NURSING 310: HEALTH ASSESSMENT Lecture 2 K.Hendrickson PhD, MSN, RN Fall 2013 1.

NURSING 310:HEALTH ASSESSMENTLecture 2

K.Hendrickson PhD, MSN, RN

Fall 2013

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CHAPTER 4General Inspection and Measurement of Vital Signs

General Inspection• General inspection begins the moment nurse meets

patient.

• Initial impressions guide nurse to areas requiring further examination:• Physical appearance• Hygiene• Body structure and movement• Emotional and mental status• Behavior

Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 3

Physical Appearance and Hygiene

• Does patient appear healthy? Any obvious findings such as tremors or facial drooping? Does patient appear close to stated age?

• Note that patient may appear older or younger than stated age due to drug and alcohol use, excessive sun exposure, chronic disease, and endocrine disorders.

• Note color and condition of skin. Any variations or obvious presence of lesions?

• Is patient clean and well groomed or disheveled? Any odors detected?


Body Structure, Positioning, and Movement

• Body structure and position:• Stature and height appropriate for age.• Nutritional status: Well nourished, cachectic, obese.• Body symmetry and positioning.

• Body movement:• Note how patient moves.• Use of assistive devices.• Are there limitations in range of motion?• Are there any involuntary movements such as a tremor or tic?


Emotional and Mental Statusand Behavior• Emotional and mental status and behavior:

• Note alertness, facial expressions, tone of voice, and affect.• Is patient oriented to person, place and time?

• Does patient maintain eye contact as culturally appropriate?

• Does patient converse appropriately?

• Are facial expressions and body language appropriate for conversation?

• Is clothing appropriate for weather?

• Is behavior appropriate?


Measurement of Vital Signs, Height, & Weight• Baseline indicators of patient’s health status include

measurement of temperature, heart rate, respiratory rate, blood pressure, oxygen saturation, height, and weight.

• Assessing presence of pain is considered standard baseline data collected for all patients and included with assessment of vital signs.

• Vital signs, pain assessment, height, and weight are usually assessed at start of physical exam or integrated into exam.


Temperature• Body temperature is regulated by the hypothalamus:

• Heat gained through processes of metabolism and exercise.• Heat lost through radiation, convection, conduction, and

evaporation.• Expected temperature ranges from 96.4F to 99.1°F (35.8°C to

37.3°C). • Average is 98.6°F (37°C).

• This is stable core temperature at which cellular metabolism is most efficient.


Oral Temperature• Temperature measurement by oral routeis safe and relatively accurate.

• Delay at least 10 minutes if patient ingested hot or cold liquids or smoked.

• Electronic thermometer (sheathed): under tongue in sublingual pocket for 15 to 30 seconds.• This location receives blood supply from carotid artery; thus

indirectly reflects core temperature. • Safe for use in school-aged children or confused adults.

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Alternative Temperature Techniques• Tympanic membrane temperature:

• Probe covered with protective sheath,

placed in external ear canal in contact

with all sides of canal for 2 to 3 seconds.

• Axillary temperature measurement has

questionable accuracy.

• Rectal temperature is used less frequently

due to newer methods.• Less comfortable, but safe for use in adults.

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Heart Rate• Palpation of arterial pulses provides valuable information about cardiovascular system.

• Pulse determines heart rate and rhythm:

• Heart rate is number of times in a minute a pulsation is felt.• Rhythm refers to regularity of pulsations or time between each

beat.

• Pulses also provide important information on strength of pulse and perfusion of blood to various parts of the body.


Heart Rate• To take a pulse, place fingers • over artery and feel for pulsations and rhythm:

• Use finger pads of index and middle fingers; apply firm pressure over pulse, but not so hard that pulsation is occluded.

• If rhythm is regular, count number of pulsations for 30 seconds and multiply by 2, or count for 15 seconds and multiply by 4.

• If pulse rhythm is irregular, note any odd rhythm, and count pulsations for full minute.

• Document irregular pulse when recording vital signs.


Most Common Pulse Location: Radial Pulse - Located at radial side of forearm at wrist

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Alternative Pulse Locations: Brachial pulse - located in groove between biceps and triceps muscles, in bend of elbow.

