LEGAL IMPLICATIONS IN NURSING, DOCUMENTATION, VITAL SIGNS, PAIN ASSESSMENT
DOCUMENTATION must reflect the complexity of care, and it must embody accuracy, completeness, and evidence of professional practice with efficient and cost-effective systems. The clinical standards (structure, outcome, process, and evaluation) are used to develop a system that complies with legal, accreditation, and professional practice requirements of documentation.
There are many methods used for documentation, including:
• Narrative charting
• Source-oriented charting
• Problem-oriented charting
• PIE charting
• Focus charting
• Charting by exception (CBE)
• Computerized documentation
• Case management with critical paths
NARRATIVE CHARTING
Narrative charting, the traditional method of nursing documentation, is a story format that describes the client’s status, interventions and treatments, and the client’s response to treatments. Before the advent of flow sheets, this was the only method for documenting care.
About 30% of nurses’ time, during an 8-hour shift, was spent on narrative charting (Miller & Pastorino, 1990)
Narrative documentation is easy to use in emergency situations, in which a simple, chronological order is needed. However, in this type of documentation it is often difficult to avoid being subjective, and there is normally a lack of analysis and critical decision making on the part of the nurse. Narrative charting is now being replaced by other formats because:
• The flow of care is disorganized. It is difficult to show a relationship between data and critical-thinking skills. Each nurse writes with a unique style, making continuity of care difficult to identify.
• It fails to reflect the nursing process. The focus is on tasks without emphasis on assessment data or progress toward achievement of outcomes.
• It is time-consuming. The paragraphs are free-flowing, so it takes more time to record accurate data and for others to read it.
• The information is difficult to retrieve. The same problems may not be addressed from shift to shift, so it is difficult to track the client’s progress. Auditors often disallow charges for equipment and supplies because consistent usage cannot be identified.
SOURCE-ORIENTED CHARTING
Source-oriented (S.O.) charting is described as a narrative recording by each member (source) of the health care team on separate records. Because each discipline has a separate record, care is often fragmented and communication between disciplines becomes time-consuming.
S.O. charting has similar advantages and disadvantages to narrative charting since nurses use an unstructured approach in documenting in the progress notes.
PROBLEM-ORIENTED CHARTING
Problem-oriented medical record (POMR) was introduced in 1969 by Lawrence Weed, a physician at
The focus of POMR documentation is on the client’s problem, with a structured, logical format to narrative charting called SOAP:
• S: subjective data (what the client or family states)
• O: objective data (what is observed/inspected)
• A: assessment (conclusion reached on the basis of data formulated as client problems or nursing diagnoses)
• P: plan (actions to be taken to relieve client’s problem) SOAPIE and SOAPIER refer to formats that add
• I: intervention (measures to achieve an expected outcome)
• E: evaluation (effectiveness of interventions)
• R: revision (changes from the original plan of care)
Figure 26-5 shows a sample of SOAPIE charting. As you chart according to these systems, think about which piece of information corresponds with each letter in the
SOAP(IE) entry.
The POMR system was modified by nonmedical caregivers and is referred to as problem-oriented record (POR). The system is used by hospitals, nursing homes, and home care agencies (Eggland & Heinemann, 1994).
There are four critical components of POMR/POR:
• Database: Assessment data, representative of all disciplines (history, physical, nursing admit assessment, laboratory findings, educational and discharge needs), which become the basis for a problem list evaluation of the client’s condition.
• Problem list: Derived from the database: a listing of the client’s problems as identified, with each problem numbered and labeled as acute, chronic, active, or inactive. Nurses use NANDA terminology in writing client problems as nursing diagnoses; the list is revised as new problems arise and others are resolved.
• Initial plan: Based on problem identification; the starting point for care plan development with client participation in setting goals, expected outcomes, and learning needs.
• Progress notes: Charting based on the SOAP, SOAPIE, or SOAPIER format.
The POR system uses flow sheets to record routine care and a discharge summary that addresses each problem on the list and notes whether it was resolved. SOAP entries are usually made every 24 hours on any unresolved problem or whenever the client’s condition changes.
PIE CHARTING
After SOAP charting gained in popularity, the problem, intervention, evaluation (PIE) system was instituted at
FOCUS CHARTING
Focus charting is a method of identifying and organizing the narrative documentation of client concerns to include data, action, and response. This method is not limited to client “problems” but allows for the identification of all “concerns” such as a significant event (e.g., results of a diagnostic test). Focus charting was created in 1981 at Eitel Hospital in Minneapolis, when the results from a SOAP audit revealed weaknesses in writing care plans (18% compliance) and charting the client’s response to care (12% compliance) (Iyer & Camp, 1999).
Focus charting uses a columnar format within the progress notes to distinguish the entry from other recordings in the narrative notes, as shown in Figure 26-7.
