1. Chapter 27 Vital Signs and Physical Assessment Fundamentals of Nursing: Standards & Practices, 2E

2.  Copyright 2002 by Delmar, a division of Thomson Learning 27-2 Vital Signs  The taking of vital signs refers to measurement of the client’s body temperature (T), pulse (P), respiratory (R) rates, and blood pressure (BP).  A baseline value establishes the norm against which subsequent measurements can be compared.

3.  Copyright 2002 by Delmar, a division of Thomson Learning 27-3  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.

4.  Copyright 2002 by Delmar, a division of Thomson Learning 27-4  The sequence for recording vital signs measurements in the nurses’ notes is T-P-R and BP.  Most agencies have graphic forms for documentation of vital signs. These forms facilitate data comparison at a glance.

5.  Copyright 2002 by Delmar, a division of Thomson Learning 27-5 Physiological Function  Thermoregulation is the body’s function of heat regulation in order to maintain a constant internal body temperature. Heat production Heat loss Behavioral control of body temperature

6.  Copyright 2002 by Delmar, a division of Thomson Learning 27-6  Respiration is the act of breathing. External respiration Internal respiration Inspiration Expiration Vital capacity

7.  Copyright 2002 by Delmar, a division of Thomson Learning 27-7  Hemodynamic regulation is the function of blood circulating in order to maintain an appropriate environment in tissue fluids. Blood flow  Systole  Diastole

8.  Copyright 2002 by Delmar, a division of Thomson Learning 27-8  Stroke volume  Cardiac output  Pulse pressure Pulse Blood pressure

9.  Copyright 2002 by Delmar, a division of Thomson Learning 27-9 Factors Influencing Vital Signs  Age  Gender  Heredity  Race  Lifestyle  Environment

10.  Copyright 2002 by Delmar, a division of Thomson Learning 27-10  Medications  Pain  Others factors Exercise Anxiety and stress Postural changes Diurnal (daily) variations

11.  Copyright 2002 by Delmar, a division of Thomson Learning 27-11 Measuring Vital Signs  Equipment Thermometer - glass, electronic, disposable, tympanic Stethoscope Ultrasound (Doppler) Sphygmomanometer Scale

12.  Copyright 2002 by Delmar, a division of Thomson Learning 27-12  Height and weight Height is expressed in inches (in), feet (ft), centimeters (cm), or meters (m). A scale for measuring height is usually attached to a standing weight scale. Measure an infant’s length from vertex of head to soles of feet while infant is lying with knees extended.

13.  Copyright 2002 by Delmar, a division of Thomson Learning 27-13 Measurement of weight is expressed in ounces (oz), pounds (lb), grams (g), or kilograms (kg). Daily weights should be obtained at the same time of the day, on the same scale, and with the client wearing the same type of clothing.

14.  Copyright 2002 by Delmar, a division of Thomson Learning 27-14 Types of scales include standing, chair, stretcher, bed, and platform scales. Measure an infant on a platform scale, keeping one hand over the top of infant to prevent accidental injury. Accurate recordings of weight are imperative because they are used in drug dosage calculations and to evaluate the effectiveness of many treatments.

15.  Copyright 2002 by Delmar, a division of Thomson Learning 27-15  Body temperature Use either the Centigrade or Fahrenheit scale to measure temperature. Internal core temperature sites are oral, rectal, and axillary. Advanced techniques include use of thermistors for pulmonary artery temperature and infrared thermometers for ear canals.

16.  Copyright 2002 by Delmar, a division of Thomson Learning 27-16 Oral and rectal temperatures are higher than axillary; rectal measurements are higher than oral. The axilla is commonly used for infants and children with disabilities because it is the safest method. Review Procedure 27-1 on measuring body temperature.

