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VITAL SIGNS Also known as CARDINAL SIGNS. Utilized to monitor the functions of the body.

ody. It reflects the changes in the body that otherwise might not be observed. There are four vital signs namely: o Body temperature o Pulse rate o Respiration rate o Blood pressure PAIN is also included as the fifth vital sign. Monitoring a clients vital sign shouldnt be a routine procedure rather, a thoughtful and scientific assessment. Vital signs are evaluated in terms of clients present and past health status and compared to accepted normal standards. These are the normal ranges of vital signs: Body temperature : 97.8-99.1 F = 37 C (Ave.: 98.6 F; 37 C ) Pulse rate : 60-80 beats per minute (at rest) Respiration rate : 12-18 breaths per minute Blood pressure : 120/80 mm/Hg

TIMES TO ASSESS VITAL SIGNS Upon admission to a health care agency to obtain baseline data. When a client has a change in health status or reports symptoms such as chest pain or feeling hot or faint. According to a nursing or medical order. Before and after surgery or an invasive diagnostic procedure. Before and after the administration of a medication that could affect the respiratory or cardiovascular systems. Before and after any nursing intervention that could affect the vital signs.

TECHNIQUES FOR OBTAINING VITAL SIGNS OF INFANTS AND CHILDREN Due to fear factor of blood pressure measurement, save the blood pressure for last. Perform as many task as possible while the child is sitting on the parents lap or in a chair next to the parent.

Let the child see and touch the equipment before you begin using it. Make measuring vital signs a game. If the child has a doll or stuffed animal, pretend to take the dolls vital signs first.

BODY TEMPERATURE Reflects the balance between the heat produced and the heat lost from the body. Measured in heat units called DEGREES CLASSIFICATIONS OF BODY TEMPERATURE CORE TEMPERATURE o Refers to the temperature of the deep tissues of the body, such as the the abdominal cavity and pelvic cavity. o Remains relatively constant. o Normal ranges: ORAL RECTAL TEMPERATURE Early morning Early morning 36 C Cold weather Cold weather Normal range Normal range 37 C Hard work, emotion Hard work, emotion Few normal adults Few normal adults 38 C Many active children Many active children Hard exercise 39-40 C SURFACE TEMPERATURE o Temperature of the skin, the subcutaneous tissue, and fat. o It by contrast rises and falls in answer to the environment.

HEAT BALANCE The amount of heat produced by the body equals the amount of heat lost. FACTORS AFFECTING THE BODYS HEAT PRODUCTION BASAL METABOLIC RATE (BMR) o The rate of energy utilization in the body required to maintain essential activities such as breathing. o It decreases with age MUSCLE ACTIVITY o It increases the metabolic rate.

THYROXINE OUTPUT o Increased output of these increases the rate of cellular metabolism throughout the body thereby effecting a chemical thermogenesis. Chemical thermogenesis The stimulation of heat production in the body through increased cellular metabolism. EPINEPHRINE, NOREPINEPHRINE AND SYMPATHETIC STIMULATION o These hormones immediately increase the rate of cellular metabolism in many body tissues. o Epinephrine and Norepinephrine affect liver and muscle cells, thereby increasing cellular metabolism. FEVER o It increases the cellular metabolic rate and thus increases the bodys temperature further.

RADIATION The transfer of heat from the surface of one object to the surface of the other without contact between the two objects. Mostly in the form of infrared rays.

CONDUCTION The transfer of heat from one molecule to a molecule of lower temperature. It cannot take place without contact between the molecules and normally accounts for a minimal heat loss, except for example when a body is immersed in cold water. CONVECTION The dispersion of heat by air currents. The body has usually a small amount of warm air adjacent to it, and this warm air is replaced by cooler air, thus people always lose a small amount of heat through convection. VAPORIZATION The continuous evaporization of moisture from the respiratory tract and from the mucosa of the mouth and from the skin.

o INSENSIBLE WATER LOSS The continuous and unnoticed water loss o INSENSIBLE HEAT LOSS The accompanying heat loss to water loss. When the body temp. increases, vaporization accounts for greater heat loss.

REGULATION OF BODY TEMPERATURE The system that regulates the body temperature has three main parts: o Sensors in the shell and in the core. o Integrator in the hypothalamus o Effector system that adjusts the production and loss of heat. Most sensory receptors are in the skin. The skin has more receptors for cold than warmth. When the skin becomes chilled, three physiologic processes takes place to increase body temperature: o Shivering increases body temp. o Sweating is inhibited to decrease heat loss. o Vasoconstriction decreases heat loss. HYPOTHALAMIC INTEGRATOR o The center that controls the core temperature. o Located in the preoptic area of the hypothalamus. o When this system is stimulated, the person automatically makes appropriate adjustments in response to the temperature of the environment.

FACTORS AFFECTING BODY TEMPERATURE AGE o Infants are greatly influenced by the temp. of the environment that is why they should be protected from extreme changes. o Childrens temp. are more variable than those of adults until puberty. o Majority of the older people especially those at the age of 75 Y.O. are at the risk of hypothermia for a variety of reasons. o Older people are also particularly sensitive to extremes in the temp. of the environment due to decreased thermoregulatory controls. DIURNAL VARIATIONS (CIRCADIAN RYTHMS)

o Body temperatures normally changes throughout the day, varying as much as 1C bet. The early morning and the late afternoon. o The point of highest body temp. is usually reached bet. 8PM and midnight. o The lowest point is reached during sleep bet. 4 and 6 AM EXERCISE o Hard work or strenuous exercise can increase body temp. to as high as 38.3 - 40C measured rectally. HORMONES o Women experience more hormone fluctuation than men. o In women, progesterone secretion during ovulation increases the body temperature by about 0.3 0.6C above basal temperature. STRESS o Stimulation of the sympathetic nervous system could increase the production of the Epinephrine and Norepinephrine, thus increasing the metabolic activity and heat production. ENVIRONMENT o Extremes in environmental temperature could affect a persons temp. regulatory systems.

TEMPERATURE ALTERATIONS There are two primary alterations in the body temperature namely: o Pyrexia o Hypothermia PYREXIA o A body temperature above the usual range is called pyrexia, hyperthermia, fever. o A very high fever, such as 41C is called hyperpyrexia o A client with fever is referred to as febrile, and the one who has not is afebrile o Kinds of fever: Intermittent The body temperature alternates at regular intervals between periods of fever and periods of normal or subnormal temperatures.