CHARTING BY EXCEPTION
Charting by exception (CBE) is a charting method that requires the nurse to document only deviations from preestablished norms. CBE was instituted in 1983 by St. Luke Medical Center in
The CBE system has three key components:
1. Flow sheets: Highlight significant findings and define assessment parameters and findings.
2. Reference documentation: Is related to the standards of nursing practice. (All standards are met unless otherwise documented.)
3. Bedside accessibility: Is related to the documentation forms. CBE requires the nurse to document significant findings or exceptions to predefined norms.
COMPUTERIZED DOCUMENTATION
The contemporary health care system has directed nurse leaders to develop computerized records in response to the large demand for clinical, administrative, and regulatory information. “The health care industry has learned from other industries that computers facilitate speed in communication, accuracy in information, capability of information storage, data retrieval, and data revision” (Eggland & Heinemann, 1994, p. 54). Nursing information systems (
The
• Administration of nursing services and resources
• Management of standardized client care information
• Linkage of research resources and educational applications to nursing practice
Health care facilities work in collaboration with producers of computer software to design medical record documents that complement existing documentation systems.
There are several advantages of computerized documentation. It enhances the systematic approach to client care through standardized protocols, teaching documents, data management, and communication. Computers are cost-effective and increase the quality of documentation.
The practical advantages to staff nurses are:
• Saves documentation time: Data entry needs to be done only once; the system avoids duplication of effort. For example, a physician’s medication order goes immediately to the pharmacy, eliminating the need to transcribe and transmit orders; the pharmacy receives the order (at preestablished computeracceptable doses and routes), and the client’s MAR is immediately updated. This system increases job satisfaction and saves more than 30% of nurses’ time spent on charting.
• Increases legibility and accuracy: A computer printout is easy to read and legible. Accuracy is achieved through standardized documents that prompt the nurse for information, making the charting more complete, thorough, concise, and organized. For example, the fall-prevention standard is automatically initiated for all high-risk clients. Bedside terminals allow for client care data to be entered in a timely fashion.
• Provides clear, decisive, and concise key words:
Standardized nursing terminology provides for usage of consistent key words (e.g., alert) and avoids ambiguous phraseology (e.g., “appears to be”).
Nurses can select nursing choices on a screen that automatically builds a comprehensive record of an event.
• Facilitates statistical analysis of data.
• Enhances implementation of the nursing process:
Uses documentation tools that provide an individualized plan of care: admission and nursing history data, diagnosis, goals, measurable outcomes, and interventions, inclusive of client teaching. Improved documentation of interventions has improved the PRO reimbursement.
• Enhances critical thinking and decision making:
Provides access to other data, such as laboratory results, that can be correlated with the nurses’ assessment data. If a trend is developing (e.g., decreasing levels of oxygenation), the nurse will recognize it quickly.
• Supports multidisciplinary networking: Information is quickly coordinated and integrated by other departments; all departments have access to the data.
Many of the disadvantages of computerized documentation are inherent in the computer and software itself: cost of installation, which limits the number of terminals at nursing stations; slow processing speed at peak usage times; and downtime (time for routine servicing or sudden unexpected failure). Practitioners are also often reluctant to change from the comfortable “penand-paper” methods to a high-tech electronic system.
A series of legal issues has developed from computerized documentation: problems in protecting client confidentiality; sharing of access codes (passwords); determining who should have access to the clinical database and how it should be used. Computerized software can be designed to record all transactions, thus permitting the identification of all staff members who request sensitive information.
POINT-OF-CARE SYSTEM
Point-of-care charting allows health care providers to gain immediate access to client information. The system allows for inputting and retrieving client data at the bedside through a hand-held portable computer. At the beginning of the shift, the nurse receives a client assignment and report with all client data downloaded from the main computer into the hand-held portable computer.
The nurse enters data (e.g., assessment, interventions, client’s response, and evaluation) into the computer at the bedside. The information is enhanced at the bedside by interfacing the new data with other data to clarify options. At the end of the shift, or when the client’s condition changes, the data from the hand-held computer are downloaded back into the main computer.
The advantages of point-of-care charting are based on the efficiency of the computer system. Since health care providers can record client data at the point of care, it:
• Controls operating costs
• Complements existing information systems
• Eliminates redundant data entry
• Allows the provider more one-on-one time for client care
• Provides crucial client information to all health care providers in a timely fashion
Point-of-care computerized documentation also facilitates the transition to a managed-care system (an integrated health care team) by focusing on the continuum of care. The focus is to provide each health care practitioner with all pertinent client data to ensure continuity of care without duplication. Because the client’s status can be reviewed at the bedside, practitioners have more time for interactions with their clients.
Because it is based on focus and outcome, this type of documentation system should promote quality of care, decrease the length of stay, and foster compliance with accreditation and regulatory standards.
