|
Factors Affecting Vital Signs
|
||||
|
Factor
|
HR
|
RR
|
SBP
|
Temp
|
|
Fever
|
↑
|
↑
|
Normal
|
↑
|
|
Anxiety
|
↑
|
↑
|
↑
|
Normal
|
|
Pain, acute
|
↑
|
↑
|
↑
|
Normal
|
|
Pain, chronic
|
↓
|
Normal
|
Normal
|
Normal
|
|
Acute MI
|
↓
|
↑
|
↓ (Late)
|
Normal
|
|
Spinal injury
|
↓
|
↓
|
↓
|
Normal/↑
|
|
Tamponade
|
↑
|
↑
|
↓
|
Normal
|
|
CHF
|
↑
|
↑
|
↑ (Early)
|
↑
|
|
Pulm. embolism
|
↑
|
↑
|
↓
|
↑
|
|
Exercise
|
↑
|
↑
|
↑
|
↑
|
|
↓ H&H
|
↑
|
↑
|
↓
|
↓
|
|
↓ Blood glucose
|
Normal/↑
|
Normal
|
Normal/↑
|
↓
|
|
↑ Blood glucose
|
↑
|
↑//Deep
|
↓
|
↑
|
|
↑ WBC
|
↑
|
↑
|
↓ (Sepsis)
|
↑
|
|
↑ K +
|
↓
|
Shallow
|
Normal/↑
|
Normal
|
|
↓K+
|
↑
|
Shallow
|
↓
|
Normal
|
|
↑Ca+
|
↓
|
Normal
|
↓
|
Normal
|
|
↓Ca+
|
↓
|
Varies
|
↓
|
Normal
|
|
↑Na+
|
↑
|
Normal/↑
|
↑
|
↑
|
|
↓Na+
|
↑
|
Normal/↑
|
↓
|
Normal
|
|
Narcotics
|
↓
|
↓
|
↓
|
↓
|
|
Beta blockers
|
↓
|
↓
|
↓
|
Normal
|
|
Ca channel blockers
|
↓
|
↓
|
↓
|
Normal
|
7/7/14
Factors Affecting Vital Signs
Adult Vital Signs: Normal Ranges
|
Adult Vital Signs: Normal
Ranges
|
||||
|
HR
|
RR
|
SBP
|
DBP
|
Temp
|
|
60–100
|
12–20
|
<120
|
<80
|
*See below
|
|
Tympanic temperature 37.0–38.1 C (98.6–100.6 F)
Oral temperature 36.4–37.6 C (97.6–99.6 F)
Rectal temperature 37.0–38 C (98.6–100.4 F)
Axillary temperature 35.9–37.0 C (96.6–98.6 F)
|
||||
Focused Symptom Analysis
|
Focused Symptom Analysis
(PQRST)
|
|
|
Below are three examples (pain, respiratory, and nausea) of how the
PQRST mnemonic can be universally applied when assessing any number of
symptoms or various Pt complaints.
|
|
|
P
|
Provocative, precipitating, and
palliative factors
|
|
|
■ Pain:
Activity at or before onset. Does anything make mpain better or worse?
■ Respiratory:
Activity at or before onset. Factors that lessen or worsen level of distress.
■ Nausea:
Last oral intake before onset. Factors that make nausea better or worse.
|
|
Q
|
Ask Pt to describe quality of the
symptom.
|
|
|
■ Pain:
Dull, stabbing, achy, pressure, or squeezing.
■ Respiratory:
Productive/nonproductive cough, chest heaviness, bronchial tickle/cough
reflex.
■ Nausea: Emesis, gagging/dry heaving, nausea only.
|
|
R
|
Ask Pt to describe location and/or whether symptom radiates to
another region of body or if there are any related symptoms.
|
|
|
■ Pain:
Location and radiation to another region of body.
■ Respiratory:
Related symptoms (e.g., CP, nausea, fever,
cough reflex, etc.).
■ Nausea:
Related symptoms (e.g., diarrhea,
constipation,
indigestion, fever, headache, etc.).
|
|
S
|
Assess severity of the symptom.
|
|
|
■ Pain:
Rate pain using 0/10 pain scale
■ Respiratory:
Can Pt speak in full sentences or must he or she take another breath after
only one–two words?
■ Nausea: Nausea only, emesis, dehydration.
|
|
T
|
Determine timing factors related to
symptom.
|
|
|
■ Determine
duration of symptom.
■ Determine
if symptom is constant or intermittent.
■ Determine
if onset of symptom is sudden or gradual (over minutes, hours, days, or
weeks).
|
Specimen Collection: Blood
Specimen Collection: Blood
General Guidelines
■ Verify if Pt has allergies to latex, iodine, adhesives, etc.
■ Tourniquet should not be left in place longer than 1 minute.
■ Previous puncture site areas should be avoided for 24–48 hours.
■ Specimens should never be collected above IV site.
■ Order of draw: If multiple tubes are required, they are collected in following order: blood cultures, red or red marble-top with gel, light blue, green, lavender, and then gray.
Procedure
■ Prepare Pt: Explain procedure to Pt, offer reassurance, and assess for allergies to latex, iodine, or tape.
■ Supplies:Tourniquet, skin cleanser, sterile 2 2 gauze, evacuated collection tubes or syringes, needle and needle holder, and tape.
■ Position patient: Sitting or lying with arm extended and supported.