Remittent A wide range of fluctuating temperatures (more than 2C) occurs over the 24-hr period, all of which are above normal. Relapsing Short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature. Constant The body temperature fluctuates minimally but always remains above normal. A fever that rises to fever level rapidly following a normal temperature and then returns to normal temperature within a few hours is called a fever spike o CLINICAL SIGNS OF FEVER Onset (cold or chill stage) Increased heart rate Increased R.R. and depth Shivering Pallid, cold skin Complaints of feeling cold Cyanotic nail beds Gooseflesh appearance of the skin Cessation of sweating Course Absence of chills Skin that feels warm Photosensitivity Glassy-eyed appearance Increased pulse and respiratory rates Increased thirst Mild to severe dehydration Drowsiness, restlessness, delirium, or convulsions Herpetic lesions of the mouth Loss of appetite (if ever the fever is prolonged) Malaise, weakness, and aching muscles Defervescence (fever abatement) Skin that appears flushed and feels warm Sweating

Decreased shivering Possible dehydration o NURSING INTERVENTIONS FOR CLIENTS WITH FEVER Monitor vital signs Assess skin color and temperature Monitor white blood cell count, hematocrit value, and other pertinent laboratory reports for indications of infection or dehydration. Remove excess blankets when the client feels warm, but provide extra warmth when the client feels chilled. Provide adequate nutrition and fluids to meet the increased metabolic demands and prevent dehydration. Measure intake and output Reduce physical activity to limit heat production, especially during the flush stage. Administer antipyretics (drugs that reduce the level of fever) as ordered. Provide oral hygiene to keep the mucous membranes moist. Provide a tepid sponge bath to increase heat loss through conduction. Provide dry clothing and bed linens. HYPOTHERMIA o A core body temperature below the lower limit of normal o The 3 physiologic mechanisms of hypothermia are: Excessive heat loss Inadequate heat production to counteract heat loss Impaired hypothalamic thermoregulation o Hypothermia could be accidental or induced Accidental Due to exposure to a cold environment Immersion in cold water Lack of adequate clothing, shelter, or heat Induced

The deliberate lowering of the body temperature to decrease the need of oxygen by the body tissues Can involve the whole body or a part only.

o CLINICAL SIGNS OF HYPOTHERMIA Decreased body temperature, pulse, and respirations Severe shivering (initially) Feelings of cold and chills Pale, cool, waxy skin Hypotension Decreased urinary output Lack of muscle coordination Disorientation Drowsiness progressing to coma

o NURSING INTERVENTIONS FOR CLIENTS WITH HYPOTHERMIA Provide a warm environment Provide dry clothing Apply warm blankets Keep limbs close to the body Cover the clients scalp with a cap or turban Supply warm oral or intravenous fluids Apply warming pads

CONVERTING CELSIUS TO FAHRENHEIT Fahrenheit to Celsius o F= (C x 9/5) + 32 Celsius to Fahrenheit o C= (F-32) x 5/9

TEMPERATURE ASSESSMENT There the: o o o are four common sites in the body for obtaining temperature, which are Oral Rectal Axillary

o Tympanic membrane ADVANTAGES AND DISADVANTAGES OF THE FOUR SITES FOR BODY TEMPERATURE MEASUREMENT SITE Oral ADVANTAGES Accessible Convenient DISADVANTAGES Glass thermometers can break if bitten Inaccurate if client has just ingested hot or cold food or fluid or smoked. Could injure the mouth following oral surgery. Inconvenient and more unpleasant for clients Difficult for client who cannot turn to the side A rectal glass thermometer does not respond to changes in arterial temperatures as quickly as an oral thermometer, a fact that may be potentially dangerous for febrile clients because misleading information may be acquired.

Rectal

Reliable measurement

Axillary

Safe Noninvasive Readily accessible Reflects the core

Tympanic Membrane

Presence of stool may interfere with the thermometer placement, if the stool is soft, the thermometer may be embedded in the stool rather than against the wall of the rectum The thermometer must be left in place a long time to obtain an accurate measurement Can be uncomfortable and involves risk of injuring the

temperature, fast

very

membrane if the probe is inserted too far Repeated measurements may vary Right and left measurements can differ Presence of cerumen can affect the reading

EQUIPMENTS IN ASSESSMENT OF BODY TEMPERATURE Thermometer o TYPES OF THERMOMETER Mercury-in-glass Chemical disposable thermometer thermometers Oral thermometers Temperature- sensitive tape Rectal thermometers Infrared thermometers Electronic thermometers Disposable probe covers Water-soluble lubricant for rectal temperature measurement Sterile gloves, if appropriate Toilet tissue, if needed Pencil or pen, paper or flowsheet Oral temperature Assess the patient to ensure that his or her cognitive functioning is intact. Assess whether the patient can close his or her lips around the thermometer. Oral temperature measurement is contraindicated in patients with diseases of the oral cavity and those who have had surgery on the nose or mouth. Ask the patient if he or she had recently smoked, has been eating chewing gum, or was eating or drinking immediately before assessing temperature. If any of these has occurred, wait 15 to 30 minutes before taking an oral temperature because of the possible direct influence on the patients temperature.

Rectal Temperature

Review the patients most recent platelet count. Do not insert a rectal thermometer into a patient who has a low platelet count. The rectum is very vascular, and a thermometer could cause rectal bleeding. Measure rectal temperature is contraindicated in newborns, small children, and in patients who have had rectal surgery, or have diarrhea or disease of the rectum. Measurement of a rectal temperature for patients with certain heart diseases or after cardiac surgery is contraindicated in some institutions. Insertion of the thermometer into the rectum can slow heart rate by stimulating the vagus nerve.

Tympanic Temperature If the patient has an earache, do not use the affected ear to take a tympanic temperature. Assess the patient for significant air drainage or a scarred tympanic membrane. These conditions can provide inaccurate results and could cause problems for the patient.

Nursing Diagnosis Risk of trauma Hyperthermia Hypothermia Risk for imbalanced body temperature Ineffective Thermoregulation

Outcome Identification and Planning Patients temperature is assessed accurately without injury and the patient experiences minimal discomfort.

Implementation ACTION RATIONALE

1. Check the physician's order or nursing care plan for frequency and route. More frequent temperature measurement may be appropriate based on nursing judgment. 2. Identify the patient. Discuss procedure with patient and assess patient's ability with procedure.