CASE MANAGEMENT PROCESS
Case management is defined as a methodology for organizing client care through an episode of illness so that specific clinical and financial outcomes are achieved within an allotted time frame (Eggland & Heinemann, 1994). The outcome of this process is a DRG-specific case management plan that contains daily assessment documentation, care plan, outcomeoriented multidisciplinary interventions, teaching, and discharge planning.
At admission, the nurse case manager and the admitting practitioner individualize the case management plan (called a critical pathway) to meet the client’s specific needs. A critical pathway (or critical path) is an abbreviated summary of key elements from the case management plan. The pathway is used by all health care providers as a monitoring and documentation tool to ensure that interventions are performed on time and that client outcomes are achieved on time. Variations, sometimes referred to as a variance, are goals not met or interventions not performed within the time frame. The nurse documents on the back of the critical pathway the unexpected event (e.g., hospitalacquired decubiti), actions taken in response to the event, and appropriate discharge planning.
The advantages of case management are that it makes efficient use of time and increases the quality of care, with the expected outcomes identified on the plan. It also promotes collaboration, communication, and teamwork, which work to the advantage of the client and the facility, with discharge occurring in a timely manner. Case management also has several limitations; mainly, it is useful for clients with only one or two diagnoses. When clients have more than two diagnoses or variations, documentation becomes complicated because of limited space. This situation requires additional documentation forms to complement the pathway, such as intervention flow sheets and nurses’ notes.
PHYSICAL ASSESSMENT
Physical assessment, an essential nursing function, is performed on every client. The measurement of vital signs and the execution of the physical examination as part of the assessment process are done to gather information regarding the physiological functioning of the body. This chapter discusses the normal physiological functioning of the body and the common deviations from normal, measurement and evaluation of these functions, preparation of the client for the physical examination, and the techniques used to perform a physical examination.
VITAL SIGNS
The “taking of vital signs” refers to measurement of the client’s body temperature (T), pulse (P) and respiratory (R) rates, and blood pressure (BP). Vital signs are fundamental to physical assessment (the first step in the physical examination) to establish baseline values of the client’s cardiorespiratory integrity. Baseline values establish the norm against which subsequent measurements can be compared. Variations from normal findings may indicate potential problems with the client’s health status. Nurses should confirm “normal” measurements with clients because the perception of what is normal may vary among clients.
Vital signs are taken whenever the client is admitted to a health care facility or service, for example, home health care, clinic, or other ambulatory setting, and on a routine basis in the hospital. The frequency of vital sign measurements for the hospitalized client is determined by the client’s health status, physician orders, and the established standards of care for the particular clinical setting or service. Whenever a change is suspected in the client’s status, the nurse should measure the vital signs, regardless of the setting.
The sequence for recording vital signs measurement in the nurses’ notes is T-P-R and BP. Agencies usually have special graphic forms used to record vital signs findings. These forms facilitate data comparison at a glance because the data are plotted on a graph.
THERMOREGULATION
Thermoregulation is the body’s physiological function of heat regulation to maintain a constant internal body temperature. The heat of the body is measured in units called degrees. The “core” internal temperature of 98.6° Fahrenheit (F) (37° centigrade [C]) does not vary more than
RESPIRATION
Respiration is the act of breathing. Respiration is defined by physiological functioning as:
• External respiration—the exchange of oxygen and carbon dioxide between the alveoli of the lungs and the pulmonary blood system
• Internal respiration—the interchange of oxygen and carbon dioxide between the circulating blood and cells throughout the body
• Inspiration (inhalation)—the intake of air into the lungs
• Expiration (exhalation)—the movement of gases from the lungs to the atmosphere
• Vital capacity—the amount of air exhaled from the lungs after a minimal full inspiration
The following five major physiological pulmonary functions provide oxygen to the tissues and remove carbon dioxide:
1. Ventilation—the inflow and outflow of air between the atmosphere and the lung alveoli.
2. Circulation—the quantity of blood flowing through the lungs is approximately 4 to 6 L/min.
3. Diffusion—the exchange of oxygen and carbon dioxide between the alveoli and the blood.
4. Transport—the carrying of oxygen and carbon dioxide in the blood and body fluids to and from the cells.
5. Regulation—the neurogenic system that adjusts the rate of alveolar ventilation to meet the demands of the body. The arterial blood oxygen pressure (Po2) and arterial blood carbon dioxide pressure (Pco2) may be altered during times of strenuous exercise and other types of respiratory stress.
The mechanics of pulmonary ventilation depend on abdominal recti and internal intercostal muscles that cause lung expansion and contraction. Normal breathing is accomplished by:
1. The downward and upward movement of the diaphragm to lengthen or shorten the chest cavity
2. The elevation and depression of the ribs to increase and decrease the anteroposterior diameter of the chest cavity
Children and meormally breathe with their diaphragm muscles; adult women generally breathe with their upper chest muscles (Firth & Watanabe, 1996).