■ Tourniquet: 3–4 inches above intended venipuncture site.
■ Choose vein: Most common and easily accessed are median cubital, cephalic, and basilic veins located in antecubital (AC) fossa anterior to elbow. Veins of forearm, wrist, and hand may also be used but are smaller and often more painful.
■ Cleanse site: Briefly remove tourniquet. With alcohol swab, cleanse site from center outward, using a circular motion. Allow site to air dry for 30–60 seconds. For blood alcohol level and blood culture specimens, use iodine in place of alcohol.
■ Perform venipuncture: Reapply the tourniquet. If necessary, cleanse end of gloved finger for additional vein palpation. Insert needle, bevel up, at 15–30 degrees using dominant hand. With nondominant hand, push evacuated collection tube completely into needle holder or pull back on syringe plunger with slow, consistent tension.
■ Remove tourniquet: If procedure will last longer than 1 minute, remove tourniquet after blood begins to flow.
■ Remove needle: Remove tourniquet if still in place. Place sterile gauze over puncture site, remove needle, and apply pressure.
■ Equipment disposal: Per facility policy/standard precautions.
■ Prepare specimen: If using syringes, transfer specimen into proper tubes. Mix additives with gentle rolling motion. Label specimen tubes with Pt’s name, ID number, date, time, and your initials.
■ Document: Record specimen collection in medical record.
Read More
General Guidelines
■ Verify if Pt has allergies to latex, iodine, adhesives, etc.
■ Tourniquet should not be left in place longer than 1 minute.
■ Previous puncture site areas should be avoided for 24–48 hours.
■ Specimens should never be collected above IV site.
■ Order of draw: If multiple tubes are required, they are collected in following order: blood cultures, red or red marble-top with gel, light blue, green, lavender, and then gray.
Procedure
■ Prepare Pt: Explain procedure to Pt, offer reassurance, and assess for allergies to latex, iodine, or tape.
■ Supplies:Tourniquet, skin cleanser, sterile 2 2 gauze, evacuated collection tubes or syringes, needle and needle holder, and tape.
■ Position patient: Sitting or lying with arm extended and supported.
■ Tourniquet: 3–4 inches above intended venipuncture site.
■ Choose vein: Most common and easily accessed are median cubital, cephalic, and basilic veins located in antecubital (AC) fossa anterior to elbow. Veins of forearm, wrist, and hand may also be used but are smaller and often more painful.
■ Cleanse site: Briefly remove tourniquet. With alcohol swab, cleanse site from center outward, using a circular motion. Allow site to air dry for 30–60 seconds. For blood alcohol level and blood culture specimens, use iodine in place of alcohol.
■ Perform venipuncture: Reapply the tourniquet. If necessary, cleanse end of gloved finger for additional vein palpation. Insert needle, bevel up, at 15–30 degrees using dominant hand. With nondominant hand, push evacuated collection tube completely into needle holder or pull back on syringe plunger with slow, consistent tension.
■ Remove tourniquet: If procedure will last longer than 1 minute, remove tourniquet after blood begins to flow.
■ Remove needle: Remove tourniquet if still in place. Place sterile gauze over puncture site, remove needle, and apply pressure.
■ Equipment disposal: Per facility policy/standard precautions.
■ Prepare specimen: If using syringes, transfer specimen into proper tubes. Mix additives with gentle rolling motion. Label specimen tubes with Pt’s name, ID number, date, time, and your initials.
■ Document: Record specimen collection in medical record.
2/21/14
Orders of Assembling Patients Chart
a. History sheet
b. Personal and social data
c. Order sheet
d. Doctor’s progress notes
e. Nurses notes
f. Vital sign sheet (graphics)
g. Intake and output recording sheet
h. Laboratory and other diagnostic reports
• Patients or relatives and friends of patients are not allowed to read the chart when necessary but can have access if allowed by patient.
Intake and out put
a. Intake: all fluids that is taken in to the body through the mouth, NG tube or parentrally
b. Output: all fluid that is excreted or put out of the body through the mouth. N/G tube, urethra, drainage tube or other route (GI-diarrhea, vomiting).
Purpose:
• To replace fluid losses
• To provide maintenance requirements
• To check for retention of body fluid
Fluid balance sheet
♦ 24 hrs the intake out put should be compared and the balance is recorded
Positive balance if intake >output
Negative balance if out put >intake
Study Questions
1. Explain at least three reasons for laboratory examination of urine.
2. Explain at least one reason for collecting specimens like sputum, blood or stool.
3. Mention purposes for sputum specimen collection.
4. Describe the process how to draw venous blood for laboratory investigation.
5. How can you obtain sterile urine specimen?
6. Differentiate between signs and symptoms.
Read More
b. Personal and social data
c. Order sheet
d. Doctor’s progress notes
e. Nurses notes
f. Vital sign sheet (graphics)
g. Intake and output recording sheet
h. Laboratory and other diagnostic reports
• Patients or relatives and friends of patients are not allowed to read the chart when necessary but can have access if allowed by patient.
Intake and out put
a. Intake: all fluids that is taken in to the body through the mouth, NG tube or parentrally
b. Output: all fluid that is excreted or put out of the body through the mouth. N/G tube, urethra, drainage tube or other route (GI-diarrhea, vomiting).
