Wounds should be assessed and documented at every dressing change. Wound assessment should include the following components:
- Anatomic location
- Type of wound (if known)
- Degree of tissue damage
- Wound bed
- Wound size
- Wound edges and periwound skin
- Signs of infection
- Pain[1]
These components are further discussed in the following sections.
Anatomic Location and Type of Wound
The location of the wound should be documented clearly using correct anatomical terms and numbering. This will ensure that if more than one wound is present, the correct one is being assessed and treated. Many agencies use images to facilitate communication regarding the location of wounds among the health care team. See Figure 20.16[2] for an example of facility documentation that includes images to indicate wound location.
The location of a wound also provides information about the cause and type of a wound. For example, a wound over the sacral area of an immobile patient is likely a pressure injury, and a wound near the ankle of a patient with venous insufficiency is likely a venous ulcer. For successful healing, different types of wounds require different treatments based on the cause of the wound.
Degree of Tissue Damage
It is important to continually assess the degree of tissue damage in pressure injuries because the level of damage can worsen if they are not treated appropriately. Refer to the “Staging” subsection of “Pressure Injuries” in the “Basic Concepts Related to Wounds” section for more information about tissue damage.
Wound Base
Assess the color of the wound base. Recall that healthy granulation tissue appears pink due to the new capillary formation. It is moist, painless to the touch, and may appear “bumpy.” Conversely, unhealthy granulation tissue is dark red and painful. It bleeds easily with minimal contact and may be covered with biofilm. The appearance of slough (yellow) or eschar (black) in the wound base should be documented and communicated to the health care provider because it likely will need to be removed for healing. Tunneling and undermining should also be assessed, documented, and communicated.
Type and Amount of Exudate
The color, consistency, and amount of exudate (drainage) should be assessed and documented at every dressing change. The amount of drainage from wounds is categorized as scant, small/minimal, moderate, or large/copious. Use the following descriptions to select the appropriate terms[3]:
- No exudate: The wound base is dry.
- Scant amount of exudate: The wound is moist, but no measurable amount of exudate appears on the dressing.
- Minimal amount of exudate: Exudate covers less than 25% of the size of the bandage.
- Moderate amount of drainage: Wound tissue is wet, and drainage covers 25% to 75% of the size of the bandage.
- Large or copious amount of drainage: Wound tissue is filled with fluid, and exudate covers more than 75% of the bandage.[4]
The type of wound drainage should be described using medical terms such as serosanguinous, sanguineous, serous, or purulent.
- Sanguineous: Sanguineous exudate is fresh bleeding.[5]
- Serous: Serous drainage is clear, thin, watery plasma. It’s normal during the inflammatory stage of wound healing, and small amounts are considered normal wound drainage.[6]
- Serosanguinous: Serosanguineous exudate contains serous drainage with small amounts of blood present.[7]
- Purulent: Purulent exudate is thick and opaque. It can be tan, yellow, green, or brown. It is never considered normal in a wound bed, and new purulent drainage should always be reported to the health care provider.[8] See Figure 20.17[9] for an image of purulent drainage.
Wound Size
Wounds should be measured on admission and during every dressing change to evaluate for signs of healing. Accurate wound measurements are vital for monitoring wound healing. Measurements should be taken in the same manner by all clinicians to maintain consistent and accurate documentation of wound progress. This can be difficult to accomplish with oddly shaped wounds because there can be confusion about how consistently to measure them. Wounds should be described by length by width, with the length of the wound based on the head-to-toe axis. The width of a wound should be measured from side to side laterally. If a wound is deep, the deepest point of the wound should be measured to the wound surface using a sterile, cotton-tipped applicator. Many facilities use disposable, clear plastic measurement tools to measure the area of a wound healing by secondary intention. Measurements are typically documented in centimeters. See Figure 20.18[10] for an image of a wound measurement tool.
