HEALTH ASSESSMENT
Concept 2
DATA COLLECTION: PROCESS & TECHNIQUE
Collecting Objective Data
· Vital Signs
· Physical Assessment
Vital Signs - Measurable signs of cardiopulmonary and thermoregulatory health status
Vital Signs or Cardinal Signs is the person’s
· Temperature
· Pulse Rate
· Respiratory Rate
· Blood Pressure
Blood Pressure
• refers to the force of the blood against arterial walls.
• arterial blood pressure
Arterial Blood Pressure- Is a measure of the pressure exerted by the blood as it flows through the arteries.
Systolic Blood Pressure - is the pressure of the blood as a result of contraction of the ventricles, that is, the pressure of the height of the blood wave.
Diastolic Blood Pressure - is the pressure when the ventricles are at rest. It is the lower pressure, present at all time within the arteries.
Pulse Pressure - the difference between the diastolic and systolic pressures. Normally is about 40 mmHg.
Determinants of Arterial Blood Pressure
( Physiology of Arterial Blood Pressure)
1. Cardiac output / pumping action of the heart-
· Cardiac output increases as a result of fever and exercise, and the systolic pressure may increase as a result.
2. Peripheral vascular resistance-
· can increase blood pressure. The diastolic pressure especially is affected. Some factors that create resistance in the arterial system are:
a) the size of the arterioles and capillaries
b) the compliance of the arteries
c) the viscosity of the blood
3. Blood volume
a) when the blood volume decreases (for example, as a result of hemorrhage or dehydration), the blood pressure decreases because of decreased fluid in the arteries.
b) Conversely, when the volume increases (for example, as a result of an intravenous infusion), the blood pressure increases because of the greater fluid volume within the circulatory system.
4. Blood viscosity-
a) viscosity is a physical property that results from friction of molecules in a fluid. In a viscous or thick fluid, there is a great deal of friction among the molecules as they slide by each other.
b) The blood pressure is higher when the blood is highly viscous, that is when the proportion of red blood cells to the blood plasma is high (hematocrit)
Equipment in Taking the Blood Pressure
1. Sphygmomanometer
2. Doppler Ultrasound
3. Direct Electronic
4. Noninvasive Blood Pressure Monitor
Factors Affecting Blood Pressure:
a) Age
· Newborns have a mean SBP of about 75 mmHg
· Pressure rises with age
b) Exercise
· Physical activity increases cardiac output therefore increases BP
c) Race
· African Americans, males greater than 35 y/o have higher BP than European Americans
d) Obesity
· Childhood and adult obesity predisposes to increased BP
e) Stress
· Stimulation of SNS causes constriction of blood vessels causing Increased BP
f) Gender
· After puberty, females have lower BP than males their age; after menopause women have higher BP than men their age
g) Medication
· Caffeine causes increased BP; Beta blockers cause decreased BP
h) Diurnal variations
· BP is lowest early in the AM; rises through out the day and peaks in late afternoon or early evening
i) Disease process
· Any condition affecting Cardiac Output, Blood Viscosity, compliance of arteries may cause increased or decreased of BP
Korotkoff Sound - The series of sounds heard when measuring blood pressure
Body Temperature
• Indicates the difference between production of heat and loss of heat.
• Heat of the body is measured in degrees.
Body Temperature Physiology
• HEAT PRODUCTION
• the primary source of heat production in the body is metabolism
• HEAT LOSS
• Heat is lost from the body through the 4 processes:
o Radiation
o Conduction
o Convection
o Vaporization
Heat is lost from the body through the 4 processes:
1. Radiation - transfer of heat from the surface of one object to the surface of another without contact between the two objects, mostly in the form of infrared rays.
2. Conduction - transfer of heat from one molecule to a molecule of low temperature. The amount of heat transferred depends on the temperature difference and the amount and duration of the contact.
3. Convection - the dispersion of heat by air currents. The body usually has a small amount of warm air adjacent to it. This warm air rises and is replaced by cooler air, and so people always lose a small amount of heat through convection.
4. Vaporization - is the continuous evaporation of moisture from the respiratory tract and from the mucosa of the mouth and from the skin.