Purpose:
• To replace fluid losses
• To provide maintenance requirements
• To check for retention of body fluid
Fluid balance sheet
♦ 24 hrs the intake out put should be compared and the balance is recorded
Positive balance if intake >output
Negative balance if out put >intake
Study Questions
1. Explain at least three reasons for laboratory examination of urine.
2. Explain at least one reason for collecting specimens like sputum, blood or stool.
3. Mention purposes for sputum specimen collection.
4. Describe the process how to draw venous blood for laboratory investigation.
5. How can you obtain sterile urine specimen?
6. Differentiate between signs and symptoms.
General Rules for Charting
• Spelling
- Make certain you spell correctly
• Accuracy
- Records must be correct in all ways, be honest
• Completeness
- No omission, avoid unnecessary words or statement
• Exactness
- Do not use a word you are not sure of
• Objective information
- Record what you see avoid saying (condition better)
• Legibility
- Print/write plainly and distinctively as possible
• Neatness
- No wrinkles, proper speaking of items
- Place all abbreviation, and at end of statement
• Composition / arrangement
- Chart carefully consult if in doubt avoid using of
- chemical formulas
• Sentences need to be complete and clear, avoid repetition
• Don’t overwrite
• Don’t leave empty spaces in between
• Time of charting
- Specific time and date
• Color of ink
- Black or blue (red for transfusion, days of surgery)
It should be recorded on the graphic sheet All orders should be written and signed. Verbal or telephone orders should be taken only in emergency verbal orders should be written in the order sheet and signed on the next visit.
Read More
- Make certain you spell correctly
• Accuracy
- Records must be correct in all ways, be honest
• Completeness
- No omission, avoid unnecessary words or statement
• Exactness
- Do not use a word you are not sure of
• Objective information
- Record what you see avoid saying (condition better)
• Legibility
- Print/write plainly and distinctively as possible
• Neatness
- No wrinkles, proper speaking of items
- Place all abbreviation, and at end of statement
• Composition / arrangement
- Chart carefully consult if in doubt avoid using of
- chemical formulas
• Sentences need to be complete and clear, avoid repetition
• Don’t overwrite
• Don’t leave empty spaces in between
• Time of charting
- Specific time and date
• Color of ink
- Black or blue (red for transfusion, days of surgery)
It should be recorded on the graphic sheet All orders should be written and signed. Verbal or telephone orders should be taken only in emergency verbal orders should be written in the order sheet and signed on the next visit.
Observations and Recording of Signs and Symptoms of the Patient
1. Objective Symptoms (signs):
• Are symptoms, which could be seen by the health personnel?
E.g. swelling, redness, rash, body discharges (defecation, diaphoresis, emesis,)
2. Subjective Symptoms:
Are symptoms, which are felt by the patient
E.g. decrease of appetite, dizziness, deafness, burning sensation, nausea, etc
3. Chart
Definition: it is a written record of history, examination, tests, diagnosis, and prognosis response to therapy
Purpose of Patients Chart
a. For diagnosis or treatment of a patient while in the hospital (find after discharge) if patient returns for treatment in the future time
b. For maintaining accurate data on matters demanded by courts
c. For providing material for research
d. For serving an information in the education of health personnel (medical students, interns, nurses, dietitians, etc)
e. For securing needed vital statistics
f. For promoting public health
Read More
• Are symptoms, which could be seen by the health personnel?
E.g. swelling, redness, rash, body discharges (defecation, diaphoresis, emesis,)
2. Subjective Symptoms:
Are symptoms, which are felt by the patient
E.g. decrease of appetite, dizziness, deafness, burning sensation, nausea, etc
3. Chart
Definition: it is a written record of history, examination, tests, diagnosis, and prognosis response to therapy
Purpose of Patients Chart
a. For diagnosis or treatment of a patient while in the hospital (find after discharge) if patient returns for treatment in the future time
b. For maintaining accurate data on matters demanded by courts
c. For providing material for research
d. For serving an information in the education of health personnel (medical students, interns, nurses, dietitians, etc)
e. For securing needed vital statistics
f. For promoting public health
Collecting Blood Specimen
The hospital laboratory technicians obtain most routine blood specimens. Venous blood is drown for most tests, but arterial blood is drawn for blood gas measurements. However, in some setting nurses draw venous blood.
Purpose
Specimen of venous blood are taken for complete blood count, which includes
• Hemoglobin and hemotocrit measurements
• Erythrocytes (RBC) count
• Leukocytes (WBC) count
• Differential counts
Equipment
• Sterile gloves
• Tourniquet
• Antiseptic swabs
• Dry cotton (gauze)
• Needle and syringe
• Specimen container with the required diluting or preservative agents, for example: anticoagulant.
• Identification/ labeling: name, age address, etc.
• Laboratory requisition forms
Procedure
1. Patient preparation
• Instruct the pt what to expect and for fasting (if required)
• Position the pt comfortably
2. Select and prepare the vein sites to be punctured
• Put on gloves
• Select the vein to be punctured. Usually the large superficial veins used such as, brachial and median cubital veins.
• Place the veins in dependent positions
• Apply tourniquet firmly 15-20 cm about the selected sites. It must be tight enough to obstruct vein blood flow, but not to occlude arterial blood flow.
• If the vein is not sufficiently to dilate massage (stroke) the vein from the distal towards the site or encourage the pt to clench and unclench repeatedly.