Tunneling can occur in a full-thickness wound that can lead to abscess formation. The depth of a tunneling can be measured by gently probing the tunneled area with a sterile, cotton-tipped applicator from the wound base to the end of the tract. When probing a tunnel, it is imperative to not force the swab but only insert until resistance is felt to prevent further damage to the area. The location of the tunnel in the wound should be documented using the analogy of a clock face, with 12:00 pointing toward the patient’s head.[11]
Undermining occurs when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound’s edge. Undermining is measured by inserting a probe under the wound edge directed almost parallel to the wound surface until resistance is felt. The amount of undermining is the distance from the probe tip to the point at which the probe is level with the wound edge. Clock terms are also used to identify the area of undermining.[12]
Wound Edges and Periwound Skin
If the wound is healing by primary intention, it should be documented if the wound edges are well-approximated (closed together) or if there are any signs of dehiscence. The skin outside the outer edges of the wound, called the periwound skin, provides information related to wound development or healing. For example, a venous ulcer often has excess wound drainage that macerates the periwound skin, giving it a wet, waterlogged appearance that is soft and grayish white in color.[13] See Figure 20.19[14] for an image of erythematous periwound with partial dehiscence.
Signs of Infection
Wounds should be continually monitored for signs of infection. Signs of localized wound infection include erythema (redness), induration (area of hardened tissue), pain, edema, purulent exudate (yellow or green drainage), and wound odor.[15] New signs of infection should be reported to the health care provider with an anticipated order for a wound culture.
Pain
The intensity of pain that a patient is experiencing with a wound should be assessed and documented. If a patient experiences pain during dressing changes, it should be managed with administration of pain medication before scheduled dressing changes. Be aware that the degree of pain may not correlate to the extent of tissue damage. For example, skin tears are often painful because the nerve endings are exposed in the dermal layer, whereas patients with severe diabetic ulcers on their feet may experience little or no pain because of existing neuropathic damage.[16]
- Cox, J. (2019). Wound care 101. Nursing, 49(10). https://doi.org/10.1097/01.nurse.0000580632.58318.08 ↵
- “putool7bfig.jpg” by unknown is in the Public Domain. Access for free at https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.html ↵
- Wound Care Advisor. (n.d.). Exudate amounts. https://woundcareadvisor.com/exudate-amounts/#:~:text=Small%20or%20minimal%20amount%20of,than%2075%25%20of%20the%20bandage ↵
- Wound Care Advisor. (n.d.). Exudate amounts. https://woundcareadvisor.com/exudate-amounts/#:~:text=Small%20or%20minimal%20amount%20of,than%2075%25%20of%20the%20bandage ↵
- Wound Care Advisor. (n.d.). Exudate amounts. https://woundcareadvisor.com/exudate-amounts/#:~:text=Small%20or%20minimal%20amount%20of,than%2075%25%20of%20the%20bandage ↵
- Wound Care Advisor. (n.d.). Exudate amounts. https://woundcareadvisor.com/exudate-amounts/#:~:text=Small%20or%20minimal%20amount%20of,than%2075%25%20of%20the%20bandage ↵
- Wound Care Advisor. (n.d.). Exudate amounts. https://woundcareadvisor.com/exudate-amounts/#:~:text=Small%20or%20minimal%20amount%20of,than%2075%25%20of%20the%20bandage ↵
- Wound Care Advisor. (n.d.). Exudate amounts. https://woundcareadvisor.com/exudate-amounts/#:~:text=Small%20or%20minimal%20amount%20of,than%2075%25%20of%20the%20bandage ↵
- “Purulant knee aspirate.JPG” by James Heilman, MD is licensed under CC BY 3.0 ↵
- “Sample Wound Measuring Guide.jpg” by Deanna Hoyord, Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
- Cox, J. (2019). Wound care 101. Nursing, 49(10). https://doi.org/10.1097/01.nurse.0000580632.58318.08 ↵
- WoundEducators.com. (2016, July 1). Wound undermining. https://woundeducators.com/measure-wound-undermining/#:~:text=Wound%20undermining%20occurs%20when%20the,surface%20until%20resistance%20is%20felt ↵
- Cox, J. (2019). Wound care 101. Nursing, 49(10). https://doi.org/10.1097/01.nurse.0000580632.58318.08 ↵
- “Post operative wound.JPG” by Intermedichbo is licensed under CC BY-SA 3.0 ↵
- Cox, J. (2019). Wound care 101. Nursing, 49(10). https://doi.org/10.1097/01.nurse.0000580632.58318.08 ↵
- Cox, J. (2019). Wound care 101. Nursing, 49(10). https://doi.org/10.1097/01.nurse.0000580632.58318.08 ↵
An instrument for measuring blood pressure typically consisting of an inflatable rubber cuff.
