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CLIENT PREPARATION
Conduct the general survey with the client sitting or standing Ask the client to remove shoes and any heavy outer clothing before you ensure height and weight (^) When weighing a hospitalized client, always weigh at the same time of the day, with the same scale, and with the client wearing the same clothing GENERAL OBSERVATION A general survey is an overall review or first impression a nurse had of a person’s well being Appearance Body structure/ mobility Behavior Observe physical and sexual development Compare client’s stated age with her apparent age and development stage Observe skin condition and color Observe dress Observe hygiene Observe posture Observe body build as well as muscle mass and fat distribution MENTAL STATUS ASSESSMENT Includes the following: Client’s LOC Posture and body movements Dress, grooming, & hygiene Facial expression Speech Mood, feelings & expressions Thought processes and perceptions Cognitive abilities Observe the client’s level of consciousness Observe behavior, body movements, and affect Observe facial expression Listen to speech Observe mood, feeling, and expression
HEIGHT AND WEIGHT
If a client has experienced a change in weight: Determine eh amount Assess the period of time over which the weight change occurred Determine he possible causes for weight loss or weight gain Weigh clients using a standing scale. Use a stretcher for clients who are unable to bear weight Calibrate scale y setting the weight at zero Have client stand on the platform scale and remain still Adjust scale weight on the balance beam, until the tip of the beam registers in the middle of the mark While the client is standing erect on a scale, rise the metal rod attached to the scale up and over the client’s head The rod should be placed level horizontally at a 90-degree angle to the measuring stick Height is measured in inches or centimeters VITAL SIGNS MEASUREMENT Normal body temperature by site: Site Fahrenheit Celsius Oral 97.6 - 99.6 36.5 - 37. Rectal 98.6 - 100.6 37.0 - 38. Axillary 96.6 - 98.6 36.0 - 37. Tympanic 98.6 - 100.6 37.0 - 38. FEVER ASSESSMENT A body temperature above the usual range Hyperthermia occurs because the heat loss mechanisms are unable to keep pace with excess heat production This result from an alteration in the hypothalamic set point TYPE OF FEVER Intermittent (^) The body temperature alternates at regular intervals between periods of fever and periods of normal or subnormal temperatures
Remittent A wide range of temperature fluctuations (more than 2 degree Celsius) which occurs over the 24-hour period all of which are above normal Relapsing Short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature Constant Body temperature fluctuates minimally but always remains above normal PHASES OF FEBRILE EPISODES
1. Chill Phase Body’ heat producing mechanism attempt to increase the core body temperature (^) Feeling of being cold and shivering Skin also appears pale and cool due to vasoconstrictions 2. Fever Phase Occurs when the fever reaches the new higher set point The client’s skin feel warms to touch and appears flushed because of vasodilation Complaints of general malaise, weakness and aching muscles 3. Flush or Crisis Phase Febrile episode (^) Client;s experiences profuse diaphoresis, decrease shivering and possible fluid volume deficit PULSE RATE Normal rate = 60 - 100 Mean / Average = 80 bpm May be as low ad 50 bpm in healthy athletes Regular in rhythm Equal bilaterally in strength/amplitude Amplitude can be quantified as follows: 1+ = thready or weak (easy to obliterate) 2+ = normal (obliterate with moderate pressure) 3+ = bounding (unable to obliterate or requires very firm pressure) Deviations from Normal Pulse Rate: >100 bpm = Tachycardia Anxiety, fear, nervousness <60 bpm = Bradycardia Prolonged sitting or standing Pulse deficit Difference between the apical and the radial pulse RESPIRATORY RATE Normal rate = 12 - 20 cpm Regular and spontaneous rhythm Equal bilateral chest expansion of 1-2 inches TYPE OF RESPIRATIONS TYPE DESCRIPTION NORMAL / EUPNEA 12 - 20 cpm and regular APNEA Absence of respiration BRADYPNEA Slow, shallow respiration TACHYPNEA More than 20 cpm and regular HYPERVENTILATION Increased rate and depth HYPOVENTILATION Decreased rate and depth CHEYNE - STOKES periods of apnea and hyperventilation KUSSMAUL Very deep with normal breathing BLOOD PRESSURE CLASSIFICATION SBP IN mmHg DBP in mmHg OPTIMAL <120 < NORMAL <130 < HIGH NORMAL 130-139 85- STAGE 1 Hypertension
STAGE 2
Hypertension
STAGE 3
Hypertension Greater than or equal to 180 Greater than or equal to 110 Factors affecting Blood Pressure: Cardiac output Distensibility of the arteries (^) Blood volume Blood velocity Blood viscosity
(^) Facial Expression : Grimacing, Fearful, Sad, Withdrawn, Tense, Frowning Body Position : Bracing, Guarding, Walking, Sitting, Stiff Gait/Movements Activity patterns : Rocking, Pulling, Rubbing, Sleeping, Hyper-Alert, Responsive, Fidgeting, Distracted, Withdrawn Body Movement: Immobilization, Purposeless movement, Protective movement, Rhythmic Movement Mood Changes: Angry, Sad, Withdrawn, Aggressive, Passive, Irritable Resistance to Care : Less able to assist in care, Actively resists care Appetite : Diminished, Loss of interest in food FAMILY HISTORY (^) Does anyone in your family experience pain? How does pain affect your family? LIFESTYLE AND HEALTH PRACTICES What are your concerns about pain? How does your pain interfere with the following? General activity Mood/ emotions Concentration Physical Ability Work Relations with other people Sleep Appetite Enjoyment of life COLLECTING OBJECTIVE DATA Preparing the Client (^) Client is seated in a quiet, comfortable, and calm environment Explain to the client that the interview will entail questions to clarify the picture of the pain experienced Pain Assessment Tool Face, Legs, Activity, Cry, Consolability Neonatal/ infant Pain Scale
Critical Care Pain Observation Tool Pain Assessment in Advance Dementia Summary of Pain Assessment Tools 0 - 1 y.o Neonatal/infant Pain Scale (NIPS) 1 - 3 y.o Face, Legs, Activity, Cry, Consolability (FLACC) 3 - above Wong and Baker Adult Numeric Rating Scale Visual Analogue Scale Non-verbal (adult) Critical Care Pain observation Tool (CCPOT) Pain Assessment in Advanced Dementia (PAINAD)