• Clean the punctured site using antiseptic swabs
3. Obtain specimen of the venous to blood
• Adjust the syringe and needles
• Clean/disinfect the area with alcohol swab, dry with sterile cotton swab
• Puncture the vein sites
• Release the tourniquet when you are sure in the vein
• Withdraw the required amount of venous blood specimen
• Withdraw the needle and hold the sites with dry cotton (to apply pressure)
• Put the blood into the specimen container
• Made sure not to contaminate outer part of the container and not to distract the blood cells while putting it into the container
4. Recomfort the patient
5. Care of the specimen and the equipment
• Label the container
• Shake gently (if indicated to mix)
• Send immediately to laboratory, accompanying the request
• Give care of used equipments
6. Documentation and reporting
Read More
Purpose
Specimen of venous blood are taken for complete blood count, which includes
• Hemoglobin and hemotocrit measurements
• Erythrocytes (RBC) count
• Leukocytes (WBC) count
• Differential counts
Equipment
• Sterile gloves
• Tourniquet
• Antiseptic swabs
• Dry cotton (gauze)
• Needle and syringe
• Specimen container with the required diluting or preservative agents, for example: anticoagulant.
• Identification/ labeling: name, age address, etc.
• Laboratory requisition forms
Procedure
1. Patient preparation
• Instruct the pt what to expect and for fasting (if required)
• Position the pt comfortably
2. Select and prepare the vein sites to be punctured
• Put on gloves
• Select the vein to be punctured. Usually the large superficial veins used such as, brachial and median cubital veins.
• Place the veins in dependent positions
• Apply tourniquet firmly 15-20 cm about the selected sites. It must be tight enough to obstruct vein blood flow, but not to occlude arterial blood flow.
• If the vein is not sufficiently to dilate massage (stroke) the vein from the distal towards the site or encourage the pt to clench and unclench repeatedly.
• Clean the punctured site using antiseptic swabs
3. Obtain specimen of the venous to blood
• Adjust the syringe and needles
• Clean/disinfect the area with alcohol swab, dry with sterile cotton swab
• Puncture the vein sites
• Release the tourniquet when you are sure in the vein
• Withdraw the required amount of venous blood specimen
• Withdraw the needle and hold the sites with dry cotton (to apply pressure)
• Put the blood into the specimen container
• Made sure not to contaminate outer part of the container and not to distract the blood cells while putting it into the container
4. Recomfort the patient
5. Care of the specimen and the equipment
• Label the container
• Shake gently (if indicated to mix)
• Send immediately to laboratory, accompanying the request
• Give care of used equipments
6. Documentation and reporting
Collecting sputum specimen
Sputum is the mucus secretion from the lungs, bronchi and trachea, but it is different from saliva. The best time for sputum specimen collection is in the mornings up on the patient’s awaking (that have been accumulated during the night). If the patient fails to cough out, the nurse can obtain sputum specimen by aspirating pharyngeal secretion using suction.
Purpose
Sputum specimen usually collected for:
• Culture and sensitivity test (i.e. to identify the microorganisms and sensitive drugs for it)
• Cytological examination
• Acid fast bacillus (AFB) tests
• Assess the effectiveness of the therapy
Equipments Required
• Disposable gloves
• Specimen container
• Laboratory requisition form
• Mouth care (wash) tray
Procedure
1. Patient preparation
• Before collecting sputum specimen, teach pt about the difference between sputum and saliva, how to cough deeply to raise sputum.
• Position the patient, usually sitting up position and splinting may help. Also postural drainage can be used.
• Give oral care, to avoid sputum contamination with microorganisms of the mouth. Avoid using tooth past because it alter the result.
2. Obtain sputum specimen
• Put on gloves, to avoid contact with sputum particularly it hemoptysis (blood in sputum) present.
• Ask pt to cough deeply to raise up sputum
• Take usually about 15-30 ml sputum
• Ask pt to spit out the sputum into the specimen container
• Make sure it doesn't contaminate the outer part of the container. If contaminated clean (wash) with disinfectant
• Cover the cape tightly on the container
3. Recomfort the patient
• Give oral care following sputum collection (To remove any unpleasant taste)
4. Care of the specimen and the equipments used
• Label the specimen container
• Arrange or send the specimen promptly and immediately to laboratory.
• Give proper care of equipments used
5. Document the amount, color, consistency of sputum, (thick, watery, tenacious) and presence of blood in the sputum.
Read More
Purpose
Sputum specimen usually collected for:
• Culture and sensitivity test (i.e. to identify the microorganisms and sensitive drugs for it)
• Cytological examination
• Acid fast bacillus (AFB) tests
• Assess the effectiveness of the therapy
Equipments Required
• Disposable gloves
• Specimen container
• Laboratory requisition form
• Mouth care (wash) tray
Procedure
1. Patient preparation
• Before collecting sputum specimen, teach pt about the difference between sputum and saliva, how to cough deeply to raise sputum.
• Position the patient, usually sitting up position and splinting may help. Also postural drainage can be used.
• Give oral care, to avoid sputum contamination with microorganisms of the mouth. Avoid using tooth past because it alter the result.
2. Obtain sputum specimen
• Put on gloves, to avoid contact with sputum particularly it hemoptysis (blood in sputum) present.
• Ask pt to cough deeply to raise up sputum
• Take usually about 15-30 ml sputum
• Ask pt to spit out the sputum into the specimen container
• Make sure it doesn't contaminate the outer part of the container. If contaminated clean (wash) with disinfectant
• Cover the cape tightly on the container
3. Recomfort the patient
• Give oral care following sputum collection (To remove any unpleasant taste)
4. Care of the specimen and the equipments used
• Label the specimen container
• Arrange or send the specimen promptly and immediately to laboratory.