A bluish discoloration of the skin, lips, and nail beds. It is an indication of decreased perfusion and oxygenation.
Vital signs are typically obtained prior to performing a physical assessment. Vital signs include temperature recorded in Celsius or Fahrenheit, pulse, respiratory rate, blood pressure, and oxygen saturation using a pulse oximeter. See Figure 1.8[1] for an image of a nurse obtaining vital signs. Obtaining vital signs may be delegated to unlicensed assistive personnel (UAP) for stable patients, depending on the state's Nurse Practice Act, agency policy, and appropriate training. However, the nurse is always accountable for analyzing the vital signs and instituting appropriate follow-up for out-of-range findings. See Appendix A to review a checklist for obtaining vital signs.
The order of obtaining vital signs is based on the patient and their situation. Health care professionals often place the pulse oximeter probe on the patient while proceeding to obtain their pulse, respirations, blood pressure, and temperature. However, in some situations this order is modified based on the urgency of their condition. For example, if a person loses consciousness, the assessment begins with checking their carotid pulse to determine if cardiopulmonary resuscitation (CPR) is required.[2]
Temperature
Accurate temperature measurements provide information about a patient’s health status and guide clinical decisions. Methods of measuring body temperature vary based on the patient’s developmental age, cognitive functioning, level of consciousness, and health status, as well as agency policy. Common methods of temperature measurement include oral, tympanic, axillary, temporal, no touch, and rectal routes. It is important to document the route used to obtain a patient’s temperature because of normal variations in temperature in different locations of the body. Body temperature is typically measured and documented in health care agencies in degrees Celsius (ºC).[3]
Oral Temperature
Normal oral temperature is 35.8 – 37.3ºC (96.4 – 99.1ºF). An oral thermometer is shown in Figure 1.9.[4] The device has blue coloring, indicating it is an oral or axillary thermometer, as opposed to a rectal thermometer that has red coloring. Oral temperature is reliable when it is obtained close to the sublingual artery.[5]
Technique
Remove the probe from the device and slide a probe cover (from the attached box) onto the oral thermometer without touching the probe cover with your hands. Place the thermometer in the posterior sublingual pocket under the tongue, slightly off-center. Instruct the patient to keep their mouth closed but not bite on the thermometer. Leave the thermometer in place for as long as is indicated by the device manufacturer. The thermometer typically beeps within a few seconds when the temperature has been taken. Read the digital display of the results. Discard the probe cover in the garbage (without touching the cover) and place the probe back into the device.[6] See Figure 1.10[7] of an oral temperature being taken.
Some factors can cause an inaccurate measurement using the oral route. For example, if the patient recently consumed a hot or cold food or beverage, chewed gum, or smoked prior to measurement, a falsely elevated or decreased reading may be obtained. Oral temperature should be taken 15 to 25 minutes following consumption of a hot or cold beverage or food or 5 minutes after chewing gum or smoking.[8]
Tympanic Temperature
The tympanic temperature is typically 0.3 – 0.6°C or 0.5 - 1°F higher than an oral temperature. It is an accurate measurement because the tympanic membrane shares the same vascular artery that perfuses the hypothalamus (the part of the brain that regulates the body’s temperature). See Figure 1.11[9] of a tympanic thermometer. The tympanic method should not be used if the patient has a suspected ear infection.[10] Accumulation of cerumen, earwax, may also reduce the accuracy of tympanic readings.
Technique
Remove the tympanic thermometer from its holder and place a probe cover on the thermometer tip without touching the probe cover with your hands. Turn the device on. Ask the patient to keep their head still. For an adult or older child, gently pull the helix (outer ear) up and back to visualize the ear canal. For an infant or child under age 3, gently pull the helix down. Insert the probe just inside the ear canal but never force the thermometer into the ear. The device will beep within a few seconds after the temperature is measured. Read the results displayed, discard the probe cover in the garbage (without touching the cover), and then place the device back into the holder.[11] See Figure 1.12[12] for an image of a tympanic temperature being taken.
