Transcript Vital signs

Islamic University of Gaza
Faculty of Nursing
Chapter 6
General Assessment Including Vital Signs
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Equipment needed:
Beam balance scale, Tape measure, Thermometer,
Sphygmomanometer Stethoscope.
Subjective data :
current health, current age, height, and weight,
recent weight changes, fever, history of
hypotension, hypertension, difficulty
breathing, changes impulse or heart rate.
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Objective data
• head to toe examination to note any gross
abnormalities in appearance or behaviors
• Assess vital signs, temperature, pulse,
respirations, and blood pressure
• Weigh the client and measure for height
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Procedure
Observe:
• Behavior: (cooperative or uncooperative).
• Mood: steady or anxious.
• Appearance: well dressed or dress bizarre or
inappropriate.
• Body movements: if there is coordinated, or
uncoordinated, shaky and unsteady
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Vital signs
•
assessment of Temp., pulse, respiration and
blood pressure are known as life signs
• indicators of the body’s physiologic status and
response to physical, environmental and
physiologic stressors.
1. Temperature:
• Rectal temp is the most accurate.
• Unless contraindicated as in a client with a
severe cardiac arrhythmia, a rectal temp is often
preferred
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Vital signs… cont.
• Pulse: "60-80 b/m" regular
• Palpate the radial pulse &count for at least
"30" second.
• If the pulse is irregular, count for full
minute.
• Note is the pulse is strong or weak,
bounding or thready .
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Vital signs… cont.
Respiration: "16-20/minut"e (for healthy adult person
Count the No. of respiration, in full minute.
• Note rhythm and depth of breathing.
• Blood pressure:
• Measure Blood Pressure in both arms.
• Palpate the systolic pressure before using the stethoscope
• Apply cuff firmly, if too loose it will give falsely high
reading.
• Use cuff in appropriate size.
• Note position of client When measuring blood pressure.
• Monitor blood pressure after client is seated or supine
quietly for "10" minute.
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Instrument needed for physical assessment
• Ophthalmoscope: "lighted instrument for visualization of
the eye".
• Otoscope: for examination of the ear.
• Snellen eye chart: used as a screening test for vision.
• Nasal speculum, for assessment of the nose.
• Vaginal speculum: examination of the vaginal canal and
cervix.
• Tuning fork: for testing auditory function and vibratory
perception.
• Percussion hammer: “reflex hammer” to test reflexes and
determine tissue density.
• Neuralgic hammer: to test reflexes during the neuralgic
assessment
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Positions for physical Examination
• Assessment positions e.g.: (Standing
position, Supine position, Sitting position,
Dorsal recumbent position, Sims position,
Prone position, Knee chest position, and
Lithotomy position)
• Each position has it's specialty for parts of
examination
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Six Possible Client Position During an Examination
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Sitting position
• Areas Assessed: Head and neck, back,
posterior thorax and lungs, anterior
thorax , breasts, axillae, heart, vital signs,
and upper extremities
• Limitations: Physically weakened client
may be unable to sit
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Supine position
• Most normally relaxed position
• Areas Assessed: Head and neck anterior
thorax and lungs, breasts, axillae, heart,
abdomen, extremities, pulses
• Limitations: Not use for client SOB, you
may need to raise head of bed
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Dorsal position
• Areas Assessed: Head and neck, anterior
thorax and lungs, breasts, axillae, heart.
• Limitations: Not used for abdominal
assessment because it promotes contracture
of abdominal muscles
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. Lithotomy Position
• Areas Assessed: Female genitalia and
genital tract.
• * Limitations:
• This position is embarrassing &
uncomfortable, so examiner minimizes time
that client spends in it.
• Client is kept well draped.
• This position not used for Client with severe
arthritis or other joint deformity
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Sims’ position
• Areas Assessed: Rectum and vagina.
• * Limitations: Joint deformities may
prevent client’s ability to Bend hip and
knee
Prone position:
• * Areas Assessed: Musculoskeletal system.
• * Limitations: don’t use this position for
client with respiratory difficulties
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Knee-chest position
Areas Assessed: Rectum.
Limitations: This position is embarrassing and
uncomfortable. Don’t use this position for Clients
with arthritis or other joint deformities.
• When palpation assess for Crepitus (crackling
sensation & noise caused by rubbing of bone
fragments).
• * If a joint appears swollen and inflamed, detect
warmth in the tissues.
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Muscle assessment
• Assess muscle strength & tone when doing Range
of motion.
• * Tone: Muscular resistance felt by examiner as
the relaxed extremity is passively moved through
its range of motion.
• * Ask client to relax or hang limb, support & move
it through Range of motion.
• * Assess for increase tone “hyper tonicity” or
decrease tone “hypo tonicity
• Strength of dominant side is more than non
dominant, and it is normally for specific ratio
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Assessment of general Appearance
Body builds, posture and gait. Note proportion of height
weight "Weight = height – “100” = ---- +/- 10kg".
• Hygiene, grooming: (Note cleanliness, body odors,
appropriate dress for age and environment).