• Give proper care of equipments used
5. Document the amount, color, consistency of sputum, (thick, watery, tenacious) and presence of blood in the sputum.
Collecting a Timed Urine Specimen
Purpose
• For some tests of renal functions and urine compositions, such as:- measuring the level of or hormones, such as adrenocortico steroid hormone creatinine clearance or protein quantitation tests.
Equipments Required
• Urine specimen collecting materials (usually obtained from the laboratory and kept in the patient's bathroom.)
• Format for recording the time, date started and end, and the amount of urine collected on each patient's voiding during the specified period for collection.
Procedure
1. Patient preparation
• Adequate explanation to the patient about the purpose of the test, when it begins and what to do with the urine
• Place alert signs about the specimen collection at the patient's bedside or bathroom.
• Label the specimen container to include date and time of each voiding as well as patient's identification data
• Containers may be numbered sequentially (e.g. 1st, 2nd, 3rd etc) in case of 24-hours urine collection.
2. Collecting the urine
• Usually it begin in the morning
• Before you begin the timing, the patient should void and do not use this urine (It is the urine that has been in the bladder some time)
• Then all urine voided during the specified time (e.g. the next 24 hours) is collected in the container
• At the end of the time (e.g. 24 hours period) the patient should void the last specimen, which is added to the rest.
• Ensure that urine is free of feces
Read More
• For some tests of renal functions and urine compositions, such as:- measuring the level of or hormones, such as adrenocortico steroid hormone creatinine clearance or protein quantitation tests.
Equipments Required
• Urine specimen collecting materials (usually obtained from the laboratory and kept in the patient's bathroom.)
• Format for recording the time, date started and end, and the amount of urine collected on each patient's voiding during the specified period for collection.
Procedure
1. Patient preparation
• Adequate explanation to the patient about the purpose of the test, when it begins and what to do with the urine
• Place alert signs about the specimen collection at the patient's bedside or bathroom.
• Label the specimen container to include date and time of each voiding as well as patient's identification data
• Containers may be numbered sequentially (e.g. 1st, 2nd, 3rd etc) in case of 24-hours urine collection.
2. Collecting the urine
• Usually it begin in the morning
• Before you begin the timing, the patient should void and do not use this urine (It is the urine that has been in the bladder some time)
• Then all urine voided during the specified time (e.g. the next 24 hours) is collected in the container
• At the end of the time (e.g. 24 hours period) the patient should void the last specimen, which is added to the rest.
• Ensure that urine is free of feces
Collecting Urine Specimen
Types of urine specimen collection
1. Clean voided urine specimen (Also called clean catch or midstream urine specimen)
2. Sterile urine specimen
3. Timed urine specimen
• It is two types
Short period → 1-2 hours
Long period → 24 hours
Purpose
• For diagnostic purposes
- Routine laboratory analysis and culture and sensitivity tests
Equipments Required
• Disposable gloves
• Specimen container
• Laboratory requisition form (Completely filled)
• Water and soap or cotton balls and antiseptic solutions (swabs).
For patients confined
• Urine receptacles (i.e. bedpan or urinals)
• Bed protecting materials
• Screen (if required)
Procedure
For ambulatory patients
Give adequate instruction to the patient about
• The purpose and method of taking specimen
• Assist the patient to move to the toilet
For patient confined in bed
1. Prepare the patient unit providing privacy
2. Prepare the patient
• Put on gloves
• Place bed protecting materials under patient's hips
• Assist the patient to position in bed and in positioning the receptacles
• Assist the patient or clean the vulva or penis thoroughly using soap and water or antiseptic swabs (Follow the steps of giving and receiving bed pan/urinal and cleaning the genitalia)
3. Obtain urine specimen
• Ask patient to void
• Let the initial part of the voiding passed into the receptacle (bed pan or urinal) then pass the next part (the midstream) into the specimen container.
• Hold the vulva or penis apart from the specimen container while the patient voids to decrease urine contamination.
• Don't allow the container to touch body parts
• Collect about 30-60 ml midstream urine
• Handle the outside parts of the container and put on the cover tightly on specimen container
• Clean the outside parts of the container with cotton if spillage occurs
• Remove the glove
4. Recomfort the patient
5. Care of the specimen and the equipment
• Handle and label the container correctly
• Send the urine specimen to the laboratory immediately together with the completed laboratory requested forms
• Empty the receptacles content properly
• Give appropriate care for the used equipments
6. Document pertinent data and report, such as
• Specimen collected, amount, time and date.
• Consistency of the urine
• Patients experience during voiding
Sterile urine specimen
collected using a catheter in aseptic techniques (The whole discussion for this procedure presented on the catheterization part)
Read More
1. Clean voided urine specimen (Also called clean catch or midstream urine specimen)
2. Sterile urine specimen
3. Timed urine specimen
• It is two types
Short period → 1-2 hours
Long period → 24 hours
Purpose
• For diagnostic purposes
- Routine laboratory analysis and culture and sensitivity tests
Equipments Required
• Disposable gloves
• Specimen container
• Laboratory requisition form (Completely filled)
• Water and soap or cotton balls and antiseptic solutions (swabs).
