Client Assessment

What is a Symptom?

Symptom: Any subjective evidence of disease. A symptom is a phenomenon that is experienced by an individual. Anxiety, lower back pain, and fatigue are all symptoms. They are sensations only the patient can perceive. In contrast, a sign is objective evidence of disease. A bloody nose is a sign. It is evident to the patient, doctor, nurse, and other observers.

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What is a Sign?

Any objective evidence of disease. A sign can be detected by a person other than the affected individual.

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Examples

What do you consider would be a sign?

What do you consider a symptom?

Gross blood in the stool is a sign of disease. It can be recognized by the patient, doctor, nurse, or others.

In contrast, a symptom is, by its nature, subjective. Abdominal pain is a symptom. It is something only the patient can know.

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Scenario

You find an elderly gentleman collapsed on the foot path outside your home. It is a very hot day. He has a large graze on his left temple, and bruising is developing around his eyes. His left leg is shorter than the other one and rotated outwards. He is confused and drowsy when you try to ask him what happened. He says he feels sick, and has a lot of pain in his hip.

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Signs & Symptoms

Signs1. Graze on temple

2. Bruising around eyes

3. Shortened & rotated leg

4. Conscious but drowsy

5. Confused

Symptoms1. Feels sick

2. Has pain in hip

Terminology

B.D. ------ Twice Daily

QID------ Four times a day

P.R.N. ----As required

Mane ------ Morning

Nocte------- At night

AC----------- Before Meals

PC-------------- After meals

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Vital Signs

What do you think vital signs may be?

Life signs. Include temperature, pulse , respirations and blood pressure.

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Performing Health Assessment

The nurse to create a quiet , calm environmentUse interview techniques that enhance trust and confidence and takes into account cultural variationsUse communication techniques that ensure comprehensive, accurate information is receivedEnsure all paperwork and equipment required is collected and functionalRecord the information as it is received

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Health Assessment

Biological dataMedical history- present and pastFamily history of illness / diseaseAny allergies – and the reactionMedicationsPsychosocial historySpiritual requirementsPhysical Assessment

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General health / observation assesses

The patients degree of independence – how much assistanceThe ability to perform ADL’S –how much assistance The ability to interact with others –affect, cognitive ability, social aspectsBasic needs – safety, nutrition, hydration, oxygenSpecific needs – diabetes, wheel chair , aids, painExcretions and secretions- normal (bowel , urinary ) discharge

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Performing physical assessment

The room is to be warm and well lit

The patient is to be informed about the procedure ( and each part of procedure)

Consent is to be gained

Patient’s dignity and privacy is to be maintained

Infection control to be maintained

The examination is to be systematic and organised

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Skills used by a doctor Inspection

A systematic approach is important to prevent omissions. The usual sequence that a doctor uses is :

– observing the general condition of various body parts, including any deviations from normal

Eg. The general appearance of patient, movement, lesion , etc

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Palpation

Is touching or feeling body parts to determine texture, temperature, moisture, motion consistency of structures

Eg chest and abdomen

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Skills used by a doctor cont… Percussion.

–Is tapping a portion of the body to elicit tenderness or sounds indication the density of underlying structures

Eg – abdomen , chest

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Auscultation

Is listening ( a stethoscope may be used)

Eg- heart sounds , respirations , cough, bowel sounds.

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The assessment skills of an RN division 2

General observation

Inspection

Hearing

Palpation

Smell

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General observations (normal findings) of physical assessment

Physical development – as would be expected for chronological ageBehaviour- cooperative attitude and behaviourMood- mild anxiety or tensenessDress – dressed for the occasionGait – erect posture, coordinated, smooth and steady gaitBody build – bilateral firm , developed muscles, height / weight ratio

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Vital signs and measurements

Vital signs are the life signs and include

Temperature

Pulse

Respirations

Blood pressure

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Other measurements taken;

Blood glucose

Blood oxygen saturation

Height / weight

Urinalysis

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What do they measure?

The state of the internal environment of the body.

Changes from normal can indicate alterations, in health status and may give rise to medical interventions / nursing care

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When do we take vital signs

On admission to hospital, visit to doctor’s rooms, visit to clinicsPrior to surgery /post surgeryPre and post diagnostic procedureTo gauge the effects of medication any change to patient’s condition.Any change to patients condition.When ordered by Dr.As an assessment of patient at any time deemed necessary.

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Internal environment

Hydrostatic pressures

Concentration of substances in the blood, body fluids and tissues (eg hormones, O2, CO2, wastes , electrolytes

Ph levels of body fluids especially blood.

Temperature of the internal environment.

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Internal environment cont…

Homeostasis of the internal environment is controlled by the nervous and endocrine systems. The central nervous system receives information from sensory organs and tissuesThe hypothalamus regulates temperature and relays information to the thalamus and pituitary gland (hormones)The brain stem contains the cardiac, vasomotor and respiratory centresThe ANS responds to bring about homeostasishttp://health.howstuffworks.com/adam-200092.htm

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Internal environment cont…

Endocrine system

The thyroid gland (thyroxine) – controls the body’s BMR

Adrenal gland (adrenaline / nor adrenaline) places the body into fight/ flight mode or assists in returning it to rest / normal function

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Guidelines to achieve accurate results in taking vital signs

Appropriate equipment chosen depending on patient’s requirements

Equipment s functional and calibrated.

Patient to be in a state of rest if possible.

If possible environmental, life style factors are to be controlled or minimised.

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Guidelines to achieve accurate results

The nurse to be aware of

Normal values for the patient

Medical history / therapies/ medications that may alter patient’s vital signs

How to read, interpret and record the findings accurately

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