Provides for patient safety

Identifying the patient ensures the right patient receives the intervention and helps prevent errors. This discussion promotes reassurance and provides knowledge about the procedure. Dialogue encourages patient participation and allows for individualized nursing care. 3. Ensure the electronic or digital Improperly functioning thermometer may thermometer is in working condition. not give an accurate reading. 4. Close curtains around bed and close Provides for patient privacy. door to room if possible. 5. Perform hand hygiene and put on Hand hygiene deters the spread of gloves if appropriate or indicates. microorganisms. Gloves prevent contact with blood and bloody fluids. Gloves are usually not required for an oral, axillary, or tympanic temperature measurement unless contact with blood or body fluids is anticipated. Gloves should be worn for rectal temperature measurement. 6. Select the appropriate site based on Ensures safety and accuracy of treatment. previous assessment data. 7. Follow the steps as outlined below for the appropriate type of thermometer. 8. When measurement us completed Hand hygiene deters the spread of remove gloves, if worn. Perform hand microorganisms. hygiene.

Assessing Oral Temperature ACTION RATIONALE

1. Remove the electronic unit from the Electronic unit must be taken into the charging unit, and remove the probe from patient's room to assess the patient's within the recording unit. temperature. On some models, by removing the probe, the machine is already turned on. 2. Cover the thermometer probe with Using a cover prevents contamination of disposable probe cover and slide it until it the thermometer probe snaps into place. 3. Place the probe beneath the patient's When the probe rests deep in the posterior tongue in the posterior sublingual pocket. sublingual pocket, it is contact with blood Ask patient to close his or her lips around vessels lying close to the surface. the probe. 4. Continue to hold the probe until you If left unsupported, weigh of the probe hear a beep. Note the temperature tends to pull it away from the correct reading. location. The signal indicates the measurement is completed. The electronic thermometer provides digital display of the measured temperature. 5. Remove the probe from the patient's Disposing of the probe cover ensues that it mouth. Dispose of the probe cover by will not be reused accidentally on another holding the probe over an appropriate patient. Proper disposal prevents spread of receptacle and pressing the probe release microorganisms. button. 6. Return the thermometer probe to the The thermometer needs to be recharged storage place within the unit. Return the for future use. If necessary, the electronic unit to the charging unit, if thermometer should stay on the charger so appropriate. that it is ready to use at all times.

Assessing Rectal Temperature ACTION 1. Place the bed at an appropriate working height. Put on nonsterile gloves. 2. Assist the patient to a side-lying position. Pull back the covers enough to expose only the buttocks. RATIONALE Having the bed at right height reduces strain on the nurse's back. The side-lying position allows the nurse to visualize the buttocks. Exposing only the buttocks keeps the patient warm and maintains as his or her dignity.

3. Remove the rectal probe from within the recording unit of the electronic thermometer. Cover the probe with a disposable probe cover and slide it into place until it snaps in place. 4. Lubricate about 1" of the probe with a water soluble lubricant. 5. Reassure the patient. Separate the buttocks until the anal sphincter is clearly visible. 6. Insert the thermometer probe into the anus about 1.5" in an adult or 1" in a child. 7. Hold the probe in place until you hear a beep, and then carefully remove the probe. Note the temperature reading on the display.

Using a cover prevents contamination of the thermometer.

8. Dispose of the probe cover by holding the probe over an appropriate waste receptacle and pressing the release button. 9. Using toilet tissue, wipe the anus of any feces or excess lubricant. Dispose toilet tissue. 10. Cover the patient and help him or her to a position of comfort. 11. Remove gloves and discard them. Perform hand hygiene. 12. Place the bed in the lowest position; elevate rails as needed. 13. Return the thermometer to the charging unit.

Lubrication reduces friction and facilitates insertion, minimizing the risk of irritation to the rectal mucous membranes. If not places directly into the anal opening, the thermometer probe may injure adjacent tissue or cause discomfort. Depth insertion must be adjusted based in the patient's age. Rectal temperature are not normally taken in an infant. If left unsupported, movement of the probe in the rectum could cause injury and/or discomfort. The signal indicates the measurement is completed. The electronic thermometer provides a digital display of the measurement temperature. Proper probe cover disposal reduces risk of microorganism transmission.

Wiping promotes cleanliness. Disposing of the toilet tissue avoids transmission of microorganisms. Ensures patient comfort. Hand hygiene avoids transmission of microorganisms. These actions provide for the patient safety. The thermometer needs to be recharged for future use.

ACTION 1. Place the bed at an appropriate working height. 2. Move the patient's clothing to expose only the axilla.

RATIONALE Having the bed at the right height reduces strain on the nurse's back. The axilla must be exposed for placement of the thermometer. Exposing only the axilla keeps the patient warm and maintains his or her dignity. 3. Remove the probe from the recording Using a cover prevents contamination of unit of the electronic thermometer. Place a the thermometer probe. disposable probe cover by sliding it on and snapping it securely. 4. Place the end of the probe in the center The deepest area of the axilla provides the of the axilla. Have the patient bring the most accurate measurement; surrounding arm down and close to the body. the bulb with skin surface provides a more reliable measurement. 5. Hold the probe in place until you hear a Axillary thermometers must be held in beep and then carefully remove the probe. place to obtain an accurate temperature. Note the temperature reading. 6. Cover the patient and help him or her to Ensures patient's comfort. a position of comfort. 7. Dispose of the probe cover by holding Discarding the probe cover ensures that it probe over an appropriate waste will not be reused accidentally on another receptacle and pushing the release button. patient. 8. Place the bed in the lowest position and Low bed position and elevated side rails elevate rails as needed. Leave the patient provide from patient safety. clean and comfortable. 9. Return the electronic thermometer to Thermometer needs to be recharged for the charging unit. future use. Assessing Axillary Temperature

EVALUATION

Patients temperature is assessed accurately without injury and the patient experiences minimal discomfort.

Pulse

Pulse is the palpable bounding of the blood flow in a peripheral artery. It is a wave of blood created by contraction of the left ventricle of the heart. It represents the tactile arterial palpation of the heartbeat. The pulse waves represent the stroke volume output and the amount of blood that enters the arteries with each ventricular contraction.