PULSE
The pulse is the bounding of blood flow in an artery that is palpable at various points on the body. The pulse is caused by the stroke volume ejection and distension of the walls of the aorta, which creates a pulse wave as it travels rapidly toward the distal ends of the arteries. As the pulse wave reaches a superficial peripheral artery and travels over an underlying bone or muscle, the pulse can be palpated by applying gentle pressure over a pulse point (a specific area where the peripheral pulses can be palpated).
Figure 27–1 shows the location of pulse points throughout the body.
BLOOD PRESSURE
Both the blood pressure and pulse are measurements that determine the volume of ejected blood into the arterial system with each ventricular contraction. Blood pressure is the measurement of pressure pulsations exerted against the blood vessel walls during systole and diastole. It is measured in terms of millimeters of mercury (mm Hg). In a healthy young adult, the pressure at the height of each pulse (the systolic pressure) is approximately
The body has four hemodynamic regulators for blood pressure control:
1. Blood volume—the volume of blood in the circulatory system. Blood pressure is proportional to the blood volume. Hemorrhage causes a loss in blood volume that, in turn, lowers the blood pressure. Rapid infusion of intravenous fluids causes an increase in volume and subsequent rise in pressure.
2. Cardiac output—the major factor that influences systolic pressure.
3. Peripheral vascular resistance—the size and distensibility of the arteries, which is the most important determinant of diastolic pressure. Arterial resistance (decreased distensibility) is encountered when the left ventricle pumps blood from the heart under pressure during the systolic phase. The arteries contain smooth muscles that allow them to contract, which decreases their compliance (tone) and causes resistance. The varying degrees of tone allow some of the arterioles to remain constricted while others dilate to protect the body’s circulatory system from accommodating a greater blood capacity than the actual blood volume.
If all of the arterioles were to dilate at one time, there would not be enough blood to fill them.
4. Viscosity—the thickness of the blood based on the ratio of proteins and cells to the liquid portion of blood. The greater the viscosity, the harder the heart must work to pump blood, with a resultant increase in blood pressure.
These regulators work in unison to create a constant blood pressure. For instance, when the blood volume decreases, the body compensates with an increased heart rate and vasoconstriction that increases peripheral resistance to maintaiormal pressure and functions of the vital organs.
Blood pressure is a result of the cardiac output and peripheral vascular resistance. Normal arteries expand during systole and contract during diastole, creating two distinct pressure phases:
• Systolic blood pressure is a measurement of the maximal pressure exerted against arterial walls during systole (when myocardial fibers contract and tighten to eject blood from the ventricles), primarily a reflection of cardiac output.
• Diastolic blood pressure is a measurement of pressure remaining in the arterial system during diastole (period of relaxation that reflects the pressure remaining in the blood vessels after the heart has pumped), primarily a reflection of peripheral vascular resistance.
Serial blood pressure readings provide significant clinical data relative to the client’s cardiovascular and fluid volume status.
FACTORS INFLUENCING VITAL SIGNS
Several factors can cause changes in one or more of the vital signs: age, gender, heredity, race, lifestyle, environment, medications, pain, and other factors such as exercise and metabolism, anxiety and stress, postural changes, diurnal variations, and hormones.
BODY TEMPERATURE
Body temperature is measured during the routine physical examination by using one of the instruments described in Table 27–3. Frequent monitoring is required for clients who have or are at risk for infection; for example, postoperative clients or those with suppressed white blood cell count. Accuracy of temperature measurement is essential because it guides nursing and medical decision making and interventions.
TEMPERATURE SCALES
The nurse should consistently measure and record the temperature using either the centigrade or Fahrenheit scale as defined in specific health care agency policies. A centigradecalibrated scale ranges from 34° to
SITES
Although the physician may order a specific site to measure the temperature, nursing judgment usually determines the best site based on the client’s age and physical and mental condition. Traditional sites for measuring the body’s internal (core) temperature are oral (OT), rectal (RT), and axillary (AT), using either glass or electronic thermometers.
Advances in clinical thermometry provide other devices and sites, such as thermistors for pulmonary artery temperature (PAT) and infrared thermometers for ear canal temperature (ET). ET is the most common site used for temperature measurements in adults because it is a safe and efficient method; however, it is less sensitive in detecting fever in infants and young children. ET should not be used in infected or draining ears or if adjacent lesions or incisions exist. The most reliable measure of core temperature is PAT. Since PAT requires placement of a thermodilution pulmonary artery catheter, it is impractical for routine care.
Oral and rectal temperature measurements are higher than axillary because the measuring device is in contact with the mucous membrane. Rectal measurements are higher than oral because of the seal created by the anal sphincter, which decreases contact with environmental air.
With the availability of electronic measuring devices, a glass thermometer should never be used for oral readingsif there is danger that the client will bite and break the thermometer. The axilla is commonly used as a site for infants and children with disabilities because it is the safest, even though least accurate, method. Axillary or rectal sites are used for clients who are uncooperative, comatose, or who have a nasogastric or feeding tube in place.