Two Kinds of Body Temperature:
1. Core Temperature
• The temperature of the deep tissues of the body, such as abdominal and pelvic cavity. It remains relatively constant.
• High temperature
• Regulated by thermoregulatory center in the Hypothalamus
• Tympanic, rectal, bladder, esophagus
2. Surface Temperature
• The temperature of the skin, the subcutaneous tissues, and fat. It, by contrast, rises and falls in response to the environment.
• Lower temperature
• Axilla. Forehead, oral
Factors Affecting Body Temperature
• Age
• Diurnal variations (circadian rhythms)
• Exercise
• Hormones
• Stress
• Environment
• Sex
Sites for Assessing Temperature
• Tympanic membrane
• Oral
• Rectal
• Axillary
Glass Thermometer
• With mercury bulb (silver colored liquid)
• Non-mercury glass thermometer (red or blue colored bulb)
• Oral thermometer – long, thin bulb
• Rectal thermometer – blunt bulb
• Calibrated in degrees either Centigrade or Fahrenheit ranges of about 34°C (94 °F) to about 42.2 °C (108 °F)
• Oral (3 min.), rectal (2-3 min.), axillary (9 min.)
• Has stem and bulb
Pulse
• a throbbing sensation that can be palpated over the peripheral arteries or auscultated over the apex of the heart.
• results as a wave of blood is pumped into the arterial circulation by the contraction of the left ventricle.
Factors that affect Pulse Rate
1. Age
• as age increases, pulse rate decreases
2. Gender
• After puberty, male’s pulse is slightly lower than females.
3. Exercise
• Increases with activity. Athletes have less pulse rate because of greater cardiac size, strength and efficacy
4. Fever
• Pulse rate increases with lowered blood pressure, elevated blood pressure andincreased metabolic rate
5. Medications
• Cardiotonics decrease the heart rate
• Anti asthma drugs have the side effect of increased heart rate
6. Hypovolemia
• loss of blood in the vascular system results in increased heart rate as a compensatory mechanism
7. Stress
• Sympathetic Nervous system stimulation causes increased heart rate
8. Position Changes
• Change of position from sitting to standing position causes increased heart rate
9. Pathology
• Pathology in the heart that can impair oxygenation may alter the resting pulse rate
Tachycardia (above 100 beats/min)
• a decrease in blood volume
• an increase in normal body temperature
• (7-10 beats for each 0.6 degree Celcius elevation from the normal)
• conditions resulting to poor oxygenation
• exercise
• prolonged heat application
• pain
• strong emotions
• medications
Badycardia (below 60 beats/min)
• hypothermia
• medications
• trained athletes at rest/asleep
• vagus nerve stimulation
• medical condition (M.I.)
Respiratory Rate
Respiration
• the act of breathing
• includes the exchange of oxygen (intake) and carbon dioxide (output)
• exchange of gases, oxygen and carbon dioxide between an organism and its environment
Ventilation
• refers to the movement of air in and out of the lungs.
Inhalation/ Inspiration
• intake of air into the lungs
Exhalation/ Expiration
• breathing out or the movement of gases from the lungs to the atmosphere
External respiration
• refers to the interchange of oxygen and carbon dioxide between the alveoli of the lungs and the pulmonary blood.
