Student id 2010002610

A multitude of assessments are performed every time a nurse sees a client/patient. When a patient is first presented to a nurse the assessments begin. By observing their skin colour, turgor, and the general condition of the skin, vital signs, what the client has come in for, what sort of lifestyle they have along with their mental state including mood, and emotional state (basic nursing assessments, 2008). How the client comprehends what is happening to them and how the hospital environment, doctors surgery, or home affects the patient is all part of assessing a client (Mosbys Medical Dictionary 8th ed, 2009). It is imperative that the assessments are completed properly and accurately, the data collected can then be collated and used to devise an appropriate nursing care plan (Basic nursing assessment, 2008). The appearance of a client can tell you a lot about the condition of that person, for instance the colour of their skin. Cyanosis can cause skin to be bluish mainly around the mouth, tongue, and under finger and toe nails. This may indicate that there is a problem with the heart or the respiratory system and enough oxygen is not getting to cells. Yellow skin may mean that the liver is not functioning properly, causing jaundice. Anaemia, shock or a chronic infection could cause the skin to be pale or look grey. The skin turgor (the ability of the skin to revert back to its original state) if too loose and takes more than a few seconds to reform back to normal state will mean that the client is dehydrated; oedema could cause the skin to be tight and swollen (Basic nursing assessment,2008). Dry skin could indicate that the client may be malnourished or have an underlying medical condition such as diabetes, hypothyroidism or be a result of medications that they are taking. Smoking, alcohol, soaps, laundry powder, and environmental conditions are further reasons that a client may have dry skin (Hess, 2008). Assessing fingernails, toenails, and the condition of the hair can tell a nurse if the client is undernourished or will need further investigation (Johannsen, 2005). It is worth noting that eczema can often be linked with hay fever and asthma (Asthma and Eczema, 2009). The information that is gathered from the initial assessment of the client then is collated with the following assessments, the vital signs.

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Taking the vital signs is one of the most critical assessments that a nurse can do; the information gathered from taking the vital signs can tell the medical staff a lot about the client (Dugdale, 2011). There are five vital signs that are measured, one being blood pressure. Blood pressure is taken by using a sphygmomanometer and a stethoscope to see how hard the heart is working. The normal blood pressure range is between 120-140mmHg systolic and 60-90 diastolic. If blood pressure is above the normal rate, it is called hypertension. This can be caused by an illness such as an infection, but if the hypertension is on-going and not managed it can cause a heart attack, stroke or kidney failure and blindness (Rosman, 2010). If the client has hypotension, their blood pressure is too low and can suggest that they have poor nutrition and low vitamin levels or there may be a problem with the adrenal gland. Symptoms of hypotension can include dizziness, fainting, lack of endurance, sensitivity to heat and cold and anaemia (Blood Pressure Low, 2011). The second is temperature: tympanic temperature is normally taken by placing a tympanic thermometer in the ear for a few seconds (Nursing Journal, 2007). The normal range is between 36.4 to 37.5 degrees Celsius. Extreme cold is the most common reason for hypothermia (low temperature) but the following illnesses can also lead to hypothermia: Hepatitis C, thyroid problems, sepsis, pneumonia, liver disease, adrenal problems, and anaemia (Shandilya, 2010). Some main reasons for pyrexia (high temperature over 37.5 degrees Celsius ) and hyperpyrexia (extremely high temperature over 41.1 degrees Celsius) are as follows: extremely hot environmental conditions, viral or bacterial infections, hormonal imbalance, exercise, and injury to the hypothalamus which is the part of the brain that regulates the bodys temperature (Normal body temperature, 2011). The pulse is the next vital sign that is taken. The radial pulse is normally the best way to take the reading, and can be taken by pushing the radial artery on the radius bone on the distal side of the wrist, when in anatomical position (How to take your pulse, 2009). The strength, speed, and consistency of the pulse can tell a nurse about the hearts performance. Bradycardia means that the heart rate is below 50 beats per minute. Some reasons for bradycardia include massive loss of blood and the client may be going into shock, or is on medication that causes the
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heart beat to slow down (What is sinus bradycardia, 2010). Tachycardia or rapid heartbeat can mean an infection is present. The client is very distressed or has just undertaken vigorous exercise. Dizziness, fainting, chest pain, or shortness of breath can be symptoms of both bradycardia, and tachycardia (Tachycardia, 2011). Respiratory rate is simply taken by observing the rise and fall off the clients chest and/or stomach for one minute. The normal range for the respiratory rate for an adult is between 12 and 20 breaths per minute (Duty, 2009). Dyspnoea, difficulty in breathing, may be caused by heart disease, obstruction in the respiratory tract, chronic obstructive pulmonary disease, alternatively known as COPD which includes bronchitis, and emphysema. Lung infections can also cause dyspnoea. Hyperventilation, rapid breathing, can lead to dizziness, fainting, numbness of fingers and toes (Mosbys Medical Dictionary, 2009). Some causes of hyperventilation are asthma, fever, infections, early emphysema, head injuries, drugs and acute anxiety (World Health Organization, 2010). Oxygen saturations can be taken to assess how much oxygen the haemoglobin is carrying in the clients arterial bloodstream. A pulse oximeter is use to get the arterial oxygen saturation by placing a peg-like device on the clients thumb that shines a infer-red light through the clients tissues and veins to get the reading(Saunders, 2001). The reading should be 95% saturation or over. If the reading is below 95%, the client is not getting enough oxygen to the cells in the body, and tissues and organs are not performing properly (Dash, 2008). Signs of hypoxemia include restlessness, fatigue, headache, confusion and disorientation (Webster, 1999). With the vital signs completed, the nurse can assess the clients mood and emotional state. Often a client will feel apprehensive, nervous, or worried about their condition and being in an unfamiliar environment, in most cases when first presented to a nurse. There are many reasons a client may be seen by a nurse: illness, injury, or abuse, or simply wanting some advice. Communication, listening to the client and having empathy (being able to understand how the client is feeling), and being able to relate those feelings back to the client play a vital role in
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maintaining a good emotional state. A cross sectional study completed in 2008 that involved 1.7 million people showed that clients that are treated with respect and well cared for emotionally recover faster and with more satisfactory results then clients that receive bad emotional care. It is important to assess the clients emotional state so the nurse can adapt the care to the patient for example if the client is agitated the nurse will be able to use techniques to calm the client. Some simple techniques like holding the clients hand, a gentle reassuring voice, or simply smiling can help with the emotional wellbeing of a client (Raising positive expectations, 2008). There are multiple assessments made every time a nurse sees a client; these vary from client to client. Above are some initial assessments that are made and that are continued throughout the clients care. The importance of assessments and the information gathered from them has been included. Knowing how a client is feeling, and what their medical state is from completing the initial assessments, including the vital signs, emotional state, and general condition of the clients skin, helps the nurse to complete a care plan based on a mostly scientific basis, that will assist in the best outcome for the client.