For patients confined
• Urine receptacles (i.e. bedpan or urinals)
• Bed protecting materials
• Screen (if required)
Procedure
For ambulatory patients
Give adequate instruction to the patient about
• The purpose and method of taking specimen
• Assist the patient to move to the toilet
For patient confined in bed
1. Prepare the patient unit providing privacy
2. Prepare the patient
• Put on gloves
• Place bed protecting materials under patient's hips
• Assist the patient to position in bed and in positioning the receptacles
• Assist the patient or clean the vulva or penis thoroughly using soap and water or antiseptic swabs (Follow the steps of giving and receiving bed pan/urinal and cleaning the genitalia)
3. Obtain urine specimen
• Ask patient to void
• Let the initial part of the voiding passed into the receptacle (bed pan or urinal) then pass the next part (the midstream) into the specimen container.
• Hold the vulva or penis apart from the specimen container while the patient voids to decrease urine contamination.
• Don't allow the container to touch body parts
• Collect about 30-60 ml midstream urine
• Handle the outside parts of the container and put on the cover tightly on specimen container
• Clean the outside parts of the container with cotton if spillage occurs
• Remove the glove
4. Recomfort the patient
5. Care of the specimen and the equipment
• Handle and label the container correctly
• Send the urine specimen to the laboratory immediately together with the completed laboratory requested forms
• Empty the receptacles content properly
• Give appropriate care for the used equipments
6. Document pertinent data and report, such as
• Specimen collected, amount, time and date.
• Consistency of the urine
• Patients experience during voiding
Sterile urine specimen
collected using a catheter in aseptic techniques (The whole discussion for this procedure presented on the catheterization part)
Collecting Stool Specimen
Purpose
• For laboratory diagnosis, such as microscopic examination, culture and sensitivity tests.
Equipments required
◘ Clean bedpan or commode
◘ Wooden spatula or applicator
◘ Specimen container
◘ Tissue paper
◘ Laboratory requests
◘ Disposable glove, for patients confined in bed
◘ Bed protecting materials
◘ Screen
Procedure
For ambulatory patient
Give adequate instruction to the patient to
• Defecate in clean bedpan or commode (toilet)
• Avoid contaminating the specimen by urine, menstrual period or used tissue papers, because these may affect the laboratory analysis.
• Void before collecting the specimen
• Transfer the sample (specimen) to the container using spatula or applicator
For patients confined in bed
1. Prepare the patient's unit
• Provide privacy by drawing screen, closing windows and doors (To provide privacy)
2. Prepare the patient
• Put on gloves
• Position the patient
• Place bed protecting materials under the patient's hips
• Assist the patient and place the bed pan under the patient's buttocks (follow the steps under "Giving and removing bedpan")
• Give patient privacy by leaving alone, but not far
• Instruct the patient about how to notify you when finished defecation.
• Remove the bedpan and keep on safe place by covering it
• Recomfort the patient
3. Obtain stool sample
• Take the used bedpan to utility room/toilet container using spatula or applicator without contaminating the outside of the container.
• The amount of stool specimen to be taken depends on the purpose, but usually takes.
o 3.5 gm sample from formed stool
o 15.30 ml sample from liquid stool
• Visible mucus, pus or blood should be included into sample stool specimen taken.
4. Care of equipments and the specimen collected.
• Handle and label the specimen correctly
• Send the specimen to the laboratory immediately, unless there is an order for its handling. Because fresh specimen provides the most accurate results.
• Dispose the bedpan's content and give proper care of all equipments used.
5. Documentation and report
Read More
• For laboratory diagnosis, such as microscopic examination, culture and sensitivity tests.
Equipments required
◘ Clean bedpan or commode
◘ Wooden spatula or applicator
◘ Specimen container
◘ Tissue paper
◘ Laboratory requests
◘ Disposable glove, for patients confined in bed
◘ Bed protecting materials
◘ Screen
Procedure
For ambulatory patient
Give adequate instruction to the patient to
• Defecate in clean bedpan or commode (toilet)
• Avoid contaminating the specimen by urine, menstrual period or used tissue papers, because these may affect the laboratory analysis.
• Void before collecting the specimen
• Transfer the sample (specimen) to the container using spatula or applicator
For patients confined in bed
1. Prepare the patient's unit
• Provide privacy by drawing screen, closing windows and doors (To provide privacy)
2. Prepare the patient
• Put on gloves
• Position the patient
• Place bed protecting materials under the patient's hips
• Assist the patient and place the bed pan under the patient's buttocks (follow the steps under "Giving and removing bedpan")
• Give patient privacy by leaving alone, but not far
• Instruct the patient about how to notify you when finished defecation.
• Remove the bedpan and keep on safe place by covering it
• Recomfort the patient
3. Obtain stool sample
• Take the used bedpan to utility room/toilet container using spatula or applicator without contaminating the outside of the container.
• The amount of stool specimen to be taken depends on the purpose, but usually takes.
o 3.5 gm sample from formed stool
o 15.30 ml sample from liquid stool
• Visible mucus, pus or blood should be included into sample stool specimen taken.
4. Care of equipments and the specimen collected.
• Handle and label the specimen correctly
• Send the specimen to the laboratory immediately, unless there is an order for its handling. Because fresh specimen provides the most accurate results.
• Dispose the bedpan's content and give proper care of all equipments used.
5. Documentation and report
General Considerations for Specimen Collection
When collecting specimen, wear gloves to protect self from contact with body fluids.