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Alternative Pulse Locations: Carotid Pulse - medial edge of sternocleidomastoid muscle in lower third of neck.

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Heart Rate • Heart rate can also be assessed by auscultating heart,

which is known as apical pulse, and counting heart sounds for 1 minute.

• Located over the fifth intercostal

space at the mid clavicular line

• Must use a stethoscope

to auscultate heart rate

• Also called the PMI:

Point of Maximal Impulse

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Respiratory Rate• Respiratory rate involves counting number of ventilatory cycles and inhalation and exhalation, each minute.

• Men usually breathe diaphragmatically, increasing movement of abdomen.

• Women tend to be thoracic breathers, noted with movement of chest.

• Count respiratory rate when patient is unaware to prevent self-conscious changing of breathing rate or pattern.

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Respiratory Rate • Note rhythm, depth, and effort of breathing:

• Rhythm is pattern or regularity of breathing and described as regular or irregular.

• Depth assessed by observing excursion or movement of chest wall.

• Depth described as deep (full lung expansion with full exhalation), normal, or shallow.

• Normal breathing should be even, quiet, and effortless when patient is sitting or lying down.

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Blood Pressure• Blood pressure is force of blood against

arterial walls.

• It reflects relationship between cardiac output and peripheral resistance.

• Cardiac output is volume of blood ejected from heart each minute.

• Peripheral resistance is force that opposes flow of blood through vessels; when arteries are narrow, peripheral resistance to blood flow is high, and reflected in elevated blood pressure.

• Blood pressure is dependent on velocity of blood, intravascular blood volume, and elasticity of vessel walls.

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Measurement of Blood Pressure

• Blood pressure measured in• millimeters of mercury (mm Hg).

• Systolic blood pressure is maximum pressure exerted on arteries when ventricles eject blood from heart contracts

• Diastolic blood pressure represents minimum amount of pressure exerted on vessels when ventricles of heart relax.

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Recording Blood Pressure• Blood pressure is recorded with systolic pressure written

on top of diastolic pressure (e.g., 130/76), but it is not a fraction.

• Pulse pressure is the difference between systolic and diastolic pressures and normally ranges from 30 mm Hg to 40 mm Hg.

• Orthostatic blood pressures:are a series obtained when the patient is lying, sitting, and then standing.

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Direct Blood Pressure Measurement

•Direct measurement done by inserting a small catheter into artery that provides continuous blood pressure measurements and arterial waveforms.

• Direct measurement donein critical care settings when continuous monitoring required.

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Indirect Blood Pressure Measurement: Auscultation Method• Indirect measurement in all other settings done by

auscultation with sphygmomanometer and stethoscope or with noninvasive blood pressure monitor.

• Sphygmomanometer consists of gauge to measure pressure, a cuff enclosing an inflatable bladder, and bulb with valve used to inflate and deflate bladder within cuff.

• Stethoscope used to auscultate blood pressure.

• Listen carefully for Korotkoff sounds.

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Korotcoff Phases

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Mechanism of Blood Pressure Measurement• Blood flows freely through artery

until inflated cuff interrupts blood flow.

• As cuff pressure slowly released, nurse listens for sounds of blood pulsating through artery again

• Initial sound is called first Korotkoff sound, characterized by a clear, rhythmic thumping that gradually increases in intensity.

• Fifth Korotkoff sound marks cessation of sound and indicates artery completely open.

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Automated Blood Pressure Monitoring

• Noninvasive blood pressure (NIBP) monitor is an electronic device attached to cuff.

• It senses blood flow vibrations and converts them to electric impulses transmitted to digital readout.

• Readout indicates blood pressure, mean arterial pressure, and pulse rate.

• May be programmed to repeatmeasurements on a schedule and to sound alarm if readings are outside desired limits.

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Physiologic Factors That Affect Blood Pressure Measurement• Age: From childhood to adulthood there is gradual rise.

• Gender: After puberty, women usually have a lower blood pressure than men; however, after menopause, women’s blood pressure may be higher than men’s.

• Race: Incidence of hypertension is twice as high in black Americans as in whites. (Cultural)

Weight: Obese patients tend to have higher blood pressures than non-obese patients.

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Physiologic Factors That Affect Blood Pressure Measurement

• Diurnal variations: Pressure is lower in early morning and peaks in late afternoon or early evening.