17.  Copyright 2002 by Delmar, a division of Thomson Learning 27-17 Alterations in thermoregulation  Pyrexia  Heat exhaustion  Heat stroke  Hypothermia  Frostbite

18.  Copyright 2002 by Delmar, a division of Thomson Learning 27-18  Pulse Pulse is the measurement of a pressure pulsation created when the heart contracts and ejects blood into the aorta. Pulse points include temporal, carotid, apical, brachial, radial, ulnar, femoral, popliteal, posterior tibial, and dorsalis pedis.

19.  Copyright 2002 by Delmar, a division of Thomson Learning 27-19 A Doppler ultrasound stethoscope is used on superficial pulse points. A stethoscope is used to auscultate the apical pulse. Review Procedure 27-2 on assessing pulse rate.

20.  Copyright 2002 by Delmar, a division of Thomson Learning 27-20 A pulse deficit occurs when the apical pulse rate is greater than the radial pulse rate. Pulse characteristics  Pulse quality  Pulse rate - bradycardia, tachycardia  Pulse rhythm  Pulse volume

21.  Copyright 2002 by Delmar, a division of Thomson Learning 27-21  Respirations Respiratory assessment is the measurement of the breathing pattern. Assessment of respirations provides clinical data regarding the pH of arterial blood.

22.  Copyright 2002 by Delmar, a division of Thomson Learning 27-22 The nurse ascertains the rate, depth, and rhythm of respirations. Review Procedure 27-3 on assessing respirations.

23.  Copyright 2002 by Delmar, a division of Thomson Learning 27-23 Characteristics of breath sounds  Eupnea, bradypnea, tachypnea  Hypoventilation  Hyperventilation  Costal breathing  Diaphragmatic breathing  Dyspnea

24.  Copyright 2002 by Delmar, a division of Thomson Learning 27-24 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.

25.  Copyright 2002 by Delmar, a division of Thomson Learning 27-25  Blood pressure The most common site for indirect measurement is the client’s arm over the brachial artery. The radial, popliteal, posterior tibial, or dorsalis pedis arteries can also be used to measure blood pressure if the brachial artery is inaccessible.

26.  Copyright 2002 by Delmar, a division of Thomson Learning 27-26 A sphygmomanometer is a device used to measure indirect blood pressure - mercury or aneroid types. An accurate measurement requires the correct width blood pressure cuff as determined by the circumference of the client’s extremity.

27.  Copyright 2002 by Delmar, a division of Thomson Learning 27-27 Techniques of measurement  Auscultation - Korotkoff sounds  Palpation  Review Procedure 27-4 on assessing blood pressure

28.  Copyright 2002 by Delmar, a division of Thomson Learning 27-28 Hypotension refers to a systolic blood pressure less than 90 mm Hg or 20 to 30 mm Hg below the client’s normal systolic pressure. Hypertension refers to a persistent systolic pressure greater than 135 to 140 mm Hg and a diastolic pressure greater than 90 mm Hg.

29.  Copyright 2002 by Delmar, a division of Thomson Learning 27-29 Physical Examination  Purposes of physical examination It ascertains client’s level of health and physiological function. It identifies factors placing the client at risk and determines areas of preventive nursing.

30.  Copyright 2002 by Delmar, a division of Thomson Learning 27-30 It confirms alterations, disease, or inability to perform the activities of daily living. It identifies the need for additional testing or examination. It evaluates the outcomes of treatment and therapy.

31.  Copyright 2002 by Delmar, a division of Thomson Learning 27-31  Preparation for the physical examination The nurse should keep the client informed while performing the examination. The nurse should appear calm, organized, and competent at the bedside. The nurse should review the agency’s assessment forms prior to meeting with the client.

32.  Copyright 2002 by Delmar, a division of Thomson Learning 27-32  Environment Accommodate any special needs of the client. Allow for placement of the equipment on a surface that is clean and free from movement at the bedside. The room needs to be quiet, warm, and well lit. Make necessary adjustments to ensure privacy.

33.  Copyright 2002 by Delmar, a division of Thomson Learning 27-33  Equipment Wash hands and gather necessary equipment. Secure the forms required for documenting the assessment findings. Gather enough clean gloves to change as needed for the examination.