Circulatory system control Pulse is regulated by the autonomic nervous system through the cardiac sinoatrial node (often called the pacemaker) Parasympathetic stimulation via the vagus nerve decreases the heart rate, and Sympathetic stimulation increases the heart rate and force of contraction Heart rate and rhythm Heart rate The heart rate increases and decreases in response to a variety of physiologic mechanisms. The heart rate tells how often a persons heart beats per minute. The normal adult heart rate is 60 to 100 beats per minute (BPM). Bradycardia is a heart rate less than 60 bpm in an adult Tachycardia is a heart rate in excess of 100 bpm in a normal adult Rhythm It is the pattern of the pulsations and the pauses between them. An irregular rhythm caused by an early, late, or missed heartbeat is called dysrhythmia. Factors affecting the heart rate: Age- as age increases, the pulse gradually decreases Age Approx. Range Approx. Average Newborn to 1 mo 120-160 140 1 to 12 mo 80-140 120 12 mo to 2 yr 80-130 110 2 to 6 yr 75-120 100 6 to 12 yr 75-110 95 Adolescence to adult 60-100 80

Gender- after puberty the average males pulse rate is slightly lower than the females Exercise- the pulse rate normally increases with activity. The rate of increase in the professional athlete is often less than in the average person because of greater cardiac size, strength, and efficiency. Disease process- the pulse rate increases (a) in response to the lowered blood pressure that results from peripheral vasodilatation associated with elevated body temperature and (b) because of the increased metabolic rate. Medications- some medications decrease the pulse rate, and others increase it (e.g. Cardiotonics- digitalis preparations decrease the heart rate whereas epinephrine increases it) Hypovolemia- loss of blood from the vascular system normally increases pulse rate. In adults, the loss of circulating volume results in an adjustment of the heart rate to increase blood pressure as the body compensates for the lost blood volume. Adults can usually lose up to 10% of their normal circulating volume without adverse effects. Stress- in response to stress, sympathetic nervous stimulation increases the over-all activity of the heart. It increases the rate as well as the force of the heartbeat. Fear and anxiety as well as the perception of severe pain stimulate the sympathetic system. Position changes- when a person is sitting or standing, blood usually pools in dependent vessels of the venous system. Pooling results in a transient decrease in the venous blood return to the heart and the subsequent reduction in the blood pressure and increase in heart rate. Pathology- certain diseases such as some heart conditions or those that impair oxygenation can alter the resting pulse rate.

Evaluating pulse quality Pulse Quality refers to the feel of the pulse, its rhythm and forcefulness. The pulse amplitude describes the quality of the pulse in terms of its fullness and reflects the strength of left ventricular contraction. It assessed by the feel of the blood flow through the vessel. Pulse rate assessment The nurse should begin the assessment by speaking with the client about the normal pulse rate. The clients medical record should be reviewed for baseline data, if available, and any medications that could affect the heart rate should be noted

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.

Taking radial pulse Purposes To establish baseline data for subsequent evaluation

Assessment Clinical signs of cardiovascular alterations, other than pulse rate, rhythm, or volume (e.g., dyspnea, fatigue, pallor, cyanosis, syncope) Factors that may alter pulse rate (e.g., emotional status, activity level, and medications that affect heart rate such as digoxin, beta blockers, or calcium channel blockers) Planning Delegation Due to the degree of skill and knowledge required, UAP are generally not responsible for assessing apical pulses. Equipment Watch with a second hand or indicator Implementation ACTION

Rationale 1. Reduces transmission of 1. Perform hand hygiene. microorganisms. 2. Inform client of the site(s) at which you 2. Encourages participation and allays will measure pulse. anxiety. 3. Maintains wrist in full extension and exposes artery for palpation. Placing 3. Flex clients elbow and place lower part clients hand over chest will facilitate of arm across chest. later respiratory assessment without undue attention to your action.

4. Support clients wrist by grasping outer 4. Stabilizes wrist and allows pressure to aspect with thumb. be exerted. 5. Fingertips are sensitive, facilitating 5. Place your index and middle finger on palpation of pulsating pulse. Feel your inner aspect of clients wrist over the own pulse if palpating with thumb. radial artery and apply light but firm Applying light pressure prevents pressure until pulse is palpated. occlusion of blood flow and pulsation. 6. Palpate pulse until rhythm is 6. Identify pulse rhythm. determined. Describe as regular or irregular. 7. Quality of pulse strength is an indication 7. Determine pulse volume. of stroke volume. Describe as normal, weak or strong. 8. An irregular rhythm requires a full minute of assessment to identify the number of inefficient cardiac contractions that fail to transmit a 8. Count pulse rate by using second hand pulsation referred to as a skipped or on watch. irregular beat. For a regular rhythm, count number of beats for 30 seconds and multiply by 2. For an irregular rhythm, count number of irregular beats. Taking apical pulse Purposes To establish baseline data for subsequent evaluation To obtain the heart rate of newborns, infants, and children 2 to 3 years old or of an adult with irregular peripheral pulse To determine whether the cardiac rate is within the normal range and the rhythm is regular To monitor clients with cardiac disease and those receiving medications to improve heart ac Assessment Clinical signs of cardiovascular alterations, other than pulse rate, rhythm, or volume (e.g., dyspnea, fatigue, pallor, cyanosis, syncope)

Factors that may alter pulse rate (e.g., emotional status, activity level, and medications that affect heart rate such as digoxin, beta blockers, or calcium channel blockers)

Planning Delegation Due to the degree of skill and knowledge required, UAP are generally not responsible for assessing apical pulses.

Equipment Watch with a second hand or indicator Stethoscope Antiseptic wipes If using a DUS, the transducer probe, the stethoscope headset, transmission gel, and tissues/wipes.

Implementation Action 1. Perform hand hygiene. 1. 2. 2. Cleanse earpiece and diaphragm of stethoscope with an alcohol swab. 3. 4. 5.

3. Put stethoscope around your neck. 4. Raise clients gown to expose sternum and left side of chest. 5. Locate apex of heart: With client lying on left side, locate suprasternal notch. Palpate second intercostals space to left of sternum. Place index finger in intercostal space, counting downward until fifth intercostal space is located. Move index finger along fourth intercostal space, left from the midclavicular line to palpate the

Rationale Reduces transmission of microorganisms. Decreases transmission of microorganisms from one practitioner to another (earpiece) and from one client to another (diaphragm). Ensure stethoscope is nearby for frequent use. Allows access to clients chest proper placement of stethoscope. Identification of landmarks facilities correct placement of the stethoscope at the fifth intercostals space in order to hear point of maximal impulse. Ensures correct placement of stethoscope.

point of maximum impulse (PMI). Keep index finger of nondominant hand on the PMI. 6. Inform client that you are going to listen to his heart. Instruct client to remain silent.

6. Elicits client support. Stethoscope amplifies noise.

1. With dominant hand, put earpiece of the stethoscope in your ears and grasp diaphragm of the stethoscope in palm of your hand for 5 to 10 seconds. 2. Place diaphragm of stethoscope over the PMI and auscultate for sounds S1 and S2 to hear lub-dub sound.