Internal respiration
• takes place throughout the body. It is the interchange of these same gases between the circulating blood and the cells of the body tissues
Apnea
• absence of breathing
Dyspnea
• difficulty or labored breathing
Bradypnea
• abnormally slow rate of breathing
Tachypnea
• rapid breathing
Orhtopnea
• type of dyspnea where breathing is easier when the patient sits or stands
FACTORS THAT AFFECT RESPIRATION
— Age – the respiratory rate decreased with age, ranging from a normal values between 30 and 60 breaths/min
— Gender – in males, respiratory movements are primarily diaphragmatic; in females, there is greater intercostals muscle movement
— Exercise – causes an increase in rate and depth
— Acid-base balance – alterations in acid-base balance commonly result in increased rate and depth in respiration (hyperventilation)
— Brain lesions – lesions of the brain (e.g., hemorrhage and tumors) on brain stem can likewise cause a change in depth and rate of respiration; most commonly manifested in Cheyne-Stokes respirations
— Increased altitude – healthy people may exhibit Cheyne-Stokes especially when asleep. It may also increase respiratory rate and depth prior to adaptation by increase hemoglobin levels
— Respiratory diseases – any alteration in the normal respiratory structures may result in changes in respiratory rate, depth and patterns, which is most manifested as difficult breathing, using accessory muscles where the depth may be shallower. Smoking can also alter the pulmonary airways
— Anemia – decrease in oxygen-carrying hemoglobin may result in an increase rate of respiration
— Anxiety – can cause sighing type of respiration and increase respiratory rate
— Medications – narcotics, sedatives and anesthetic agents slow respiratory rate and depth
— Acute pain – it increases respiratory rate but may decrease respiratory depth
CHARACTERISTICS OF EUPNIC RESPIRATION
• Term for normal quiet breathing (eu = normal; pnoia = breath)
• 12 – 20 breaths each minute
• Infants and young children breathe more rapidly
• Normal respiration is quiet, rhythmic and effortless (eupnea).
PATTERNS OF RESPIRATION
• Normal – characterized by 12-20 breaths/min; regular
• Tachypnea - >24 breaths/min; shallow
• Bradypnea - < 10 breaths/min; regular
• Hyperventilation – increased rate and depth
• Hypoventilation – decreased rate and depth
• Cheyne-Stokes respiration – alternating periods of deep, rapid breathing followed by periods of apnea; regular
• Biot’s respiration – varying depth and rate of breathing followed by periods of apnea; irregular
HEALTH ASSESSMENT - Referring to a critical investigation and evaluation of client status
Purposes of PA
§ Obtain physical data about the client’s functional abilities
§ Supplement, confirm, or refute data obtained in the client’s health history
§ Obtain data that will help the nurse data establish diagnoses and plan the client’s care
§ Evaluate the physiologic outcomes of health care and thus the progress of a patient’s health problem
§ To make clinical judgments about a client’s health status
§ To identify areas for health promotion and disease prevention
It is the FIRST STEP of the Health Care Process. The following are its key components:
§ Health Interview
§ Physical Examination
§ Laboratory or Diagnostic Examination
§ Records Review
PA - A systematic way of collecting objective data from a client using the four examination techniques, to assess or identify current health status.
Different Approaches:
§ Cephalocaudal
§ Proximodistal
§ Mediolateral
§ Outer to Inner
§ External to Internal
Factors to Assess During a Health History
§ Biographical data
§ Chief complaint
§ History of present illness
§ Past medical history
§ Family history
§ Lifestyle
Preparing the Patient for Physical Assessment
§ Consider the physiological and psychological needs of the patient.
§ Explain the process to the patient.
§ Explain that physical assessments will not be painful (decrease patient fear and anxiety).
§ Ask the patient to change into a gown and empty bladder.
§ Answer patient questions directly and honestly
Preparing the Environment for Physical Assessment
§ Agree upon a time for the assessment.
Ø The time should not interfere with meals, daily routines, or visiting hours.
§ Patient should be as free of pain as possible.
§ Prepare the examination table.
§ Provide a gown and drape for the patient.
§ Gather the supplies and instruments needed for the assessment.
§ Provide a curtain or screen if the area is open to others.
Preparatory Phase
§ Introduce self to the client. Verify his identity. Explain the purpose why such procedure is necessary and how he could cooperate (i.e. positioning).
§ Help him put on a clean gown and offer a bedpan or a urinal to empty his bladder.
§ Ensure privacy by closing the doors or pulling the curtains around him.
§ Invite a relative or a significant other to stay with the client, as necessary
§ Provide adequate lighting.
§ Gather the equipment:
height chart, weighing scale, Snellen’s chart, penlight, card board, sterile gloves, tongue depressor, 4x4 Gauze, tuning fork, stethoscope, wrist watch, tape measure, marker/pencil, record sheet & waste receptacle.
§ Ensure the examination table is at a comfortable working height. Perform hand hygiene.
