Basic Assessments part 1

12 Jan

Week 1 Lab Notes: May other students find them useful

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beginning your assessment from head to toe.

REMEMBER: No question is wrong! Just ask! Don’t assume anything!

Start…by looking at your patient:

  1. Do they look their age?
  2. Do they appear to be what they say to be? Chronic health problems, living situations, trauma may make the person look older. Example:  The patient says she’s 40, but she looks at least 60! She says that she always likes to tan and it’s obvious that her sun worshipper habits have made her look much older than she should
  3. How are they dressed, what is their grooming like? What’s their body language saying to you?
  4. If they look sick, they probably are!

Next….LISTEN!

Look! LISTEN!

Listen!

  1. Before each step it’s important to listen to them.
  2. When you take their blood pressure/pulse, it helps to ask them “Sir/ma’am do you run high or low?” This helps to make sure that you’re right
  3. If they’re scared or upset or confused, listen to them
  4. Use your ears when charting breathing, blood pressure, etc

MOST IMPORTANT THING YOU DO? Take vitals!

The first thing every nurse does with a patient is take their vitals. While doing this, keep “Every Good Worker Cares Always” in mind:

Every = explain what you’re doing

Good = gather your equipment by age and size.

Worker = warm your stethoscope or hands before touching your person

Cares = be CAREful! The patients comfort always comes first! If you don’t get the blood pressure right in the first two tries, it’s time to take a break, change the arm or come back later.

Always = At ease: a calm patient is easier to get readings from. If they’re nervous, scared etc then your vital signs may be distorted! Comfort and care for better information.

Lets do vitals, these are:

  • Temperature
  • Pulse
  • Respiration
  • Blood pressure

First Temperature because it’s easy!

  1. Get your thermometer. If it’s a communal one, clean it from tip to base or put on a disposable sheath
  2. There are four routes for taking a temperature. Remember by this simple rhyme: “under the tongue, under the arm, in the ear, or up the rear (rectal)”
  3. Pick your location, but the most used is mouth and ear. Under the arm takes a very long time and isn’t as reliable. Rectal can be tramatizing for all parties involved and can be risky.
  4. Hold thermometer in place for as long as needed. A digital one will beep when it’s done.
  5. THE AVERAGE TEMP: should be between 98.6-100.4 F. This may be slightly higher if rectal or lower if under the arm
  6. CHART the temp (Because if it didn’t get written then it didn’t get done). and clean your thermometer.

Next Pulse: little harder now…

  1. Find your pulse with the first three fingers (never thumb!). You can get this at many different places (SEe your text book for this) but the radial is most popular. Carteroid is easy to find but you can also turn a pulse check into a sleeper hold if you’re not careful. Lets play it safe and go for the wrist…
  2. Count the beats for 1 minute. Adults: 60-100 BPM can be normal, most people are around 72. For babies 100-170 is normal with 140 being the average.
  3. “Its’ going so fast! What’s wrong?!” Many things can affect the pulse. Is your person nervous or scared? Have they been drinking a lot of caffeine? Do they have heart disease? These are important things to know so LISTEN to your patient.

Now respiration!

  1. Rule 1#: BE A NINJA! Don’t tell your patient that you’re counting their breaths.  Count but don’t let them know that’s what you’re doing. Pretend to check their pulse or have some calming chit chat, maybe do it while they’re holding the thermometer in their mouth? Be creative and sneaky!
  2. Watch the chest rise and fall and pay attention to how they’re breathing as you count for a minute. Are they huffing and puffing? Breathing deeply? Are they using other muscles or just lightly chest breathing? What is their mouth doing. WATCH all of these and LISTEN! What do they sound like?
  3. The average person should be around 12-20 breaths a minute while they’re awake and talking to you.

Lastly blood pressure, because it’s the hardest!

  1. USE THE LEFT ARM! This has the best readings. DO NOT use this arm if: they have an IV, a fistula, a mastectomy on that side, a wound, other problems with that side etc. Use your judgement.
  2. Put the cuff on the upper arm tightly and make sure that it’s the right size for the job.
  3. Do not put on over their clothes! If their sleeve is too tight to roll up, have them take their arm out of the sleeve for a little while.
  4. ASK: do they have high blood pressure? If they do you’ll know to pump tighter
  5. PUMP IT UP! Pump up until at least 180 and place the flat side of the stethoscope in the hollow of the elbow over the veins.
  6. TURN IT DOWN!:Now SLOWLY let the air out and listen for the pulse! When you first hear it, remember where the needle is. This is the SYSTOLIC. When you stop hearing it, this is the bottom number, the DIASTOLIC!
  7. TIP: watch the needle! When the needle in the meter almost seems to pulse by itself pay attention, the beat will come soon!
  8. Listen carefully! The sounds are very hard to hear and it takes lots and lots of practice…just don’t do all of your practice on one person at one time. Two tries on each arm is enough and most patients will be upside after once. Take a break and try again later or on another willing helper.

More notes next class!

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