1. Patient Asssessment

2. Measuring Height and Weight
Used to determine if patient is underweight or overweight
Height and weight charts are used as averages
Weight greater or less than 20% considered normal
BMI or Body Mass Index a statistical measure of body weight based on a person's weight and height.
BMI from 18.5 to 24.9 is considered normal

3. Measuring Height and Weight
General Guidelines:
Use the same scale every day
Make sure the scale is balanced before use
Weigh the patient at the same time each day
Remove jacket, robe, and shoes before weighing
OBSERVE SAFETY PRECAUTIONS!
Prevent injury from falls and the protruding height lever.
Some people are weight conscious.
Make only positive comments when weighing patients

4. Types of Scales
Clinical scales contain a balance beam and measuring rod
Bed scales or Chair scales are used for patients unable to stand
Infant scales come in balanced, aneroid, or digital
When weighing an infant…keep one hand slightly over but not touching the infant
A tape measure is used to measure infant height.

5. Urine Specimens
Can provide valuable information about the patients state of health
Urine is commonly tested for:
Bacteria, pus, or blood as found in bladder and kidney infection
Sugar and acetone as found in diabetes
Hormones as found in pregnancy
Drugs

6. Common Types of Specimens
Random urine specimen
Collected for a routine urinalysis.
No special measures are needed.
Midstream specimen (clean-voided or clean-catch)
The perineal area is cleaned before collecting the specimen.
Sterile gloves and container are needed.
Double voided
Patient voids and the specimen is discarded
After 30 minutes, patient voids again and specimen is collected for testing

7. Testing Urine Urine pH measures if urine is acidic or alkaline.
Normal pH is 4.6 to 8.0.
Testing for glucose and ketones
These tests are usually done 30 minutes before each meal and at bedtime.
Information used to make drug and diet decisions.
Double-voided specimens are best for these tests.
Testing for blood
Sometimes blood is seen in the urine.
At other times it is unseen (occult).
A routine urine specimen is needed.

8. Testing Urine Using reagent strips
Universal Precautions must be used at all times
Dip the strip into urine.
Compare the strip with the color chart on the bottle at the required time interval.
Record and report results

9. Stool Specimen Stool, or feces, may be tested for:
Blood
Fat
Microbes
Worms
Other abnormal contents
The stool specimen must not be contaminated with urine.

10. Sputum Specimen
Sputum specimens may be tested for blood, microbes, and abnormal cells.
The person coughs up sputum from the bronchi and trachea.
It is easier to collect a specimen in the morning.

11. Other Types of Specimens
Specimens may be obtained from other body tissue and fluid.
A biopsy is done by removing a small piece of tissue for further examination.
A culture and sensitivity is done by swabbing a body surface and testing
for the presence of microbes

12. Seven Warning Signs of Cancer

13. Unusual bleeding or discharge
Warning Sign
Unusual bleeding or discharge
What to Look For
Blood in urine or stool
Discharge from any parts of your body, for example nipples, penis, etc

14. Warning Sign What to Look For A sore that does not heal Sores that:
don't seem to be getting better over time
are getting bigger
getting more painful
are starting to bleed

15. Change in bowel or bladder habits
Warning Sign
Change in bowel or bladder habits
What to Look For
Changes in the color, consistency, size, or shape of stools. (diarrhea, constipated)
Blood present in urine or stool

16. Warning Sign What to Look For
Lump in breast or other part of the body
What to Look For
Any lump found in the breast when doing a self examination.
Any lump in the scrotum when doing a self exam.
Other lumps found on the body.

17. Warning Sign What to Look For Change in voice/hoarseness Nagging cough
Cough that does not go away
Sputum with blood

18. Warning Sign What to Look For Obvious change in moles
Use the ABCD RULE
Asymmetry: Does the mole look the same in all parts or are there differences?
Border: Are the borders sharp or ragged?
Color: What are the colors seen in the mole?
Diameter: Is the mole bigger than a pencil eraser (6 mm)?

19. Difficulty in swallowing
Warning Sign
Difficulty in swallowing
What to Look For
Feeling of pressure in throat or chest which makes swallowing uncomfortable
Feeling full without food or with a small amount of food

20. C A U T I O N (Cancer’s Warning Signs)
C Change in bowel or bladder habits
A A sore that does not heal
U Unusual bleeding or discharge
T Thickening or lump in breast or body part
I Indigestion or difficulty in swallowing
O Obvious change in a wart or mole
N Nagging cough or hoarseness

21. Nursing Assistants as Medical Scouts
As the primary caregiver, your observations can be the difference between a resident who receives early and effective treatment, and a resident who becomes gravely ill
A recent study by Kenneth Boockvar MD, Assistant Professor in the Department of Geriatrics at Mount Sinai School of Medicine found:
That nursing assistants almost always saw that a resident was becoming ill earlier than anything noted in the chart
Illnesses that were detected early were:
UTI’s, Pneumonia, CHF, Gastroenteritis, Arrhythmias and Dehydration

22. The 5 Early Warning Signs of Illness
1. Weakness – sudden onset TIA, pneumonia, dehydration, CHF, infection, liver failure
2. A sudden change in greeting – severe hearing loss, depression confusion
3. Nervousness or Agitation –
being emotionally off can signal physical illness
4. Loss of appetite
5. A resident complains

23. ABC’s of Observation Appearance Behavior – actions, conduct, pain
Communication

24. Signs and Symptoms
Signs Objective data are seen, heard, felt, smelled. You can see urine, hear a cough, feel a pulse and smell a foul odor.
Symptoms Subjective data are thing a person tells you about that you cannot observe through your senses. Examples include nausea, pain and dizziness.

25. Observations by Body Systems
Using sight, touch, hearing, and smell

26. Integumentary System
Color – flushed, pale, ashen, icteric, cyanotic, (don’t forget nails)
Temperature – warm, hot cool
Moisture – dry, moist, perspiring
Abnormalities – rashes, bruises, wounds

27. Musculoskeletal System
Posture – stooped, fetal position, straight
Mobility – in bed, balance, ambulation
Range of Motion – performance of ADL’s

28. Circulatory System Pulse – strength, regularity, rate Blood Pressure
Skin color
Extremities – edema

29. Respiratory System
Respirations – rate, regularity, depth, dyspnea, SOB (exertion, at rest), stertorous
Cough – frequency, dry, productive
Sputum – color, consistency

30. Nervous System Mental state – orientation Ability to communicate
Senses
Eyes – pupils equal, reddened, drainage
Ears – drainage, hearing
Nose – drainage, bleeding

31. Urinary System Frequency, amount, color, dysuria
Clarity, blood or sediment, incontinent
Pain or burning upon urination

32. Digestive System
Appetite – amount of solids/liquids consumed, belching, burping, intolerance to foods
Eating – difficulty chewing or swallowing
Nausea/Vomiting
Bowel elimination – frequency, amount, consistency, color, diarrhea, constipation, flatus

33. Reproductive System Female Male
Breasts – drainage from nipples, discoloration, lumps
Vagina – discharge, amount, color, character
Male
Testes – lumps
Penis – drainage, amount and character