Position and drape the client appropriately:
§ Standing = height / weight measurement; posture (spine), gait & balance
§ Sitting = vital signs taking; thorax
§ Supine = posterior thorax; spine
§ Dorsal recumbent = abdominal palpation
§ Sim’s / Lateral = rectal area; p. thorax
§ Prone = posterior thorax
§ Lithotomy = vaginal examination
§ Knee-chest =rectal area (for brief periods)
Salient Points:
§ Subjective datashould be documented in patient’s own words.
§ Objective datashould be specific. No generalizations and judgmental phrases
§ Data gathered in the nursing health history may be confirmed or refuted by the nurse during the interview or the physical assessment
Methods of Examination - I. P. P. A. Technique
INSPECTION
§ Visual examination of the patient done in a methodical, deliberate, purposeful, and systematic manner.
§ Assess moisture, color and texture of the body surfaces, as well as shape, position, size, color, and symmetry of the body.
PALPATION
§ Examination of the body using the sense of touch.
§ The use of hand to touch and feel the patient’s skin, organs, mass, and other delineated structures in the body
§ The pads of the fingers are used because of their nerve endings that makes them sensitive to tactile discrimination
§ Assess temperature; turgor; texture; moisture; vibrations; position, size, shape, consistency and mobility of organ or masses; distention; pulsation; and the presence pain upon pressure
Palmar surfaces of the examiner's fingertips and finger pads are used for discriminatory sensation, such as texture, vibration, presence of fluid, or size and consistency of a mass
The dorsum, or back of the hand, is used to assess surface temperature.
Light Palpation
§ Place the hand with fingers together parallel to the skin surface or area being palpated, while moving the hand in circle.
§ Light palpation, light pressure is applied by placing the fingers together and depressing the skin and underlying structures about 1/2 inch (1 cm).
§ Use to check muscle tone and to assess for tenderness
Deep palpation
§ is used with caution because pressure can damage internal organs. The skin and underlying structures are depressed about 1 inch (2 cm).
§ To identify abdominal organs and abdominal masses.
§ Two – handed deep palpation place the fingers of one hand on top of those of the other.
§ The top hand applies pressure while the lower hand remains relaxed to perceive the tactile sensation.
§ Deep Palpation is done with two hands (bimanually) or one hand.
§ Usually not indicated in clients who have acute abdominal pain or pain that is not yet diagnosed
PERCUSSION
§ Striking of the body surface with short, sharp strokes in order to elicit palpable vibrations and characteristic sound.
§ It is used to determine the location, size, shape, and density of underlying structures; to detect the presence of air or fluid in a body space; and to elicit tenderness.
TYPES OF PERCUSSION
§ Direct Percussion - using sharp rapid movements from the wrist, strike the body surface to be percussed with the pads of two, three, or four fingers or with the pad of the middle finger alone. Primarily used to assess sinuses in the adult.
§ Indirect Percussion - percussion in which two hands are used and the plexor strikes the finger of the examiner’s other hand, which is in contact with the body surface being percussed (pleximeter- the middle finger of the nondominant hand).
Percussion technique
Strike at a right angle to the pleximeter using quick, sharp but relaxed wrist motion. Withdraw the plexor immediately after the strike to avoid damping the vibration. Strike each are twice and then move to a new area.
Types of sounds heard when using Percussion
§ Flat — soft, e.g., thigh area
§ Dull — medium, e.g., liver
§ Resonance — loud, e.g., normal lung
§ Hyperresonance — very loud, e.g., emphysematous lung
§ Tympany — loud, e.g. puffed-out cheek
AUSCULTATION
§ Listening to sounds produced within the body.
Characteristics of sound heard when using Auscultation
§ Pitch - ranging from high to low
§ Loudness - ranging from soft to loud
§ Quality - e.g., gurgling or swishing
§ Duration - short, medium or long
Stethoscope bell and diaphragm.
Use the diaphragm of the stethoscope to detect high-pitched sounds. The diaphragm should be at least 1.5 inches wide for adults and smaller for children. Hold the diaphragm firmly against the body part being auscultated. Use the bell of the stethoscope to detect low-pitched sounds. The bell should be at least 1 inch wide. Hold the bell lightly against the body part being auscultated.