ASSESSING BODY TEMPERATURE
Assess the client for the most appropriate site and gather the necessary equipment. When checking the client’s oral temperature, the nurse should confirm that the client has neither consumed hot or cold food or beverage nor smoked for 15 to 30 minutes before the measurement. Mouth breathing and tachypnea may also cause an inaccurate oral reading. The nurse should wear nonsterile gloves when assessing oral temperature in clients with herpetic lesions (Crow, 1997). Herpes viruses are extremely contagious and require implementation of Standard Precautions of the Centers for Disease Control and Prevention. Clients with herpetic lesions should have their own glass thermometer to prevent transmission to others.
When using a glass thermometer stored in a disinfectant solution, the nurse should rinse it under cold water to remove the solution. Hot water should not be used on the thermometer because it will cause the mercury to expand and could break the thermometer.
Procedure 27–1 describes the actions involved in measuring body temperature according to site.
Alterations in Thermoregulation
When heat production exceeds heat loss and body temperature rises above the normal range pyrexia occurs. This condition is caused by an elevation of the body’s set-point in the hypothalamus. When the body’s temperature rises above
NURSING CONSIDERATIONS
The nurse should place the client experiencing heat exhaustion in a cool environment. The goal of nursing care is to stop diaphoresis by administering fluid and electrolytes as prescribed by a physician.
Victims of heat stroke do not perspire because of severe electrolyte loss and impaired hypothalamic function as discussed in Table 27–4.
Heat stroke victims are usually discovered outdoors, with emergency measures instituted to lower the temperature during transport to an emergency center. Nursing’s primary role relative to heat stroke is prevention. The nurse is usually involved in teaching preventive measures, such as drinking liquids before, during, and after exercise; avoiding strenuous exercise in humid, hot weather; and wearing light-colored, loose-fitting clothing and covering the head when working outdoors in hot climates.
Hypothermia and frostbite victims found injured in cold weather or who were immersed in cold water are treated while in transit to an emergency center with heating blankets and instillation of warm fluids into the stomach. Nursing’s role is to teach preventive measures to groups at risk, such as the homeless, and to parents or guardians of mentally ill or handicapped clients who live in cold environments.
DOCUMENTATION
Record the temperature measurement and the site on the designated medical record form. Schmitz and colleagues (1995) identify the importance of both consistency in the measurement process for the purpose of establishing a client’s temperature trend and awareness of the method used when interpreting clinical data.
Temperature measurements are usually plotted on a graph to identify alteration patterns, such as sharp elevations and declines in temperature (a condition known as spiking).
PULSE
Pulse assessment is the measurement of a pressure pulsation created when the heart contracts and ejects blood into the aorta. Assessment of pulse characteristics provides clinical data regarding the heart’s pumping action and the adequacy of peripheral artery blood flow.
SITES
There are multiple pulse points. The most accessible peripheral pulses are the radial and carotid sites.
Because the body shunts blood to the brain whenever a cardiac emergency such as hemorrhage occurs, the carotid site should always be used to assess the pulse in these situations.
Variances exist among health care agencies regarding which pulse sites to assess. The common sites for each type of assessment are:
• Complete physical assessment—apical and all bilateral peripheral pulses
• Initial assessment—apical and bilateral peripheral radial and dorsalis pedis pulses
• Routine vital sign assessment—apical and radial pulses in adults and apical and temporal pulses in infants and children Disorders that alter the client’s cardiovascular status require different pulse point assessments (Table 27–5).
Whenever circulation is compromised, the corresponding pulse point should be assessed.
ASSESSING PULSE RATE
The nurse should begin the assessment by speaking with the client about the normal pulse rate. The client’s medical record should be reviewed for baseline data, if available, and any medications that could affect the heart rate should be noted. Because physical activity increases the heart rate, ensure that the client rests 5 to 10 minutes before the pulse is assessed.
Clinical data regarding the efficacy of blood circulation to an extremity are obtained by assessing the characteristics (quality, rate, rhythm, and volume) of the peripheral pulses. These attributes are described in the section entitled
PULSE CHARACTERISTICS.
Palpate a peripheral pulse by placing the first two fingers on the pulse point with moderate pressure. A firm pressure will obliterate the pulse; if the pressure is too light, the pulse cannot be felt.
A Doppler ultrasound stethoscope (DUS) is used on superficial pulse points to detect and magnify heart sounds and pulse waves when the peripheral pulse cannot be palpated. The DUS, which has an earpiece similar to that of a stethoscope, is connected by a cord to volume-control audio unit with an ultrasound transducer.
Normal radial and apical pulses are identical in rate.The stethoscope is used to auscultate the heart’s rate and rhythm. The stethoscope should be placed on the fifth intercostal space at the midclavicular line, as described in Procedure 27–2.
COUNT THE RATE FOR A FULL MINUTE, NOTING THE REGULARITY (RHYTHM).