• Signs of illness.: (Note posture, skin color, respirations, and
nonverbal communications of pain or distress).
• Affect. Attitude, mood. (Note speech, facial expressions,
ability to relax, eye contact, behavior.
• Cognitive process. (Note speech content and patterns,
orientation, appropriate verbal responses).
• Height and weight: Weigh client without shoes, and
without extra clothing.
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Assessment of skin, Hair, and nails
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Skin infection, rashes, lesions, itching.
( Precipitating factors: stress, weather, drugs, exposure to
allergens.
•
Changes in skin color, lesions, and bruising.
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Amount of sun exposure (type of lotions used).
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Scalp lesions, itching, and infections.
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Changes in texture and amount of hair.
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Changes in nails and Nail breaking, and inflammation.
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** The examination of skin includes, inspections of skin
color moisture, temperature, and thickness, and turgor.
Vascular changes, edema, and any lesions are noted.
Skin odors are usually noted in the skin fold.
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Color of skin
• varies from body part to body part and from
person to person.
• * Normal changes in skin color my occur with
aging
• Assessment first involves area, of skin not
exposed to the sun e.g. palms of the hands.
• Pallor easily perceived in the buccal “mouth”
mucosa particularly in individuals with dark
skin.
• Cyanosis seen in areas, e.g. lips, nail beds
conjunctiva, and palm.
• Jaundice: seen in client’s sclera.
• Erythema may indicate circulatory changes
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Moisture of skin
Moisture in the skin: related to the degree of client’s hydration
and the condition of the outer lipid layer of the skin surface.
• Skin is normally smooth and dry.
• Skin folds e.g. axillae are normally moist.
• Assessment of skin done by palpation.
• In presence of skin lesions: nurse must wear gloves to
prevent exposure to infections.
• Temperature: Temp of skin depends on the amount of blood
circulating through dermis.
• Palpation of skin with dorsum of the hand.
• Assessment of skin is critical point in some conditions e.g.
after cast application, or tight bandage, or after vascular
surgery.
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• Texture : Character of skin surface and the feel of
deeper portion are its texture.
• Texture of skin normally smooth, soft and flexible.
If any abnormalities in texture, Ask the client is he
exposed to any recent injury to the skin?
• Turgor: Is the skin elasticity which can be
diminished by edema or dehydration, (done by
pinching skin between the thumb and forefinger
and released)
• Normally skin return immediately to its position.
• Failure of this process means dehydration.
• Vascularity : Assessment of circulation of skin. E.g.
petechiae may indicate serious blood clotting
disorders, drug reactions. Or liver disease
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• Edema: "Build up of fluid in tissues".
• Edematous areas should be inspected for location,
color, and shape.
• Edema separates the skin’s surface from the
pigmented and vascular layers masking skin color.
• palpates areas of edema to determine mobility,
consistency, and tenderness.
• lesions: If lesion present inspection must done for
color, location, size, shape type, grouping, and
distribution.
• N.B: cancerous lesions frequently undergo changes
in color and size
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Hair and Scalp
• Assess for lesions or lice are probable, the nurse wears
disposable gloves to avoid infection.
• Types of hair covering the body:
- Terminal hair (long, coarse, thick) and easily visible on
the scalp, axillae, and pubic areas.
- Vellus hair” small, soft, tiny” covering the whole body
except palms and soles.
• Assessment done for distribution, thickness, texture,
and lubrication of the hair.
• Some events which affect the distribution of hair over
the body e.g. client with hormone disorders, woman
with hersutism.
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Hair and Scalp cont.
• Normal color of terminal hairs: black, red, yellow, or
variations of these colors.
• Older men lose facial hair; but older women may
develop hair on chin and upper lip.
• Amount of hair covering extremities may be reduced
as a result of aging and arterial insufficiency especially
in lower limbs.
• Scaliness or dryness of the scalp is frequently caused
by dandruff or psoriasis.
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Nails Assessment
• Nails reflect an individual's general state of health,
state of nutrition, and occupation.
• Vascularity of the nail bed creates the nails underlying
color.
• Nails are normally transparent, smooth, and convex.
• The surrounding cuticles are smooth, intact and
without inflammation.
• Nail bed is normally firm on palpation.
• Nails normally grow at a constant rate.
• Hemorrhage, transverse band, and abnormal
thickness.
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Nails Assessment cont.
• N.B: "vitamins, proteins and electrolytes changes
can result in various lines or band forming on the
nail beds".
• The color of nails is an indicator of blood
oxygenation:
• Bluish color means cyanosis.
• White or pallor means anemia
• Palpation of the nails determines the adequacy of
circulation or capillary refill.
• Calluses are commonly found on the toes or
fingers
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Some Abnormalities of the nails
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Paronychia: inflammation surrounding the nail.
Anonachia: complete abscenc of nail.
Platunychia : flatting of the nails.
Kolilonychia: nails spoon like shape.
Racketnail: flattened and expanded nails (signs
of secondary syphilis)
• Onycholysis: nails separated from nail bed.
• Leukonychia Totalis: white nails (entire plate).
• Melanonychia: brown color in nails plate
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Thank you
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