Axillary Temperature
The axillary method is a minimally invasive way to measure temperature and is commonly used in children. It uses the same electronic device as an oral thermometer (with blue coloring). However, the axillary temperature can be as much as 1ºC lower than the oral temperature.[13] An armpit (axillary) temperature is usually 0.3⁰ C (0.5⁰ F) to 0.6⁰ C (1⁰ F) lower than an oral temperature.
Technique
Remove the probe from the device and place a probe cover (from the attached box) on the thermometer without touching the cover with your hands. Ask the patient to raise their arm and place the thermometer probe in their armpit on bare skin as high up into the axilla as possible. The probe should be facing behind the patient. Ask the patient to lower their arm and leave the device in place until it beeps, usually about 10–20 seconds. Read the displayed results, discard the probe cover in the garbage (without touching the cover), and then place the probe back into the device. See Figure 1.13[14] for an image of an axillary temperature.[15]
Rectal Temperature
Measuring rectal temperature is an invasive method. Some sources suggest its use only when other methods are not appropriate. However, when measuring infant temperature, it is considered a gold standard because of its accuracy. A rectal temperature is 0.5°F (0.3°C) to 1°F (0.6°C) higher than an oral temperature.[16] See Figure 1.14[17] for an image of a rectal thermometer.
Technique
Before taking a rectal temperature, ensure the patient’s privacy. Wash your hands and put on gloves. For infants, place them in a supine position and raise their legs upwards toward their chest. Parents may be encouraged to hold the infant to decrease movement and provide a sense of safety. When taking a rectal temperature in older children and adults, assist them into a side lying position and explain the procedure. Remove the probe from the device and place a probe cover (from the attached box) on the thermometer. Lubricate the cover with a water-based lubricant, and then gently insert the probe 2–3 cm (approximately 0.5 in for babies less than 6 months old to 1 inch) into the anus or less, depending on the patient’s size.[18] Remove the probe when the device beeps. Read the result and then discard the probe cover in the trash can without touching it. Cleanse the device as indicated by agency policy. Remove gloves and perform hand hygiene.
Temporal Temperature
Temporal temperature is taken by using a device placed on the forehead. Temporal thermometers contain an infrared scanner that measures the heat on the surface of the skin resulting from blood moving through the temporal artery in the forehead. Temporal temperature is typically 0.5°F (0.3°C) to 1°F (0.6°C) lower than an oral temperature. It is a quick, noninvasive method, but accurate measurement is dependent on good contact with the skin and good placement on the forehead.
See Table 1.3a for normal temperature ranges for various routes.
Table 1.3 Normal Temperature Ranges[19]
| Method | Normal Range |
|---|---|
| Oral | 35.8 – 37.3ºC (96.4 -99.1ºF) |
| Axillary | 34.8 – 36.3ºC (96.4 -97.3ºF) |
| Tympanic | 36.1 – 37.9ºC (97.0 -100.2ºF) |
| Rectal | 36.8 – 38.2ºC (98.2 -100.8ºF) |
| Temporal | 35.2 - 37.0ºC (95.4 - 98.6ºF) |
Pulse
Pulse refers to the pressure wave that expands and recoils arteries when the left ventricle of the heart contracts. It is palpated at many points throughout the body. The most common locations to palpate pulses as part of vital sign measurement include radial, brachial, carotid, and apical areas as indicated in Figure 1.15.[20]
Pulse is measured in beats per minute wherever a pulse can be palpated. The normal adult pulse rate (heart rate) at rest is 60–100 beats per minute with different ranges according to age. The pulse rate is a measurement of the number of times the heart beats per minute. The pulse rate may differ from the heart rate if the force of the heart contraction is not strong enough to generate a pulse because the pulse is palpated whereas the heart rate is typically auscultated. See Table 1.3b for normal heart rate ranges by age. It is important to consider each patient situation when analyzing if their heart rate is within normal range. Begin by reviewing their documented baseline heart rate. Consider other factors if the pulse is elevated, such as the presence of pain or crying in an infant. It is best to complete the assessment when a patient is resting and comfortable, but if this is not feasible, document the circumstances surrounding the assessment and reassess as needed.[21] For example, pulse rate may be artificially elevated when individuals experience physical or mental stress. Therefore, it is best to collect a pulse rate assessment when the patient is resting.