When an irregular peripheral pulse is present, the nurse needs to assess for a pulse deficit (condition in which the apical pulse rate is greater than the radial pulse rate). A pulse deficit results from the ejection of a volume of blood that is too small to initiate a peripheral pulse wave. When a discrepancy exists between the apical and radial pulses, the deficit is assessed by simultaneously measuring the apical and radial pulses for a minute. This procedure is usually performed by two nurses; however, it can be performed by one nurse if necessary.
PULSE CHARACTERISTICS
***A normal pulse has defined characteristics: quality, rate, rhythm, and volume (strength or amplitude)***
Pulse quality refers to the “feel” of the pulse, its rhythm and forcefulness.
Pulse rate is an indirect measurement of cardiac output obtained by counting the number of apical or peripheral pulse waves over a pulse point. A normal pulse rate for adults is between 60 and 100 beats per minute.
Bradycardia is a heart rate less than 60 beats per minute in an adult. Tachycardia is a heart rate in excess of 100 beats per minute in an adult.
Pulse rhythm is the regularity of the heartbeat. It describes how evenly the heart is beating: regular (the beats are evenly spaced) or irregular (the beats are not evenly spaced).
Dysrhythmia (arrhythmia) is an irregular rhythm caused by an early, late, or missed heartbeat.
Pulse volume is a measurement of the strength or amplitude of force exerted by the ejected blood against the arterial wall with each contraction. It is described as normal (full, easily palpable), weak (thready and usually rapid), or strong (bounding). To facilitate data comparison of this measurement, a standard pulse volume scale should be used in documenting findings (see the accompanying display). Procedure 27-2 describes the actions involved in assessing the pulse rate.
Clients on certain cardiac medications, such as cardiovascular agents and cardiac glycosides, need to monitor their pulse rate. Clients receiving cardiovascular agents (verapamil hydrochloride) and cardiac glycosides (digoxin) may experience an irregular pulse or pulse rate change that should be reported to their physician. In addition, clients who follow an exercise regimen should assess their pulse rate to measure their heart’s response to the exercise. Routine or regular exercise lowers the resting and activity pulses. When teaching clients how to monitor their own heart rate, nurses should show them the procedure in assessing the radial or carotid pulse points.
DOCUMENTATION
All pulse measurements are documented by recording in the client’s medical record on the appropriate forms (e.g., the vital sign flow sheet). The nurse should report and document an irregular pulse.
RESPIRATIONS
Respiratory assessment is the measurement of the breathing pattern. Assessment of respirations provides clinical data regarding the pH of arterial blood.
SITES
Normal breathing is slightly observable, effortless, quiet, automatic, and regular. It can be assessed by observing chest wall expansion and bilateral symmetrical movement of the thorax. Another method the nurse can use to assess breathing is to place the back of the hand next to the client’s nose and mouth to feel the expired air.
ASSESSING RESPIRATIONS
When assessing respirations ascertain the rate, depth, and rhythm of ventilatory movement. The nurse should assess the rate by counting the number of breaths taken per minute. Note the depth and rhythm of ventilatory movements by observing for the normal thoracic and abdominal movements and symmetry in chest wall movement.
Normal respirations are characterized by a rate ranging from 12 to 20 breaths per minute. Procedure 27-3 describes the actions involved in assessing resiprations.
One inspiration and expiration cycle is counted as one breath. The nurse should observe the rise and fall of the chest wall and count the rate by placing the hand lightly on the chest to feel its rise and fall. Count the number of respirations as explained in Procedure 27-3.
MOVEMENT OF THE DIAPHRAGM
When the chest wall moves, so do the lungs, because the lungs are attached to the inner wall of the thoracic cavity by the outer layer of the pleura (lining of the chest cavity). The movement of the chest wall should be even and regular, without noise and effort. On inspiration the chest changes shape and expands as the rib cage is raised and the diaphragm is lowered. Before inspiration, the pressure inside the chest cavity is negative (–4.5 to –9.0 mm Hg below atmospheric pressure). Air flows along the concentration gradient from a higher atmospheric pressure to the lower intrathoracic pressure.
The opposite action occurs with expiration. The muscles relax, causing the rib cage to lower, and the diaphragm to rise, compressing the chest. Intrathoracic pressure decreases to –3 to –6 mm Hg to allow the air to escape into the atmosphere.
Characteristics of
Eupnea refers to easy respirations with a normal rate of breaths per minute that are age-specific.
Bradypnea is a respiratory rate of 10 or fewer breaths per minute.
Hypoventilation is characterized by shallow respirations.
Tachypnea is a respiratory rate greater than 24 breaths per minute.
Hyperventilation is characterized by deep, rapid respirations.
The nurse can also observe alterations in the movement of the chest wall:
1. costal (thoracic) breathing occurs when the external intercostal muscles and the other accessory muscles are used to move the chest upward and outward;
2. diaphragmatic (abdominal) breathing occurs when the diaphragm contracts and relaxes as observed by movement of the abdomen.
