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Health Assessment 125
DAY TWO:
VITAL SIGNS
HEALTH HISTORY
PHYSICAL ASSESSMENT
HEALTH ASSESSMENT OF SKIN AND MENTAL
STATUS
JERRY THOMPSON RN, MSN
Vital Signs and Physical Assessment
At the completion of this class the student will be able to:
 Describe factors that effect vital signs and how to
measurement of them
 Explain how to take a health history
 Explain what is included in a physical assessment
 Demonstrate performing a general survey / mental
status exam
 Discuss how to assess the skin
The Nursing Process
 What is the first step? What do you do?
 What is the second step? What do you do?
 What is the third step? What do you do?
 What is the forth step? What do you do?
 What is the fifth step? What do you do?
 ADPIE
Task Based Nurse
Role Based Nurse
 What do they do?
 What do they do?
 Tasks.. Such as
 Manage patient care
 Vital signs
 Includes tasks and also…
 Dressing changes
 Collaboration with other
 Ambulating
 Giving medications
health care professionals
 Monitoring & follow
through
 MAKE DECISIONS
Vital Signs
Chapter 29
.
.
 Temperature, pulse, respiratory rate, blood
pressure
 Pain
 Oxygen saturation also frequently measured
 Vital signs are used to:
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To establish baseline data to compare to for future
measurements
Identify problems
Evaluate response to intervention
Temperature Alterations
• Acceptable temperature range:
• 96.8° F to 100.4° F or 36° C to
38° C
• Pyrexia / Hyperthermia (fever):
important defense mechanism
• Febrile/afebrile
• Hypothermia
What causes Hyperthermia?
Hypothermia?
Assessing Body Temperature
Electronic Thermometer
Temporal Artery Thermometer
Chemical Dot Thermometer
Temperature sites:
Oral, rectal, axillary, and
tympanic membrane
Assessment of Pulse
+ Apical
 Rate = normal 60-100

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Bradycardia < 60
Tachycardia > 100
Pulse deficit = Difference between radial
and apical pulse rates
 Rhythm
 Dysrhythmia: irregular or regularly irregular
 Strength: 4+, 3+, 2+ (normal), 1+, 0
Where would you assess the pulse of an
infant?
Unresponsive and not breathing?
Assessment of Respirations
 Easy to assess
 Respiratory rate: breaths/minute
 Ventilatory depth: deep, normal, shallow
 Ventilatory rhythm: regular/irregular
 Diffusion and perfusion
What is the preferred method of assessing
Respirations?
Breathing Patterns
12 to 20 for an adult.
bradypnea <12
 Bradypnea
 Tachypnea
 Hyperpnea
tachypnea > 20
 Apnea
newborn / infant = 30 to 60
 Hyperventilation
1 year old = 20 to 40
2 year old = 20 to 30
8 year old = 15 to 25
16 year old = 15 to 20
 Hypoventilation
 Cheyne-Stokes
respiration
 Kussmaul’s respiration
 Biot’s respiration
Measurement of arterial oxygen saturation
(SaO2)
 Percent of hemoglobin that is bound with oxygen in
the arteries

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Usually 95% to 100%
Pulse oximeter
What can interfere with accurate assessment?
Arterial Blood Pressure
 Force exerted on the walls of an artery by
pulsing blood under pressure from the heart

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Systolic = Maximum peak pressure during ventricular
contraction
Diastolic = Minimal pressure during ventricular
relaxation
 Pulse pressure = Difference between systolic
and diastolic pressures
 http://vimeo.com/8068713
Physiology of Arterial Blood Pressure
Factors affecting arterial blood pressure:
Cardiac output
Peripheral resistance
Blood volume
Viscosity
Elasticity
Blood pressure levels
(from http://www.heart.org)
Blood Pressure
Category
Normal
Systolic
mm Hg
(upper #)
Diastolic
mm Hg (lower #)
less than 120
and
less than 80
Prehypertension
120 – 139
or
80 – 89
High Blood Pressure
(Hypertension) Stage 1
140 – 159
or
90 – 99
High Blood Pressure
(Hypertension) Stage 2
160 or higher
or
100 or higher
Hypertensive Crisis
(Emergency care needed)
Higher than
180
or
Higher than 110
Hypertension versus Hypotension

Hypertension
 More common than
hypotension
 Thickening of walls
 Loss of elasticity
 Family history
 Risk factors

Hypotension
 Systolic <90 mm Hg
 Dilation of arteries
 Loss of blood
volume
 Decrease of blood
flow to vital organs
 Orthostatic/postural
Pain
 ALWAYS assess for pain
when taking vitals and
after providing pain
relief measures
 Location / character /
Level / what can help to
relieve?
Rate on a Scale of 1 to 10
Pain assessment PQRST
 P = Provocation and
Palliation