Table 1.3b Normal Heart Rate by Age
| Age Group | Heart Rate |
|---|---|
| Preterm | 120 - 180 |
| Newborn (0 to 1 month) | 100 - 160 |
| Infant (1 to 12 months) | 80 - 140 |
| Toddler (1 to 3 years) | 80 - 130 |
| Preschool (3 to 5 years) | 80 - 110 |
| School Age (6 to 12 years) | 70 - 100 |
| Adolescents (13 to 18 years) and Adults | 60 - 100 |
Pulse Characteristics
When assessing pulses, the characteristics of rhythm, rate, force, and equality are included in the documentation.
Pulse Rhythm
A normal pulse has a regular rhythm, meaning the frequency of the pulsation felt by your fingers is an even tempo with equal intervals between pulsations. For example, if you compare the palpation of pulses to listening to music, it follows a constant beat at the same tempo that does not speed up or slow down. Some cardiovascular conditions, such as atrial fibrillation, cause an irregular heart rhythm. If a pulse has an irregular rhythm, document if it is “regularly irregular” (e.g., three regular beats are followed by one missed and this pattern is repeated) or if it is “irregularly irregular” (e.g., there is no rhythm to the irregularity).[22]
Pulse Rate
The pulse rate is counted with the first beat felt by your fingers as “One.” It is considered best practice to assess a patient’s pulse for a full 60 seconds, especially if there is an irregularity to the rhythm.[23]
Pulse Force
The pulse force is the strength of the pulsation felt on palpation. Pulse force can range from absent to bounding. The volume of blood, the heart’s functioning, and the arteries’ elastic properties affect a person’s pulse force.[24] Pulse force is documented using a four-point scale:
- 3+: Full, bounding
- 2+: Normal/strong
- 1+: Weak, diminished, thready
- 0: Absent/nonpalpable
If a pulse is absent, a Doppler ultrasound device is typically used to verify perfusion of the limbs. The Doppler is a handheld device that allows the examiner to hear the whooshing sound of the pulse. This device is also commonly used when assessing peripheral pulses in the lower extremities, such as the dorsalis pedis pulse or the posterior tibial pulse. See the following video demonstrating the use of a Doppler device.
Pulse Equality
Pulse equality refers to a comparison of the pulse forces on both sides of the body. For example, a nurse often palpates the radial pulse on a patient’s right and left wrists at the same time and compares if the pulse forces are equal. However, the carotid pulses should never be palpated at the same time because this can decrease blood flow to the brain. Pulse equality provides data about medical conditions such as peripheral vascular disease and arterial obstruction.[26]
Radial Pulse
Use the pads of your first three fingers to gently palpate the radial pulse. The pads of the fingers are placed along the radius bone on the lateral side of the wrist (i.e., the thumb side). Fingertips are placed close to the flexor aspect of the wrist (i.e., where the wrist meets the hand and bends). See Figure 1.16[27] for correct placement of fingers in obtaining a radial pulse. Press down with your fingers until you can feel the pulsation, but not so forcefully that you are obliterating the wave of the force passing through the artery. Note that radial pulses are difficult to palpate on newborns and children under the age of five, so the brachial or apical pulses are typically obtained in these populations.[28]
Carotid Pulse
The carotid pulse is typically palpated during medical emergencies because it is the last pulse to disappear when the heart is not pumping an adequate amount of blood.[29]
Technique
Locate the carotid artery medial to the sternomastoid muscle, between the muscle and the trachea, in the middle third of the neck. In order to palpate the carotid, place the index and middle fingers on the patient's neck to the side of individual's trachea. With the pads of your three fingers, gently palpate one carotid artery at a time so as not to compromise blood flow to the brain. See Figure 1.17[30] for correct placement of fingers in a seated patient.[31]
Brachial Pulse
A brachial pulse is typically assessed in infants and children because it can be difficult to feel the radial pulse in these populations. If needed, a Doppler ultrasound device can be used to obtain the pulse.
