Unit 2 Patient Assessment and Monitoring

• Observation • Evaluation • Assessment • Communication ➢Relaying information

• A = Acknowledge • I = Introduce • D = Duration • E = Explanation • T = Thanks

• Questioning techniques ➢Open-ended questions ➢Facilitation ➢Silence ➢Reflection or reiteration ➢Clarification or probing ➢Summarization Elements of a History • Onset • Duration/chronology • Specific location • Quality of symptoms • Severity of pain • What aggravates/alleviates • Associate manifestations

• How did it start? • What happened? • When did it first trouble you? • Was it sudden or a complaint that gradually became worse?

• Have you ever experienced it before? • Has it been continuous? • Does it bother you all the time? • How long has this attack been bothering you?

• Where does it hurt (or where is the problem)? • Can you put your finger where it hurts the most? • Does it hurt anywhere else?

• What does it feel like? ➢Sharp, stabbing pain? ➢Dull ache? ➢Throbbing pain?

• How severe is it? • Mild, moderate, or severe? ➢Some like to use a pain scale of 1–5 or 1–10, with 0 being no pain at all and the highest number representing the worst pain the patient can imagine. • Does it wake you up at night?

• What seems to make it worse? • When is it worst? • Is it worse after meals? • At night? • When you walk?

• What has helped in the past? • Does that still help? • What seems to help now? • Does the time of day (amount of rest, change in position, and so on) make a difference?

• Are there any other symptoms that you are experiencing that are associated with your chief complaint?

• Checking the chart ➢Obtain more specific information. • Physical assessment ➢An ongoing process of observation, comparison, and measurement of patient’s condition before, during, and after imaging procedures • Vital signs ➢Temperature, pulse rate, respiratory rate, and blood pressure

-DNR(Do Not Resuscitate): purple -Allergy: red -Fall risk: yellow

• Skin color and temperature • Level of consciousness (LOC) • Breathing

Digital, electronic thermometer for taking oral, axillary, and rectal temperature

Inserted into external ear canal

➢Contains an infrared sensor ➢Measures over the temporal artery in the forehead ➢Easy and quick; not objectionable to patients ➢Research indicates that this method is more accurate than the tympanic method.

• Measured in beats per minute (BPM) • Tachycardia ➢Heart rate that is too fast(150-250 bpm) • Bradycardia ➢Heart rate that is too slow

number of breaths per minute • Normal range = 12–20 breaths/min • Bradypnea ➢Fewer than 12 breaths/min • Tachypnea ➢More than 20 breaths/min

• Measured with sphygmomanometer • Expressed as: ➢Systolic (A) ➢Diastolic (B) • Normal range ➢Systolic = 95–119 ➢Diastolic = 60–79

High blood pressure ➢Two stages • Stage 1—systolic ranges 140–159 mm Hg; diastolic ranges 90–99 mm Hg • Stage 2—the most severe form, Systolic reading is 160 mm Hg or greater and diastolic is 100 mm Hg or greater.

Low blood pressure ➢Diastolic pressure <50 mm Hg or systolic pressure <90 mm Hg ➢May also indicate shock

• Complete Blood Count • Erythrocyte Sedimentation Rate • Blood-Clotting Assessments • Blood-Chemistry Tests

Placed on a finger, toe, or earlobe, where it continuously monitors both pulse rate and blood oxygen levels (oxygen saturation of hemoglobin)