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References Asthma and eczema. (2007). Retrieved May 26, 2011, from http://www.infantseczema.com Basic nursing assessment. (2008). Retrieved June 2, 2011, from http://medtrng.com Blood pressure low. (2010). Retrieved May 28, 2011, from http://www.healthy.co.nz COPD definition. (2010). Retrieved June 2, 2011, from http://www.who.int Dash, P. (2008). Reproductive and cardiovascular disease. Retrieved June 5, 2011, from http://www.sgul.ac.uk Dugdale, D. C. (2011). Vital signs. Retrieved May 28, 2011, from http://www.nlm.nih.gov Duty, M. (2009). About respiratory rate. Retrieved May 28, 2011, from http://www.ehow.com Johannsen, L. L. (2005). Skin assessment. Retrieved May 28, 2011, from http://medscape.comskin Hess, C. T. (2008). Advances in skin and wound care. Retrieved June 2, 2011, from http://www.nursingcentre.com How to take your pulse. (2009). Retrieved June 2, 2011, from http://www.drugs.com Illness such as heart disease. (2009). Retrieved June 5, 2005, from http://www.upstate.edu Mosbys Medical Dictionary (8th ed.).(2009). New York, NY: Elsevier. Normal body temperature. (n.d.). Retrieved June 5, 2011, from http://www.healthcareonline.org

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Raising positive expectations help patients with minor ailments: A cross sectional study. (2008). Retrieved June 2, 2011, from http://www.ncbi.nlm.nih.gov Rosman, J. (2010). Blood pressure. Retrieved June 4, 2011, from http://www.bloodpressure.org.nz Saunders, W. B. (2001). Pulse oximetry. Retrieved June 5, 2011, from http://www.aacn.org Shadilya, A. (2010). Low body temperature. Retrieved June 5, 2011, from http://www.buzzle.com Tachycardia. (2011). Retrieved June 2, 2011, from http://www.mayoclinic.com The editors of the nursing journal. (2007). Take care with tympanic temperature readings. The Nursing Journal, 37(4), 88. doi:10.1097/01.nurse.00002.66043.19416.88 Webster, N. R. (1999). Monitoring the critically ill patient. Retrieved June 2, 2011, from http://rcsed.ac.uk What is sinus bradycardia? (2010). Retrieved June 5, 2011, from http://bradycardia.net