Technique
The brachial pulse is located by feeling the bicep tendon in the area of the antecubital fossa. Move the pads of your three fingers medially from the tendon about 1 inch (2 cm) just above the antecubital fossa. It can be helpful to hyperextend the patient’s arm to accentuate the brachial pulse so that you can better feel it. You may need to move your fingers around slightly to locate the best place to accurately feel the pulse. You typically need to press fairly firmly to palpate the brachial pulse.[32] See Figure 1.18[33] for correct placement of fingers along the brachial artery.
Apical Pulse
The apical pulse rate is considered the most accurate pulse and is indicated when obtaining assessments prior to administering cardiac medications. It is obtained by listening with a stethoscope over a specific position on the patient’s chest wall. Read more about listening to the apical pulse and other heart sounds in the “Cardiovascular Assessment” section.
Respiratory Rate
Respiration refers to a person’s breathing and the movement of air into and out of the lungs. Inspiration refers to the process causing air to enter the lungs, and expiration refers to the process causing air to leave the lungs. A respiratory cycle (i.e., one breath while measuring respiratory rate) is one sequence of inspiration and expiration.[34]
When obtaining a respiratory rate, the respirations are also assessed for quality, rhythm, and rate. The quality of a person’s breathing is normally relaxed and silent. However, loud breathing, nasal flaring, or the use of accessory muscles in the neck, chest, or intercostal spaces indicate respiratory distress. People experiencing respiratory distress also often move into a tripod position, meaning they are leaning forward and placing their arms or elbows on their knees or on a bedside table. If a patient is demonstrating new signs of respiratory distress as you are obtaining their vital signs, it is vital to immediately notify the health care provider or follow agency protocol.
Respirations normally have a regular rhythm in children and adults who are awake. A regular rhythm means that the frequency of the respiration follows an even tempo with equal intervals between each respiration. However, newborns and infants commonly exhibit an irregular respiratory rhythm.
Normal respiratory rates vary based on age. The normal resting respiratory rate for adults is 10–20 breaths per minute, whereas infants younger than one year old normally have a respiratory rate of 30–60 breaths per minute. See Table 1.3c for ranges of normal respiratory rates by age. It is also important to consider factors such as sleep cycle, presence of pain, and crying when assessing a patient’s respiratory rate.[35]
Read more about assessing a patient’s respiratory status in the “Respiratory Assessment” section.
Table 1.3c Normal Respiratory Rate by Age[36]
| Age | Normal Range |
|---|---|
| Newborn to one month | 30 - 60 |
| One month to one year | 26 - 60 |
| 1-10 years of age | 14 - 50 |
| 11-18 years of age | 12 - 22 |
| Adult (ages 18 and older) | 10 - 20 |
Oxygen Saturation
A patient’s oxygenation status is routinely assessed using pulse oximetry, referred to as SpO2. SpO2 is an estimated oxygenation level based on the saturation of hemoglobin measured by a pulse oximeter. Because the majority of oxygen carried in the blood is attached to hemoglobin within the red blood cells, SpO2 estimates how much hemoglobin is “saturated” with oxygen. The target range of SpO2 for an adult is 94-100%. For patients with chronic respiratory conditions, such as chronic obstructive pulmonary disease (COPD), the target range for SpO2 is often lower at 88% to 92%. Although SpO2 is an efficient, noninvasive method to assess a patient’s oxygenation status, it is an estimate and not always accurate. For example, if a patient is severely anemic and has a decreased level of hemoglobin in the blood, the SpO2 reading is affected. Decreased peripheral circulation can also cause a misleading low SpO2 level.