• Emotions: Anxiety, anger, or stress may increase blood pressure. (White Coat Syndrome)

• Pain: Acute pain may increase blood pressure.

• Personal habits: Caffeine or smoking within 30 minutes before measurement may increase reading.


Oxygen Saturation

• Measurement of oxygen saturationis included with vital signs in many settings:

• Oxygen saturation is measured by a pulse oximeter—a device that estimates oxygen saturation of hemoglobin in blood.

• Probe is taped or clipped to patient’s fingertip, toe, earlobe, or nose; oxygen saturation appears as a digital readout within 10 to 15 seconds after oximeter is placed.

• Oxygen saturation levels lower than 90% are considered abnormal and require further evaluation.

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Pain• Routine assessment of patient’s pain or comfort level is

standard practice in all health care settings and often assessed with vital sign measurement.

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Weight

• Measure weight using a balance scale by asking patient to stand on platform while large and small weights are balanced.

• Adjust smaller weight to balance scale reading weight to nearest quarter pound.

• Body weight or mass is influenced by a number of factors, including genetics, dietary intake, exercise, and fluid volume.

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Height• Ask patient to stand on scale withoutwearing shoes; lower height attachment until horizontal headpiece touches top of patient’s head.

• Vertical measuring scale can measure in inches or centimeters

• Adult height attained by age 18 to 20 years.

• Height is influenced by genetics and dietary intake; measured on a platform scale with a height attachment

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Special Age-Related Variations:Infants and Children• Measurement of height (recumbent length), weight, and

head and chest circumferences are important indicators of growth.

• Data are plotted on growth chartsto assess growth patterns of infant and child and to compare growth to infants and children of same age and gender.

• Same process for general inspection and vital signs measurement among infants and children is followed as previously described.

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Special Age-Related Variations:Older Adults

•Measurement of height, weight, and vital signs in older adults is generally the same as previously described.

•Techniques and equipment may vary depending on medical conditions, and patient mobility/ability

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Question 1

The nurse is working in a primary care clinic. She walks into the room, and the general inspection begins. What is not part of the general inspection?

A.Patient’s facial expressions are consistent with verbalized emotions.B.Patient is wearing clothes that are normally worn by whites.C.Patient is staring down at the floor through most of the interview.D.Patient’s gait is strong and symmetrical.


Question 2The nurse collects patient data through assessment of vital signs. Many nurses will delegate the performance of temperature data collection to unlicensed assistive personnel. As the nurse talks to the assistant, the nurse knows to teach that:

A.Tympanic thermometers touch the tympanic membrane.B.Axillary temperatures are taken with the red probe on the electronic thermometer.C.Axillary temperatures are usually most accurate because of the local blood supply.D.Rectal thermometers are placed 2.8 cm to 3.5 cm into the rectum.


Question 3

A woman in labor suffers from preeclampsia. Nurses in the labor and delivery unit need to assess her blood pressure. The nurse explains to the patient that:

A.Using a cuff that is too narrow will give a reading that is inaccurate and high.B.Deflating the cuff too quickly will make the reading inaccurate and high.C.Deflating the cuff 5 mm Hg per second will make the reading inaccurate and high.D.Waiting 3 minutes before repeating the blood pressure measurement will result in a false-high blood pressure measurement.


CHAPTER 6Pain Assessment

What is Pain?


Anatomy & Physiology of Pain• Physiology of pain involves

journey:

• Transduction from site of stimulation of peripheral receptors to spinal cord.

• Transmission up spinal cord.

• Perception at cerebral cortex.

• Modulation back down spinal cord.

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A&P of Pain: Step One• The pain process begins with response of nociceptors to

noxious stimuli.

• Nociceptors are primary sensory nerves located in:

• Tendons• Muscles• Subcutaneous tissue• Epidermis• Skeletal muscles

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A&P of Pain: Step TwoSensory peripheral nerves are stimulated.•Large A-Delta fibers – associated with sharp, pricking, acute, well localized pain of short duration.•Small C fibers – associated with dull, aching, throbbing, or burning sensations.

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A&P of Pain: Step Three

• Thalamus receives impulses from spinothalamic tract:

• Impulses travel to parietal lobe in cerebral cortex and to limbic system.