3. Note regularity of rhythm. 4. Start to count while looking at second hand of watch. Count lubhub sound as one beat: For a regular rhythm, count rate for 30 seconds and multiply by 2. For an irregular rhythm, count rate for a full minute, noting number of irregular beats. 5. Share your findings with client. 6. Record by the site the rate, rhythm, and, if applicable, number of irregular beats. 7. Perform hand hygiene.

1. Dominant hand facilitates psychomotor dexterity for placement of earpiece with one hand. Heat warms metal or plastic diaphragm and prevents startling client. 2. Movement of blood through the heart valves creates S1 and S2 sounds. Listen a regular rhythm (heartbeats are evenly spaced) before counting. 3. Establishment of a rhythmic pattern determines length of time to count the heartbeats to ensure accurate measurement.

4. Ensure

sufficient time to count irregular beats.

5. Promotes client participation care. 6. Record rate and characteristics at

bedside to ensure accurate documentation. 7. Reduces transmission of microorganisms.

Taking apical-radial pulse

Purposes To determine adequacy of peripheral circulation or presence of pulse deficit

Assessment Clinical signs of hypovolemic shock (hypotension, pallor, cyanosis, and cold, clammy skin)

Planning Delegation UAP are generally not responsible for assessing apical-radial pulses using the one-nurse technique. UAP may perform the radial pulse count for twonurse technique. Equipment Watch with a second hand or indicator Stethoscope Antiseptic wipes Implementation *This is performed by two nurses. Action Rationale Perform hand hygiene. 1. Reduces transmission of microorganisms. Inform client of the site(s) at which 2. Encourages participation and allays you will measure pulse. anxiety. Cleanse earpiece and diaphragm of 3. Decreases transmission of stethoscope with an alcohol swab. microorganisms from one practitioner to another (earpiece) and from one client to another (diaphragm). Flex clients elbow and place lower 4. Maintains wrist in full extension and part of arm across chest. (For radial exposes artery for palpation. pulse); Raise clients gown to Placing clients hand over chest will expose sternum and left side of facilitate later respiratory chest. (for apical pulse) assessment without undue attention to your action; Allows access to clients chest proper placement of

1. 2. 3.

4.

5. Support clients wrist by grasping outer aspect with thumb.( for radial pulse); 6. Locate apex of heart: With client lying on left side, locate suprasternal notch. Palpate second intercostals space to left of sternum. Place index finger in intercostal space, counting downward until fifth intercostal space is located. Move index finger along fourth intercostal space, left from the midclavicular line to palpate the point of maximum impulse (PMI). Keep index finger of nondominant hand on the PMI.

stethoscope. 5. Stabilizes wrist and allows pressure to be exerted; 6. Identification of landmarks facilities correct placement of the stethoscope at the fifth intercostals space in order to hear point of maximal impulse. Ensures correct placement of stethoscope.

1. Inform client that you are going to listen to his heart. Instruct client to remain silent. (For apical pulse); Place your index and middle finger on inner aspect of clients wrist over the radial artery and apply light but firm pressure until pulse is palpated. (for radial pulse) 2. With dominant hand, put earpiece of the stethoscope in your ears and grasp diaphragm of the stethoscope in palm of your hand for 5 to 10 seconds. 3. Place diaphragm of stethoscope over the PMI and auscultate for sounds S1 and S2 to hear lub-dub sound.

4. Identify pulse)

pulse

rhythm.(for

radial

1. Elicits client support. Stethoscope amplifies noise; Fingertips are sensitive, facilitating palpation of pulsating pulse. Feel your own pulse if palpating with thumb. Applying light pressure prevents occlusion of blood flow and pulsation. 2. Dominant hand facilitates psychomotor dexterity for placement of earpiece with one hand. Heat warms metal or plastic diaphragm and prevents startling client. 3. Movement of blood through the heart valves creates S1 and S2 sounds. Listen a regular rhythm (heartbeats are evenly spaced) before counting. 4. Palpate pulse until rhythm is determined. Describe as regular or irregular; Establishment of a rhythmic pattern determines length of time to count the heartbeats to ensure accurate measurement.

5. Start to count while looking at second hand of watch. Count lubhub sound as one beat: For a regular rhythm, count rate for 30 seconds and multiply by 2. For an irregular rhythm, count rate for a full minute, noting number of irregular beats. 6. Determine pulse volume. 7. Share your findings with client.

5. Ensure

sufficient time to count irregular beats.

8. Perform hand hygiene.

6. Quality of pulse strength is an indication of stroke volume. Describe as normal, weak or strong. 7. Promotes client participation care. 8. Reduces transmission of microorganisms.

Taking peripheral pulse Peripheral pulse is the series of waves of arterial pressure caused by left ventricular systoles as measured in the limbs. It is palpable in the extremities, e.g. legs, neck and head; the usual sites for measuring the pulse rate. Purposes To establish baseline data for subsequent evaluation To indentify whether the pulse rate is within the normal range To determine whether the pulse rhythm is regular and the pulse volume is appropriate To compare the equality of corresponding peripheral pulses on each side of the body To monitor and assess changes in the clients health status To monitor clients at risk for pulse alterations (e.g., those with a history of heart disease or experiencing cardiac arrhythmias, hemorrhage, acute pain, infusion of large volumes of fluids, fever)

Assessment Clinical signs of cardiovascular alterations, other than pulse rate, rhythm, or volume (e.g., dyspnea [difficult respirations], fatigue, pallor, cyanosis [bluish discoloration of skin and mucous membranes], palpitations, syncope[fainting], impaired peripheral tissue perfusion as evidenced by skin discoloration and cool temperature) Factors that may alter pulse rate (e.g., emotional status and activity level) Planning Delegation Measurement of the clients radial pulse can be delegated to UAP or family member/caregivers. Reports of abnormal pulse rates or rhythms require reassessment by the nurse, who also determines appropriate action if the abnormality is confined. Due to the skill required in locating and interpreting peripheral pulses other than the radial artery and in using Doppler ultrasound devices, UAPs are generally not delegated these techniques. Equipment

Watch with a second hand or indicator If using a DUS, the transducer probe, the stethoscope headset, transmission gel, and tissues/wipes

Implementation ACTION 1. Perform hand hygiene. 2. Draw curtain around bed and/or close the door 3. Inform client of the site(s) at which you will measure pulse. 4. Place your index and middle finger against the pulse site and applying gentle pressure. Pulse sites to be assessed generally include brachial, radial, femoral, popliteal, posterior tibial, and dorsalis pedis (pedal). 5. Identify pulse rhythm.