Dyspnea refers to difficulty in breathing as observed by labored or forced respirations through the use of accessory muscles in the chest and neck to breathe. Dyspneic clients are acutely aware of their respirations and complain of shortness of breath.
NURSING CONSIDERATIONS
Respiratory alterations may cause changes in skin color as observed by a bluish appearance in the nail beds, lips, and skin. The bluish color (cyanosis) results from reduced oxygen levels in the arterial blood.
Changes in the level ofconsciousness may also occur with decreased oxygen levels. Dyspneic clients will assume a forward-leaning position to increase the expansion capacity of the lungs.
Clients with respiratory alterations require additional nursing assessment. Noninvasive oxygen assessment can be performed with an oximeter (a machine that measures the oxygen saturation of the blood through a probe clipped to the fingernail or earlobe) or an apnea monitor (a machine with chest leads that monitors the movement of the chest).
Both noninvasive machines have alarm features that are set to specific parameters. For example, if the client’s respirations fall below 6 breaths per minute, the apnea monitor alarm will sound. The apnea monitor is used in the home environment for apneic clients; when the alarm sounds, it wakes the person and causes him to breathe.
DOCUMENTATION
Document the assessment findings for the respiratory rate, depth, rhythm, and character on the appropriate form (e.g., the vital sign flow sheet). Report a respiratory rate outside the normal age range, an irregular rhythm, inadequate depth, or any abnormal characteristics such as dyspnea.
BLOOD PRESSURE
Blood pressure measurement is performed during a physical examination, at initial assessment, and as part of routine vital signs assessment. Depending on the client’s condition, the blood pressure is measured by either a direct or an indirect technique. The direct method requires an invasive procedure in which an intravenous catheter with an electronic sensor is inserted into an artery and the artery-transmitted pressure on an electronic display unit is read. The indirect method requires use of the sphygmomanometer and stethoscope for auscultation and palpation as needed.
SITES
The most common site for indirect blood pressure measurement is the client’s arm over the brachial artery. When the client’s condition prevents auscultation of the brachial artery, the nurse should assess the blood pressure in the forearm or leg sites (see the accompanying display).
When pressure measurements in the upper extremities are not accessible, the popliteal artery, located behind the knee, becomes the site of choice. The nurse can also assess the blood pressure in other sites, such as the radial artery in the forearm and the posterior tibial or dorsalis pedis artery in the lower leg. Because it is difficult to auscultate sounds over the radial, tibial, and dorsalis pedis arteries, these sites are usually palpated to obtain a systolic reading.
ASSESSING BLOOD PRESSURE
Selecting the proper equipment and following procedural technique are basic to ensuring an accurate reading. Psychomotor skills, acquired with practice, are needed to manipulate the blood pressure equipment.
Procedure 27-4 describes the actions involved in assessing blood pressure.
As shown in Table 27-
The sphygmomanometer wears with usage. If there is a defect in any part of the system, the blood pressure reading will be inaccurate. The aneroid gauge needle or mercury in the manometer column should be at a zero reading when the cuff is deflated and should rise evenly when pressure is applied to the bulb. The valve should turn freely and all tubing should be intact, with secured connections to prevent air from leaking out of the system.
An accurate reading also requires the correct width of the blood pressure cuff as determined by the circumference of the client’s extremity. The bladder cuff must encircle the width and length of the site. According to the American Heart Association (1987), the bladder width should be approximately 40% of the circumference or 20% wider than the diameter of the midpoint of the extremity. To measure the width of the bladder, the nurse should place the cuff lengthwise on the client’s extremity and extend the width to cover 40% of the extremity’s circumference (Figure 27-14).
The length of the sphygmomanometer bladder should be twice the width.
Table 27-6 recommends bladder sizes based on different arm circumferences. A falsely elevated reading will result if the bladder is too narrow, and a falsely low reading will result if it is too wide.
Electronic sphygmomanometers are used by clients for self-measurements. A stethoscope is not required because the device electronically inflates and deflates the cuff while simultaneously reading and displaying the systolic and diastolic pressures. The electronic device is useful for clients who must monitor their own pressure at home. However, it must be recalibrated routinely to ensure an accurate reading.
ASSESSMENT OF PAIN
Assessment of pain includes collection of subjective and objective data through the use of various assessment tools and construction of a database to use in developing a pain management plan. Pain assessment should be performed for every client. “In the normal course of doing business, pain should be nursing’s fifth vital sign, as basic to practice as temperature, pulse, respiration, and blood pressure” (Joel, 1999, p. 9).