Quantity
How does it feel, look or
sound?
How much of it is there?
 R = Region and
Radiation
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What causes it?
What makes it better?
What makes it worse?
 Q = Quality and

 S = Severity and Scale
Where is it?
Does it spread?
Does it interfere with
activities?
How does it rate on a
severity scale of 1 to 10?
 T = Timing and Type
of Onset

When did it begin?
How often does it
occur?
Is it sudden or gradual
Health History
 Primary subjective data
 Biographical data : name, age,
sex
 Chief complaint / reason for
visit
 History of present illness
 History of other illnesses
 Family history of illnesses
 Review of systems head to toe
(asking questions, receiving
subjective data)
 Life style = personal habits,
diet, sleep patterns, amount of
exercise etc…
 Social data = support systems,
occupation
 Psychological data,
observations of both verbal and
nonverbal queues.
Description of Chief complaint
 When did the symptoms first appear?

Was it sudden or gradual?
 How often does the problem occur?
 Exact location of distress?
 Character of the complaint

Intensity of pain / quality of sputum / amount of discharge …
 Factors that aggravate or relieve symptoms
Methods of Data Collection
 Patient-centered interview = An organized
conversation with the patient
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Set the stage (preparation, environment, greeting).
Set an agenda/gather information about patient’s
concerns.
Collect the assessment or nursing health history; assure
the patient of confidentiality.
Terminate the interview (cue the end).
Interview Techniques
 Open-ended vs. closed-ended questions
 Back-channeling
 Probing
------------------------------------------ Because a patient’s report includes subjective
information, validate data from the interview
later with objective data.
 Obtain information (as appropriate) about a
patient’s physical, developmental, emotional,
intellectual, social, and spiritual dimensions.
Physical Examination
Chapter 30
,


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Assessment of each body system
Follows the nursing history
Systematic and organized
Head-to-toe approach
Techniques of Physical Assessment
 Inspection
 Palpation
 Percussion
 Auscultation
Inspection
 Use adequate lighting.
 Use direct lighting to inspect body cavities.
 Inspect each area for size, shape, color,
symmetry, position, and abnormality.
 Position and expose body parts as needed so all
surfaces can be viewed but privacy can be
maintained.
 When possible, check for symmetry.
 Validate findings with the patient.
 What do you assess by inspection?
Palpation
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Used to gather information
Use different parts of hands to detect different characteristics
Hands should be warm, fingernails short.
Start with light palpation; end with deep palpation.
What do you assess by Palpation?
Percussion
 Tap body with fingertips to produce a vibration.
 Sound determines location, size, and density of
structures.
Auscultation
 Involves listening to sounds
 Learn normal sounds first before identifying
abnormal sounds or variations.
 Requires a good stethoscope
 Requires concentration and practice
Bed Side Assessment
Your lab “final” will consist of a Bed Side Assessment
 Vital signs
 General Survey & Mental Status
 Skin
 Chest / Lungs
 Heart & Major Vessels
 Peripheral Vascular Assessment
 Abdominal Assessment
 Neurological Assessment
General Survey / Mental Status
what are we assessing?
Mental status
 Overall observation (grooming / appearance / odor? posture & gait)
 Oriented to Person, Place, Time (oriented X 3)
 Affect / Mood (appropriateness of responses / cooperative)
 Speech (fast / slurred / slow / clear)
 Able to express thought clearly / reality based
 Any expressed concerns?
General Survey / Mental Status
documentation
 Slender female with good posture and steady gait.
Cooperative and friendly, able to maintain eye
contact while conversing. Speech at normal rate
and easily understood, she is oriented to person,
place and time and situation. Able to express
thoughts clearly.
Skin
 Integument
 Color
 Pigmentation
 Cyanosis
 Jaundice
 Erythema
 Moisture
 Temperature
 Texture
 Turgor
Skin (cont’d)
 Vascularity
 ABCD:
 Edema
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 Lesions
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Asymmetry
Border irregularity
Color
Diameter
Skin (cont’d)
Skin
 Inspect for color
 Assess edema if present
 List any lesions / describe
 Assess for moisture
 Assess for temperature / compare bilaterally
 Assess for skin turgor
Assessment
Condition of the Skin documentation
 Client has no current complaints associated with
the skin. Skin color is uniform and warm to touch.
Skin intact with no moisture, edema or lesions
noted. Skin turgor is good with no tenting.
HESI
 Go to: https://evolve.elsevier.com

 COURSE ID: 10358_nhaugen_1007

 USE SAMUEL MERRITT EMAIL WHEN SETTING
UP AN ACCOUNT
What did we cover today?
 Vital signs
 Health history
 Physical assessment
 Assessing General survey & the skin