1. 2.

3. 4.

Rationale Reduces transmission of microorganisms. Enhances cooperation and participation; reduces anxiety and fear, which can affect readings. Encourages participation and allays anxiety. Fingertips are sensitive, facilitating palpation of pulsating pulse. Feel your own pulse if palpating with thumb. Applying light pressure prevents occlusion of blood flow and pulsation.

6. Determine pulse volume.

7. Count pulse rate by using second hand on watch.

8. Assess equality of pulses (amplitude and elasticity of vessel) bilaterally, i.e., right side compared to left side. Assess for any pulse deficit

5. Palpate pulse until rhythm is determined. Describe as regular or irregular. 6. Quality of pulse strength is an indication of stroke volume. Describe as normal, weak or strong. 7. An irregular rhythm requires a full minute of assessment to identify the number of inefficient cardiac contractions that fail to transmit a pulsation referred to as a skipped or irregular beat. For a regular rhythm, count number of beats for 30 seconds and multiply by 2. For an irregular rhythm, count number of irregular beats. 8. Determines if there is an unbalanced pulse between the different pulse points.

between upper extremities. 9. Perform hand hygiene

and

lower 9. Reduces transmission microorganisms. of

Pulse Point Temporal: over temporal superior and lateral to eye bone,

Carotid: bilateral, under lower jaw in neck along medial edge of sternocleidomastoid muscle Apical: left midclavicular line at fourth to fifth intercostals space Brachial: inner aspect between groove of biceps and triceps muscles at antecubital fossa Radial: inner aspect of forearm on thumb side of wrist Ulnar: outer aspects of forearm on finger side of wrist. Femoral: in groin, below inguinal ligament (midpoint between symphysis pubis and anterosuperior iliac spine) Popliteal: behind knee , at center in popliteal fossa Posterior tibial: inner aspect of ankle between Achilles tendon and tibia (below medial malleolus) Dorsalis pedis: over instep, midpoint between extension tendons of great and second toe RESPIRATION

Assessment Criteria Accessible; used routinely for infants and when radial is inaccessible Accessible; used routinely for infants and during shock or cardiac arrest when other peripheral pulses are too weak to palpate; also used to assess cranial circulation Used to auscultate heart sounds and assess apical-radial deficit Used in cardiac arrest for infants, to assess lower arm circulation, and to auscultate blood pressure Accessible; used routinely in adults to assess character of peripheral pulse Used to assess circulation to ulnar side of hand and to perform the Allens test. Used to assess circulation to legs and during cardiac arrest Used to assess circulation to legs and to auscultate leg blood pressure Used to assess circulation to feet

Used to assess circulation to feet

Is the act of breathing External Respiration- interchange of oxygen and carbon dioxide between the alveoli of the lungs and the pulmonary blood Internal Respiration- interchange of the same gases between the circulating blood and the cells of the body tissues Inhalation/ inspiration- intake of air into the lungs Exhalation/ expiration- breathing out or the movement of air in and out of the lungs

Assessment Resting respirations are assessed when the client is relaxed because exercise and the like affects respirations, rate and depth. Respirations may also need to be assessed after exercise to identify clients tolerance to activity. Before assessing a clients respiration, a nurse should be aware of the following: Normal breathing pattern Influence of the clients health problems Any medications or therapies Relationship of the clients respirations to cardiovascular function

The rate, depth and quality and effectiveness of respirations should be assessed. The respiratory rate is described in breaths per minute. Eupnea- breathing that is normal in rate and depth Bradypnea- breathing that is abnormally slow Tachypnea- breathing that is abnormally fast Apnea- absence of breathing

Anxiety also affects the respiratory rate and depth as well.

Types of breathing

Costal (thoracic) breathing- involves the external intercostal and accessory muscles, such as sternocleidmastoid muscles. Observed by the movement of the chest upward and outward. Diaphragmatic (abdominal) breathing- involves the contraction and relaxation of the diaphragm. Observed by the movement of the abdomen as a result of the diaphragms contraction and downward movement.

Mechanical control of breathing During inhalation, the diaphragm contracts or flattens. The ribs move upward and outward and the sternum, outward as well. During exhalation, the diaphragm relaxes. The ribs move downward and inward and the sternum, inward as well. Normal breathing is carried out automatically and effortlessly. Respiration is controlled by: Respiratory centers in the medulla oblangta and the pons of the brain Chemoreceptors located centrally in the medulla and peripherally in the carotid and aortic bodies

BLOOD PRESSURE

The arterial blood pressure is the lateral pressure, or force, exerted by the blood on a unit area of the blood vessel wall. The arterial blood pressure is constantly changing during the course of the cardiac cycle. Blood pressure measurements are helpful in evaluating cardiac output, fluid and circulatory status, and arterial resistance. Blood pressure measurements consist of systolic and diastolic readings. The systolic reading reflects the maximum pressure exerted on the arterial wall at the peak of left ventricular contraction. Normal systolic pressure ranges from 100 to 140 mm Hg. The diastolic reading reflects the minimum pressure exerted on the arterial wall during left ventricular relaxation. This reading is generally more significant than the systolic reading because it evaluates arterial pressure when the heart is at rest. Normal diastolic pressure ranges from 60 to 90 mm Hg.

The numerical difference between the two is the pulse pressure. A typical blood pressure is expressed thus: 120/80 mm Hg.

Physiology of Arterial Pressure A number of factors acting in dynamic equilibrium and integrated through the central nervous system, determine the arterial blood pressure: Pumping Action of the Heart When the pumping action of the heart is weak, less blood is pumped into arteries (lower cardiac output), and the blood pressure decreases. When the hearts pumping action is strong and the volume of blood pumped into the circulation increases (higher cardiac output), the blood pressure increases. Peripheral Vascular Resistance Peripheral resistance can increase blood pressure. The diastolic pressure especially is affected. Some factors that create resistance in the arterial system are the capacity of the arterioles and capillaries, the compliance of the arteries, and the viscosity of blood.

o Arteriosclerosis If the elastic and muscular tissues of the arteries are replaced with fibrous tissue, the arteries lose much of their ability to constrict and dilate.