Data Collection
Cheever (1999) emphasizes the need to prevent pain rather than treat it. Prevention calls for accurate assessment in order to alleviate pain before it escalates. “Even if a patient fails to report pain, you must make efforts to detect it” (Loeb, 1999, p. 52). Gathering subjective information regarding the client’s pain is the first step in pain assessment. The client’s perception of the pain should cover a description of several qualifiers, including:
• Intensity
• Location
• Quality (radiating, burning, diffuse)
• Associated manifestations (factors that often accompany the pain, such as nausea, constipation, or dizziness)
• Aggravating factors (variables that worsen the pain, such as exercise, certain foods, or stress)
• Alleviating factors (measures the client can take that lessen the effect of the pain, such as lying down, avoiding certain foods, or taking medication)
Nurses must look for nonverbal signs of pain such as changes in motor activity or facial expression. It is also important to ask family members to share their observations; they may be the first ones to note subtle behaviour changes indicative of pain. When assessing a client’s report of pain, the nurse should also determine a client’s pain threshold and pain tolerance level. Pain threshold is the level of intensity at which pain becomes appreciable or perceptible and will vary with each individual and type of pain. Pain tolerance is the level of intensity or duration of pain the client is willing or able to endure. A client’s perceptions and attitudes about pain are dramatically influenced by many factors, including previous experiences and cultural background.
Clients’ behavioral adaptation may yield no report of pain unless questioned specifically. Distraction (focusing attention on stimuli other than pain) may also be used by clients. McCaffery and Pasero (1999) recognize that clients often minimize the pain behaviors they are able to control for a number of reasons including:
• To be a “good” client and avoid making demands
• To maintain a positive self-image by not becoming a “sissy”
• By using distraction as a method of making pain more bearable (young children are particularly adept at this)
• Exhaustion
Pain is fatiguing as a significant amount of energy is used to deal with pain. The longer a person suffers from pain, the greater the level of fatigue. Although there is no conscious awareness of pain during sleep, there may be a dream-state awareness (McCaffery & Pasero, 1999). The stress response continues, and the body physiologically pays the price. Clients also wake up with considerably more pain than they had going to sleep, thereby requiring even more intervention (pharmacologic and nonpharmacologic) to reduce the pain.
ASSESSMENT TOOLS
Pain assessment tools are the single most effective method of identifying the presence and intensity of pain in clients. These tools must be used, and the results must be believed. Tools used for assessing pain must be appropriate to the client’s age and cultural context.
Pain Intensity Scales
Pain intensity scales are another quick, effective method for clients to rate the intensity of their pain (Figure 33-5). The verbal rating scale (VRS) and the numeric rating (NRS) are often used together to collect more accurate client input. The VRS uses adjectives ranging from “no pain” to “excruciating pain” in order to describe intensity. Frequent use of these tools will increase understanding of the pain severity. When using the NRS, clients are asked to assign their pain a number, with zero meaning no pain and 10 representing the worst possible pain. “On a scale of 0 to 10, with 0 being no pain at all and 10 being the worst pain you could ever have, how much do you hurt right now?” If there are multiple painful areas, this question can be asked regarding each area.
PAIN DIARY
Client input is essential if accurate assessment data are to be collected. Self-monitoring of symptoms can be promoted by having clients complete a pain diary; see the accompanying display.
PSYCHOSOCIAL PAIN ASSESSMENT
Plaisance and Price (1999) state the following questions should be included on the psychosocial assessment of a client experiencing pain:
• Do the client and family/caregivers understand the diagnosis?
• How have previous experiences with pain affected the client and family?
• How does the client usually cope with pain and/or stress?
• What concerns do the client and family have about using certain medications such as opioids?
• Do the client and family understand the differences between tolerance, dependence, and addiction?
DEVELOPMENTAL CONSIDERATIONS
Because pain experiences and reports can be influenced by age and developmental level, special consideration should be used to factor in those influences.
Children and Adolescents
Infants, children, and adolescents provide a special challenge in pain assessment because their pain behaviors often differ from those considered normal in the adult population. Certain myths hinder the accurate assessment and management of pain in children; see Table 33-4.
Two useful tools for assessing pain in children are the Wong/Baker Faces Rating Scale and the Poker Chip Tool. The Wong/Baker Faces Rating Scale can be used with children as young as 3 years, and it helps children express their level of pain by pointing to a cartoon face that most closely resembles how they are feeling (Figure33-6).
The Poker Chip Tool consists of four red poker chips that can easily be carried in a pocket to be available wheeeded. The chips are aligned horizontally on a hard surface in front of the child, and they are described as “pieces of hurt.” The chips are described from left to right as just a little bit of hurt, a little more hurt, more hurt, and the most hurt you could ever have.
The child is then asked, “How many pieces of hurt do you have right now?” This tool can be used with children 4 to 13 years old.
The verbal 0 to 10 scale is also frequently used for school-age and adolescent clients in a number of settings. It is important to remember that any child under stress or with anxiety will regress, and regression may make use of the verbal 0 to 10 scale in children under 8 to 10 years of age of questionable value.