34.  Copyright 2002 by Delmar, a division of Thomson Learning 27-34  Positioning and draping Position the client to ensure accessibility to the body part being assessed. Drape the client to prevent unnecessary exposure during the examination. A bath blanket, sheet, towels and/or the client’s gown can be used as drapes.

35.  Copyright 2002 by Delmar, a division of Thomson Learning 27-35  General survey Observe for signs of distress. Observe the client’s state of health, stature, and sexual development. Weight, height, and vital signs are measured. Note posture, motor activity, gait, dress, grooming, and personal hygiene.

36.  Copyright 2002 by Delmar, a division of Thomson Learning 27-36 Observe facial expressions and behaviors. Listen to quality of speech and note the level of consciousness. Special considerations  Elderly clients  Disabled clients  Abused clients

37.  Copyright 2002 by Delmar, a division of Thomson Learning 27-37  Sexual History Illness and medical interventions can interfere with sexual functioning. Sexual responsiveness can be altered by taking narcotics, sedatives, antidepressants and antispasmodics. Prolonged therapies may cause physiologic changes that affect sexual desire.

38.  Copyright 2002 by Delmar, a division of Thomson Learning 27-38  Techniques Inspection Palpation Percussion Auscultation

39.  Copyright 2002 by Delmar, a division of Thomson Learning 27-39  Integument Skin Hair Nails Review Tables 27-9, 27-10, and 27-11 for assessment of the integumentary system.

40.  Copyright 2002 by Delmar, a division of Thomson Learning 27-40  Head and neck Skull and face Eyes Ears Nose and sinuses

41.  Copyright 2002 by Delmar, a division of Thomson Learning 27-41 Mouth and pharynx Neck Review table 27-13 for assessment of the head and neck.

42.  Copyright 2002 by Delmar, a division of Thomson Learning 27-42  Thorax and lungs Normal breath sounds  Vesicular  Bronchovesicular  Bronchial

43.  Copyright 2002 by Delmar, a division of Thomson Learning 27-43 Adventitious breath sounds  Crackles  Rhonchi  Wheezes  Pleural friction rub  Stridor Review Table 27-14 for assessment of the thorax and lungs.

44.  Copyright 2002 by Delmar, a division of Thomson Learning 27-44  Heart and vascular system Heart Vascular system Review Table 27-15 for assessment of the heart and vascular system.

45.  Copyright 2002 by Delmar, a division of Thomson Learning 27-45  Breasts and Axilla Review Table 27-16 for assessment of the breasts and axilla.  Abdomen Review Table 27-17 for assessment of the abdomen.

46.  Copyright 2002 by Delmar, a division of Thomson Learning 27-46  Female genitalia and anus Review Table 27-18 for assessment of the female genitalia and anus.  Male genitalia and anus Review Table 27-19 for assessment of the male genitalia and anus.

47.  Copyright 2002 by Delmar, a division of Thomson Learning 27-47  Musculoskeletal system Review Table 27-20 for assessment of the musculoskeletal system.  Neurologic system Mental status Cognitive abilities and mentation Sensory assessment

48.  Copyright 2002 by Delmar, a division of Thomson Learning 27-48 Cranial nerves assessment Motor assessment Cerebellar assessment Reflex assessment  Review Table 27-22 for assessment of common deep tendon reflexes. Review Table 27-21 for assessment of the neurologic system.

49.  Copyright 2002 by Delmar, a division of Thomson Learning 27-49  Care of the client after the examination Home or outpatient setting Acute or extended care setting

50.  Copyright 2002 by Delmar, a division of Thomson Learning 27-50  Data documentation Health care agencies have specific forms for recording the assessment findings. Record findings on the appropriate form as the data are gathered. Reporting information is a critical part of documentation.

51.  Copyright 2002 by Delmar, a division of Thomson Learning 27-51 Documentation should reflect the objective data obtained from the examination regarding the client’s current condition. Abnormal findings should be addressed when planning the nursing care and client outcomes.