Blood Volume When the blood volume decreases, the blood pressure decreases because of decreased fluid in the arteries. Conversely, when the volume increases, the blood pressure increases because of the greater fluid volume within the circulatory system. Blood Viscosity Blood Pressure is higher when the blood is highly viscous (thick), that is, when the proportion of red blood cells to the blood plasma is high. This proportion is referred to as the hematocrit. The viscosity increases markedly when the hematocrit is more than 60% to 65%

Blood pressure Variations Classification:

Arterial pressure varies in individuals from moment to moment

Category Hypotension Normal Prehypertension Primary Hypertension Secondary Hypertension

Systolic, mm Diastolic, Hg mm Hg <90 90-120 121-139 130-159 >160 <60 60-80 81-89 90-99 >100

Follow-up Recommended Recheck in 2 yrs. Recheck in 1 yr. Confirm within 2 mos. Refer to source of care within 1 mo. Refer to source of care immediately

(for Adults Age 18 Years and Older)

Hypotension is a blood pressure that is below normal, that is, a systolic reading consistently between 85-110 mm Hg in an adult whose normal pressure is higher than this. Can also be caused by analgesics such as meperidine hydrochloride (Demerol), bleeding, severe burns, and dehydration.

Orthostatic hypotension Is a blood pressure that falls when the client sits or stands. It is usually the result of peripheral vasodilatation in which blood leaves the central body organs, especially the brain, and moves to the periphery, often causing the person to feel faint.

It is important to monitor hypotensive clients carefully to prevent falls. When assessing for orthostatic hypotension: Place the client in a supine position for 2 to 3 minutes.

Record the clients pulse and blood pressure. Assist the client to slowly sit or stand. Support the client in case of faintness. After 1 minute in the upright position, recheck the pulse and blood pressure in the same sites as previously. Record the results. A rise in pulse of 40 beats per minute or a drop in blood pressure of 30 mm Hg indicates abnormal orthostatic vital signs.

Hypertension A Blood pressure that is persistently above normal. It is usually asymptomatic and is often a contributing factor to myocardial infarctions (heart attacks) Factors associated with hypertension include thickening of the arterial walls, which reduces the size of the arterial lumen, and inelasticity of the arteries as well as such lifestyle factors as cigarette smoking, obesity, heavy alcohol consumption, lack of physical exercise, high blood cholesterol levels, and continued exposure to stress. Follow-up care should include lifestyle changes conducive to lowering blood pressure as well as monitoring the pressure itself.

Prehypertention An above normal blood pressure with a diastolic reading of 80-89 or systolic blood pressures of 121-139 mm Hg and without intervention, may develop cardiac disease.

Primary Hypertension An elevated blood pressure of unknown cause. Is when the diastolic blood pressure is 90 mm Hg or higher or when the systolic blood pressure is higher than 140 mm Hg.

Secondary Hypertension An elevated blood pressure of known cause.

Factors affecting Blood pressure: Age Newborns have a mean systolic pressure of about 75 mm Hg. The pressure rises with age, reaching a peak at the onset of puberty , and then tends to decline somewhat. In older people, elasticity of the arteries is decreasedthe arteries are more rigid and less yielding to the pressure of the blood. This produces an elevated systolic pressure. Because the walls no longer retract as flexibility with decreased pressure, the diastolic pressure is also high. Exercise Physical activity increases the cardiac output and hence the blood pressure; thus 20-30 minutes of rest following exercise is indicated before the resting blood pressure can be reliably assessed. Stress Stimulation of the sympathetic nervous system increases cardiac output and vasoconstriction of the arterioles, thus increasing the blood pressure reading; however, severe pain can decrease blood pressure greatly by inhibiting the vasomotor center and producing vasodilatation. Gender After puberty, females usually have lower blood pressures than males of the same age; this difference is thought to be due to hormonal variations. After menopause, women generally have higher blood pressures than before. Medications Many medications may increase or decrease the blood pressure. Obesity Both childhood and adult obesity predispose to hypertension. Diurnal variations Pressure is usually lowest early in the morning, when the metabolic rate is lowest, then rises throughout the day and peaks in the late afternoon or early evening. Disease process Any condition affecting the cardiac output blood volume, blood viscosity, and/or compliance of the arteries has a direct effect on the blood pressure.

Blood Pressure Equipments Blood pressure is measured with:

Blood Pressure Cuff Consist of a rubber bag that can be inflated with air It is called the bladder. It is covered with cloth and has two tubes attached to it. One tube connects to a rubber bulb that inflates the bladder. When turned counterclockwise, a small valve on the side of this bulb releases the air in the bladder. When the valve on the side of this bulb releases the air in the bladder. When the valve is tightened (turned clockwise), air pumped into the bladder remains there. The other tube is attached to a sphygmomanometer. Comes in various sizes because the bladder must be the correct width and length for the clients arm. The width should be 40% of the circumference, or 20% wider than the diameter of the midpoint of the limb on which it is used. The arm circumference, not the age of the client, should always be used to determine bladder size. The length of the bladder also affects the accuracy of measurement. The bladder should be sufficiently long to cover at least two-thirds of the limbs circumference.

Sphygmomanometer

-Indicates the pressure of the air within the bladder. o Aneroid o Mercury Is a calibrated cylinder filled with mercury. The pressure is indicate 1 at the point to which the rounded curve of the meniscus (the crescent-shaped dome) rises. The blood pressure reading should be made with the eye at the level of the rounded curve in order to be accurate. Is a calibrated dial with a needle that points to the calibrations.

o Electronic

Eliminate the need to listen to the sounds of the clients systolic and diastolic blood pressures through a stethoscope. Should be calibrated periodically to check accuracy.

Stethoscope Also used to assess blood pressure. These are of particular value when blood pressure sounds are difficult to hear, such as infants, obese clients, and clients in shock. Systolic pressure may be the only blood pressure obtainable with some ultrasound models.

Taking Blood Pressure Blood Pressure Sites

The blood pressure is usually assessed in the clients arm using the brachial artery and a standard stethoscope. Assessing the blood pressure on a clients thigh is usually indicated in these situations: o The blood pressure cannot be measured on either arm (e.g., because of burns or other trauma). o The blood pressure in one thigh is to be compared with the blood pressure in the other thigh. Blood pressure is not measured on a clients arm or thigh in the following situations: o The shoulder, arm or hand is injured or diseased. o A cast or bulky bandage is on any part of the limb. o The client has had removal of axilla lymph nodes on that side. o The client has an intravenous infusion in that limb. o The client has an arteriovenous fistula (e.g., for renal dialysis) in that limb. Methods o Directly (Invasive monitoring) Involves the insertion of a catheter into the brachial, radial, or femoral artery. Arterial Pressure is represented as wavelike forms

displayed on an oscilloscope. With correct placement, this pressure reading is highly accurate. o Indirectly (Noninvasive monitoring) Auscultatory Most commonly used in hospitals, clinics and homes. Required equipment is a sphygmomanometer, a cuff, and a stethoscope. When carried out correctly, this method is relatively accurate.