• When impulses reach parietal lobe, patient feels pain.

• Although journey takes a fraction of a second, no pain is perceived until parietal lobe is stimulated.

• Stimulation of limbic system generates emotional response to pain:• Crying• Anger

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A&P of Pain: Step Four Pain journey ends when body produces substances to reduce pain perception:

As sensory nerve fibers travel to brainstem, they stimulate nerves that inhibit nociceptor stimuli. Descending fibers start in brainstem and travel down the dorsal horn of the spinal cord.

Release of substances that inhibit transmission of noxious stimuli and produce analgesia: Endogenous opioids, e.g., endorphins and enkephalins Serotonin (5HT) Norepinephrine (NE) Gamma-aminobutyric acid (GABA)

These substances occupy the receptors sites, which prevent A and C nerve fibers from opening “the gate.”

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Types of Pain• Pain is categorized in several ways, but clear distinctions

among types may not be possible.

• Acute pain has recent onset and results from tissue damage, is usually self-limiting, and ends when tissue heals.• May cause physiologic signs associated with pain.

• Persistent (chronic) pain may be intermittent or continuous pain lasting more than 6 months.• Clinical manifestations of chronic pain are not those of physiologic

stress because patient adapts to pain, but often reports symptoms of irritability, depression, withdrawal, or insomnia.


Types of Pain• Nociceptive pain:

• Arises from somatic structuressuch as bone, joint, or muscle.• Results from activation of normalneural systems.

• Neuropathic pain:• Occurs because of abnormalprocessing of sensory input.

• Referred pain:• Pain felt in a location away from the injury.• Often visceral pain, as many abdominal organs have no pain receptors.

• Phantom pain:• Pain felt in an amputated extremity.

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Pain Threshold and Tolerance• Concepts of pain threshold and pain tolerance affect patient’s pain experience.

• Pain threshold is point at which a stimulus is perceived as pain.

• This threshold does not vary significantly among people or in same person over time.

• Pain tolerance is duration or intensity of pain a person will endure before outwardly responding.• Pain tolerance decreases with repeated exposure to pain, fatigue, anger,

boredom, and sleep deprivation.• Tolerance increases after alcohol consumption, medications, hypnosis,

warmth, distracting activities, and strong faith-related beliefs.


Cognitive & Cultural Influences on Pain

Perception of and response to pain is influenced by cognitive and cultural factors: Patient’s previous experiences with pain and current

physical and mental status affect pain perception and response.

Cognitive factors: Attention people give to the pain. Expectation or anticipation of pain. Appraisal or expression of pain.

Cultural factors: Cultural influences may affect how pain is communicated.

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Effects of Pain and Treatment• Pain:

• Increases catabolic demands• Poor wound healing• Weakness• Muscle break down

• May reduce mobility. (↑ risk of thromboembolic event)• May affect respiratory status

• Shallow breathing• Tachypnea

• May affect cardiac status• Tachycardia• Hypertension

• May Impair sleep.• May contribute to loss of appetite.• May contribute to depression and/or anxiety

• Narcotics change elimination pattern.

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Pain Assessment• Pain relief is primary responsibility of all health care

providers.

• Assessing patient’s pain is first step in achieving goal of pain relief.

• Pain assessment and management often referred to as fifth vital sign.


Standards for Pain Assessment• The Joint Commission standards assert that patients have

a right to appropriate assessment and management of pain, including the following:

• Pain is assessed in all patients.

• Initial assessment and regular reassessment of pain, taking into account personal, cultural, spiritual, and ethnic beliefs.

• Education of all relevant providers in pain assessment and management.

• Education of patients and families regarding roles in managing pain and potential limitations and side effects of pain treatments.


Health History:Present Health Status

• Do you have any chronic illnesses? If so, do they cause you pain? • Describe

• Do you take any medications? • What, and how often? • Do they relieve your pain?• Are you allergic to any medications? • What kind of allergic reaction occurs from these medications?


Problem-Based History• Pain is a complex, multidimensional, subjective

experience• Collect data from patients using a symptom analysis

applying the mnemonic OLD CARTS• O = Onset• L = Location• D = Duration

• C = Characteristics• A = Aggravating factors• R = Related symptoms• T = Treatment by the patient• S = Severity


Beliefs about Pain• Do you communicate your pain verbally or nonverbally?