1. Get request for specimen collection and identify the types of specimen being collected and the patient from which the specimen collected.
2. Give adequate explanation to the patient about the purpose, type of specimen being collected and the method used.
3. Assemble and organize all the necessary materials for the specimen collection.
4. Get the appropriate specimen container and it should be clearly labeled have tight cover to seal the content and placed in the plastic bag or racks, so that it protects the laboratory technician from contamination while handling it.
• The patient's identification such as, name, age, card number, the ward and bed number (if in-patient).
• The types of specimen and method used (if needed).
• The time and date of the specimen collected.
6. Put the collected specimen into its container without contaminating outer parts of the container and its cover. All the specimens should be sent promptly to the laboratory, so that the temperature and time changes do not alter the content.
Read More
1. Get request for specimen collection and identify the types of specimen being collected and the patient from which the specimen collected.
2. Give adequate explanation to the patient about the purpose, type of specimen being collected and the method used.
3. Assemble and organize all the necessary materials for the specimen collection.
4. Get the appropriate specimen container and it should be clearly labeled have tight cover to seal the content and placed in the plastic bag or racks, so that it protects the laboratory technician from contamination while handling it.
• The patient's identification such as, name, age, card number, the ward and bed number (if in-patient).
• The types of specimen and method used (if needed).
• The time and date of the specimen collected.
6. Put the collected specimen into its container without contaminating outer parts of the container and its cover. All the specimens should be sent promptly to the laboratory, so that the temperature and time changes do not alter the content.
Specimen Collection
Learning Objectives:
At the end of this chapter, students will be able to:
• Identify at least three reasons for laboratory examination of urine.
• Demonstrate correct collection of the following urine specimens: midstream, 24-hours, fractional, and indwelling urine catheter.
• Explain at least one reason for collecting specimen like sputum, blood or stool.
• Demonstrate correct collection of a stool specimen.
• Demonstrate correct collection of a sputum specimen.
Key Terminology:
Hemoglobine
Hematocrite
Leukocyte
Occult
Stroke
Urinalysis
Specimen Collection:
refers to collecting various specimens (samples), such as, stool, urine, blood and other body fluids or tissues, from the patient for diagnostic or therapeutic purposes. Various types of specimen collected from the patient in the clinical settings, either in out patient departments (OPD) or in-patient units, for diagnostic and therapeutic purposes. These includes, stool, urine, blood and other body fluid or tissue specimens.
Read More
At the end of this chapter, students will be able to:
• Identify at least three reasons for laboratory examination of urine.
• Demonstrate correct collection of the following urine specimens: midstream, 24-hours, fractional, and indwelling urine catheter.
• Explain at least one reason for collecting specimen like sputum, blood or stool.
• Demonstrate correct collection of a stool specimen.
• Demonstrate correct collection of a sputum specimen.
Key Terminology:
Hemoglobine
Hematocrite
Leukocyte
Occult
Stroke
Urinalysis
Specimen Collection:
refers to collecting various specimens (samples), such as, stool, urine, blood and other body fluids or tissues, from the patient for diagnostic or therapeutic purposes. Various types of specimen collected from the patient in the clinical settings, either in out patient departments (OPD) or in-patient units, for diagnostic and therapeutic purposes. These includes, stool, urine, blood and other body fluid or tissue specimens.
Assessing Blood pressure
Purpose
◘ To obtain base line measure of arterial blood pressure for subsequent evaluation
◘ To determine the clients homodynamic status
◘ To identify and monitor changes in blood pressure resulting from a disease process and medical therapy.
EQUEPMENT
◘ Stethoscope
◘ Blood pressure cuff of the appropriate size
◘ Sphygmomanometer
Procedure
1. Prepare and position the patient appropriately
• Make sure that the client has not smoked or ingested caffeine, with in 30 minutes prior to measurement.
• Position the patient in sitting position, unless otherwise specified. The arm should be slightly flexed with the palm of the hand facing up and the fore arm supported at heart level
• Expose the upper arm
2. Wrap the deflated cuff evenly around the upper arm.
• Apply the center of the bladder directly over the medial aspect of the arm. The bladder inside the cuff must be directly over the artery to be compressed if the reading to be accurate.
• For adult, place the lower border of the cuff approximately 2 cm above antecubital space.
3. For initial examination, perform preliminary palipatory determination of systolic pressure
• Palpate the brachial artery with the finger tips
• Close the valve on the pump by turning the knob clockwise.
• Pump up the cuff until you no longer feel the brachial pulse
• Note the pressure on sphygmomanometer at which the pulse is no longer felt
• Release the pressure completely in the cuff, and wait 1 to 2 minutes before making further measurement
4. Position the stethoscope appropriately
• Insert the ear attachments of the stethoscope in your ears so that they tilt slightly fore ward.
• Place the diaphragm of the stethoscope over the brachial pulse; hold the diaphragm with the thumb and index finger.
5. Auscultate the client's blood pressure
• Pump up the cuff until the sphygmomanometer registers about 30 mm Hg above the point where the brachial pulse disappeared.
• Release the valve on the cuff carefully so that the pressure decreases at the rate 2-3 mmHg per second.
• As the pressure falls, identify the manometer reading at each of the five phases
• Deflate the cuff rapidly and completely
• Repeat the above step once or twice as necessary to confirm the accuracy of the reading.
