors: Arm Position
above heart - dec BP (gravity assists)
below heart - inc BP (working against gravity)
BP Errors: Deflating the Cuff
too quickly - dec systolic, inc diastolic
too slowly - inc diastolic
halting/ reinflating - dec diastolic
Choosing the correct bladder length (BP cuff)
width = 80% arm circumference
length - 80-100% arm circumference
Normal Vital Signs
temperature - 35.8-37.3
pulse - 50-95 bpm
respirations - 10-20 breaths per min
pulse oximetry - >95%
blood pressure - 120/80
Abnormal Vital Signs
temperature - <35 or >38
pulse - <50 or >95
respirations - <10 or > 20
pulse oximetry - <95%
blood pressure - <90/60 or > 130/80