A pulse oximeter includes a sensor that measures light absorption of hemoglobin. See Figure 1.19[37] for an image of a pulse oximeter. The sensor can be attached to the patient using a variety of devices. For intermittent measurement of oxygen saturation, a spring-loaded clip is attached to a patient’s finger or toe. However, this clip is too large for use on newborns and young children; therefore, for this population, the sensor is typically taped to a finger or toe. An earlobe clip is another alternative for patients who cannot tolerate the finger or toe clip or have a condition, such as vasoconstriction or poor peripheral perfusion, that could affect the results.
Read more about pulse oximetry in the “Oxygen Therapy” chapter.
Technique
Nail polish or artificial nails can affect the absorption of light waves from the pulse oximeter and decrease the accuracy of the SpO2 measurement when using a probe clipped on the finger. An alternative sensor that does not use the finger should be used for these patients or the nail polish should be removed. If a patient’s hands or feet are cold, it is helpful to clip the sensor to the earlobe or tape it to the forehead.
Blood Pressure
Read information about how to accurately obtain blood pressure measurement in the “Blood Pressure” chapter.
Interpreting Results
After obtaining a patient’s vital signs, it is important to immediately analyze the results, recognize deviations from expected normal ranges, and report deviations appropriately. As a nursing student, it is vital to immediately notify your instructor and/or collaborating nurse caring for the patient of any vital sign measurement out of normal range.
A reduced amount of oxyhemoglobin the skin or mucous membranes. Skin and mucous membranes present with a pale skin color.
Learning Activities
(Answers to "Learning Activities" can be found in the "Answer Key" at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)
Mr. Jones is a 76-year-old patient admitted to the medical surgical floor with complications of a nonhealing foot ulcer. Mr. Jones has a history of diabetes, hypertension, and COPD. He has a BMI of 29. His daily medications include metformin, Lisinopril, and prednisone. His wife has recently passed away and he lives alone.
- Based upon what is known about Mr. Jones, what factors might be contributing to his nonhealing wound?
- What other factors that influence wound healing might be important to assess with Mr. Jones?
Test your clinical judgment with an NCLEX Next Generation-style question: Chapter 20, Assignment 1.
Test your clinical judgment with an NCLEX Next Generation-style question: Chapter 20, Assignment 2.
Test your clinical judgment with an NCLEX Next Generation-style question: Chapter 20, Assignment 3.
Table 1.5 compares expected and unexpected findings when performing a general survey assessment. These findings are included in documentation regarding the general survey assessment.
Table 1.5 Expected Versus Unexpected Findings on General Survey Assessment
| Assessment | Expected Findings | Unexpected Findings (notify provider if a new finding*) |
|---|---|---|
| Signs of distress | No signs of distress | Unresponsive, difficulty breathing, confused, moaning, or grimacing |
| Mood and appearance | Calm and cooperative
Responds appropriately to questions Appears stated age |
Mood is depressed, anxious, or agitated
Signs of suspected substance use disorder are present, such as the scent of alcohol |
| Orientation | Alert and oriented to person, place, and time | Unable to provide name, location, or day |
| Hygiene | Well groomed. Clothing is appropriate for weather | Unkempt appearance or inappropriate clothing according to the weather |
| Family dynamics | Family members demonstrate mutual respect, trust, and caring | Family members communicate in an unfriendly, disrespectful, or hostile manner
Signs of suspected abuse are present |
| Speech and communication | Speech is clear and understandable; patient follows instructions appropriately | Speech is garbled or difficult to understand; unable to respond appropriately to questions or follow commands |
| Range of motion | Moves all extremities equally bilaterally with good posture | New facial drooping or altered/unequal movement of extremities |
| Mobility | Gait is smooth and even and can maintain balance without assistance. If present, assistive devices are used appropriately and this is documented | Gait is shuffling, staggering, or limping. Balance is impaired; assistive devices like a cane or walker are not used appropriately |
| Nutrition | BMI within normal range | BMI out of range. Unexplained weight loss or gain has occurred |
| Fluid status | Moist mucous membranes | Dry skin and dry mucous membranes; sunken eyes in adults; sunken fontanel in infants |
| CRITICAL CONDITIONS to report immediately: | Newly unresponsive or altered mental status; difficulty breathing; vital signs out of range; skin is cool, clammy, or cyanotic |