6. Remove the cuff from the client’s arm
7. For initial determination, repeat the procedure on the client's other arm, there should be a difference of no more than 5 to 10 mmHg between the arms. The arm found to have the higher pressure, should be used for subsequent examinations
8. Document and report pertinent assessment data, report any significant change in client's blood pressure to the nurse in charge. Also report these finding:
A. Systolic blood pressure (of adult) above 140 mmHg.
B. Diastolic blood pressure (of an adult) above 90 mmHg
C. Systolic blood pressure of (an adult) below 100mmHg
Study questions
1. Explain vital sings and list what it includes.
2. Identify important times to assess vital signs.
3. Mention some of the factors affecting body temperature.
4. What does pulse deficit mean?
5. Define arterial blood pressure.
6. Explain the two methods of assessing blood pressure.
Read More
◘ To obtain base line measure of arterial blood pressure for subsequent evaluation
◘ To determine the clients homodynamic status
◘ To identify and monitor changes in blood pressure resulting from a disease process and medical therapy.
EQUEPMENT
◘ Stethoscope
◘ Blood pressure cuff of the appropriate size
◘ Sphygmomanometer
Procedure
1. Prepare and position the patient appropriately
• Make sure that the client has not smoked or ingested caffeine, with in 30 minutes prior to measurement.
• Position the patient in sitting position, unless otherwise specified. The arm should be slightly flexed with the palm of the hand facing up and the fore arm supported at heart level
• Expose the upper arm
2. Wrap the deflated cuff evenly around the upper arm.
• Apply the center of the bladder directly over the medial aspect of the arm. The bladder inside the cuff must be directly over the artery to be compressed if the reading to be accurate.
• For adult, place the lower border of the cuff approximately 2 cm above antecubital space.
3. For initial examination, perform preliminary palipatory determination of systolic pressure
• Palpate the brachial artery with the finger tips
• Close the valve on the pump by turning the knob clockwise.
• Pump up the cuff until you no longer feel the brachial pulse
• Note the pressure on sphygmomanometer at which the pulse is no longer felt
• Release the pressure completely in the cuff, and wait 1 to 2 minutes before making further measurement
4. Position the stethoscope appropriately
• Insert the ear attachments of the stethoscope in your ears so that they tilt slightly fore ward.
• Place the diaphragm of the stethoscope over the brachial pulse; hold the diaphragm with the thumb and index finger.
5. Auscultate the client's blood pressure
• Pump up the cuff until the sphygmomanometer registers about 30 mm Hg above the point where the brachial pulse disappeared.
• Release the valve on the cuff carefully so that the pressure decreases at the rate 2-3 mmHg per second.
• As the pressure falls, identify the manometer reading at each of the five phases
• Deflate the cuff rapidly and completely
• Repeat the above step once or twice as necessary to confirm the accuracy of the reading.
6. Remove the cuff from the client’s arm
7. For initial determination, repeat the procedure on the client's other arm, there should be a difference of no more than 5 to 10 mmHg between the arms. The arm found to have the higher pressure, should be used for subsequent examinations
8. Document and report pertinent assessment data, report any significant change in client's blood pressure to the nurse in charge. Also report these finding:
A. Systolic blood pressure (of adult) above 140 mmHg.
B. Diastolic blood pressure (of an adult) above 90 mmHg
C. Systolic blood pressure of (an adult) below 100mmHg
Study questions
1. Explain vital sings and list what it includes.
2. Identify important times to assess vital signs.
3. Mention some of the factors affecting body temperature.
4. What does pulse deficit mean?
5. Define arterial blood pressure.
6. Explain the two methods of assessing blood pressure.
Methods of Measuring Blood Pressure
Blood pressure can be assessed directly or indirectly
1. Direct (invasive monitoring) measurement involves the insertion of catheter in to the brachial, radial, or femoral artery. The physician inserts the catheter and the nurse monitors the pressure reading. With use of correct placement, it is highly accurate.
1. Indirect (non invasive methods)
A. The auscultatory
B. The palpatory, and
The auscultatory method is the commonest method used in health activities. When taking blood pressure using stethoscope, the nurse identifies five phases in series of sounds called Korotkoff's sound.
Phase 1: The pressure level at which the 1st joint clear tapping sound is heard, these sounds gradually become more intense. To ensure that they are not extraneous sounds, the nurse should identify at least two consecutive tapping sounds.
Phase 2: The period during deflation when the sound has a swishing quality
Phase 3: The period during which the sounds are crisper and more intense
Phase 4: The time when the sounds become muffled and have a soft blowing quality
Phase 5: The pressure level when the sounds disappear
Read More
1. Direct (invasive monitoring) measurement involves the insertion of catheter in to the brachial, radial, or femoral artery. The physician inserts the catheter and the nurse monitors the pressure reading. With use of correct placement, it is highly accurate.
1. Indirect (non invasive methods)
A. The auscultatory
B. The palpatory, and
The auscultatory method is the commonest method used in health activities. When taking blood pressure using stethoscope, the nurse identifies five phases in series of sounds called Korotkoff's sound.
Phase 1: The pressure level at which the 1st joint clear tapping sound is heard, these sounds gradually become more intense. To ensure that they are not extraneous sounds, the nurse should identify at least two consecutive tapping sounds.
Phase 2: The period during deflation when the sound has a swishing quality
Phase 3: The period during which the sounds are crisper and more intense
Phase 4: The time when the sounds become muffled and have a soft blowing quality
Phase 5: The pressure level when the sounds disappear
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