• Be aware of cultural influences of pain:

• Overt pain expression• Stoicism• Silence• Smiling


Health History:Description of Pain

• Location:• Where is your pain? Point to location(s).

• Quality:• Describe what the pain feels like.

• Quantity:• How would you describe intensity, strength, or severity of the pain

on a scale of 0 to 10, with 0 being no pain and 10 being most intense pain possible?

• At what point on this scale of 0 to 10 do you usually take medication for your pain?


Problem-Based Health History:Onset of Pain• Onset:

• When does the pain occur? • During activity? • Before or after eating?

• Does the pain occur suddenly or gradually?

• What do you think is causing your pain?• Why do you think the pain started when it did?


Problem-Based Health History:Location and Duration of Pain

• Location:• Where do you feel pain?• Can you point to the location(s)?

• Duration:• How long do you feel the pain?• Is it constant or intermittent?• How often does it occur?• How long does it last?


Problem-Based Health History:

• Characteristics: Can you describe what the pain feels like?

• Aggravating factors:• What makes the pain worse?

• Related symptoms:• What other symptoms do you have during pain?

• Palpitations• Shortness of breath• Sweating• Rapid or irregular heartbeat• Nausea or vomiting


Self-Treatment by Patient• Treatment: Have you tried to relieve the pain?

• How effective have these measures been?• What medications did you take, and in what amounts?• Have you considered alternative methods?

• Massage• Mind-body medicine• Lifestyle changes

• How much pain are you expecting?• Cultural beliefs may affect expectations.


Severity of Pain• How would you describe your pain?

• On a scale of 0 to 10, with 0 being no pain and 10 being the worst pain possible, describe:• Intensity• Strength• Severity

• At which point on this 0 to 10 scale do you usually want to take your pain medicine?

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Response to Pain• How do you react to pain?

• How do you express your pain?• What do you fear most about the pain?• What problems does your pain cause you?

• Does your pain have any particular meaning to you?• Spiritual• Psychological

• Do you have any concerns about taking pain relief?

• Has the pain affected your quality of life?


Pain Reassessment• After taking the medication, how would rate your pain

now?• 30 minutes after parenteral administration.• 60 minutes after oral administration.

• Assessing those who cannot communicate:• Attempt self-report.• Search for potential causes of pain.• Observe for behavioral changes.• Question caregivers about patient’s usual response to pain.• Attempt analgesic trial and observe behavior.


Examination• Observe patient for posture and behavior that helps

relieve pain.

• Observe facial expressions.

• Listen for sounds made by patient.

• Inspect skin for color, temperature, moisture.

• Measure blood pressure and pulse.

• Assess respiratory rate and pattern.

• Observe pupillary size and reaction to light.


Age-Related Variations: Infants and Children

• Nurses find different responses to pain depending on age of patient.

• Neonate responses to pain are global, evidenced by increased heart rate, hypertension, pallor, sweating, and decreased oxygenation saturation.

• Young children have difficulty understanding pain but have a basic ability to describe pain and location.

• School-age children better understand pain

and are able to describe pain location.

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Age-Related Variations:Older Adults• Although transmission and perception of pain may have slowed down in older person,pain is felt no differently than by any other adult.

• Many older adults have a lifetime of experience in coping with pain, but pain is not an expected part of aging.

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Question 1

Initiation of intravenous access can be a painful experience for the patient. As the needle is inserted into skin, the patient is calm. However, when the needle pierces the vein, the patient pulls the hand away. The time that the person endured the pain before outwardly responding is known as:

A.Pain tolerance.B.Pain intolerance.C.Pain perception.D.Pain threshold.


Question 2

Assessment of circulation, motion, and sensation is done every 8 hours in a patient recovering from a laminectomy 3 days after surgery. The patient had the surgery for consistent low back pain. Now on day 3, the patient has a burning sensation on the lateral edge of the right foot. This is best described as:

A.Cellulitis.B.Nociceptive pain.C.Fasciitis.D.Neuropathic pain.


NURSING 310: HEALTH ASSESSMENT Lecture 2 K.Hendrickson PhD, MSN, RN Fall 2013 1.

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