** Korotkoffs sounds - The five phases in the series of sounds when taking a blood pressure using a stethoscope ** o First, the nurse pumps the cuff up to about 30 mm Hg. o Then the pressure is released slowly (2 to 3 mm Hg per sound) while the nurse observes the readings on the manometer and relates them to the sounds heard through the stethoscope. o Five phases occur but may not always be audible: Phase 1 The pressure level at which the first fain, clear tapping or thumping sounds are heard. The first tapping sound heard during deflation of the cuff is the systolic pressure. The period during deflation when the sounds have muffled, whooshing, or swishing quality. The period during which the blood flows freely through an increasingly open artery and the sounds become crisper and more intense and again assume a thumping quality but softer than in phase 1. The time when the sounds become muffled and have a soft, blowing quality. The pressure level when the last sound is heard. The pressure at which the last sound is heard is the diastolic blood pressure in adults.

2 3

4 5

Palpatory

Sometimes used when Korotkoffs sounds cannot be heard and electronic equipment to amplify the sounds is not available, or to prevent misdirection from the presence of an auscultatory gap occurs.

Auscultatory gap - occurs particularly in hypertensive clients, is the temporary disappearance of sounds normally heard over the brachial artery when the cuff pressure is highly followed by the reappearance of sounds at a lower level.

Instead of listening for the blood flow sounds, using light to moderate pressure the nurse palpates the pulsations of the artery as the pressure in the cuff is released.

Steps:
o

PREPARE: The patient should be seated or lying down. If the patient has not been injured in an accident, support her arm at the level of her heart. If the person has been injured, apply the cuff to an uninjured arm. PLACE THE CUFF & FIND THE RADIAL PULSE: Apply the cuff snugly around the upper arm so that the bottoms of the cuff is just above the elbow. If the cuff has an arrow printed on it, this arrow should be placed over the brachial artery located on the inside of the arm. Then find the radial pulse on the arm to which the blood pressure cuff has been applied. The bottom of the cuff should be 1 to 2 inches above the elbow. There are different sizes of blood pressure cuffs for adults, children and infants. Narrow cuffs are for taking children's blood pressures, and extra-large cuffs are for obese adults. Cuffs that are too small may give falsely high readings, and cuffs that are too large may give falsely low readings. Be sure to use a cuff of the correct size for your patient. With your fingertips, palpate the brachial artery at the crease of the elbow. Place the ear pieces of the stethoscope in your ears (the ear pieces should be pointing forward in the direction of your ear canals). Position the diaphragm of the stethoscope directly over the brachial pulse or over the medial anterior elbow

(front of the elbow) if no brachial pulse can be found. Do not place the head of the stethoscope underneath the cuff, since this will give you false readings. Using your index and middle fingers, hold the diaphragm snugly against the patient's arm. Do not use your thumb! If you use your thumb, you may hear your own heartbeat in the stethoscope.
o

INFLATE THE CUFF: Place the indicator dial (the gauge) in a position where you can easily see the movement of the indicator needle. Make certain that the adjustable valve is closed by turning the knob clockwise to close the valve. This knob is located on the bulb. With the bulb valve (thumb valve) closed, inflate the cuff by squeezing the bulb while watching the gauge and listening with the stethoscope. At a certain point, you will no longer hear the brachial pulse. Continue to inflate the cuff until the gauge reads 30 mm of mercury higher than the point where the pulse sound disappeared. OBTAIN THE SYSTOLIC PRESSURE: Slowly release air from the cuff by opening the bulb valve, allowing the pressure to fall smoothly at the rate of approximately 2 to 4 mm per second. Carefully watch the indicator needle and listen for the start of clicking or tapping sounds of the pulse. When you hear the first of these sounds, note the reading on the gauge. This is the systolic pressure. OBTAIN THE DIASTOLIC PRESSURE: Continue to slowly deflate the cuff, listening for the point at which these distinctive sounds fade and disappear. When the sounds turn to dull, muffled thuds, the reading on the gauge is the diastolic pressure. Sometimes you will not be able to hear a change in these sounds. When this happens, the point at which the sounds disappear is the diastolic pressure.

RECORD MEASUREMENTS: After obtaining the diastolic pressure, let the cuff deflate rapidly. Record the measurements and the time of determination with the higher systolic measurement over the top of the lower diastolic measurement. For example, "BP is 140/90 at 1:10 PM." Blood pressure is reported in even numbers (for example, 120 over 84, 90 over 40, or 186 over 98. If a reading is between two lines on the gauge, use the higher number. o If you are not certain of a reading, repeat the procedure. You should use the other arm or wait one minute before re-inflating the cuff. Otherwise, you will tend to obtain an erroneously high reading. If you are still not sure of the reading you are getting, try again or get some help. Never make up vital signs!
o

A blood pressure can be obtained on patients (clients) more than 3 years old. Blood pressures on infants and children younger than 3 years are difficult to obtain with any accuracy outside of a health care institution. In the field, client's home, or midwife's or health care provider's office, you can get more helpful information about the condition of an infant or very young child by observing for conditions such as a sick appearance, respiratory distress, or unconsciousness. Vital signs are usually taken more than once. How frequently they should be repeated depends on the condition of the patient and the patient care interventions you are performing. Stable patients need repeat vital signs at least every 15 minutes. Unstable patients need repeat vital signs at least every 5 minutes. You should also repeat vital signs after every medical intervention. Record every reading of the vital signs. To become skilled in taking blood pressures, take every opportunity to practice on as many healthy, uninjured people as possible. Try to take blood pressures of both children and elderly patients; do not spend all your time with young, healthy adults. This practice will help prepare you to measure the blood pressure of a serious ill or injured person, if the situation arises. Palpating Systolic Arterial Blood Pressure

PREPARE:
The patient should be seated or lying down. If the patient has not been injured in an accident, support her arm at the level of her heart. If the person has been injured, apply the cuff to an uninjured arm.

PLACE THE CUFF & FIND THE RADIAL PULSE:

Apply the cuff snugly around the upper arm so that the bottoms of the cuff is just above the elbow. If the cuff has an arrow printed on it, this arrow should be placed over the brachial artery located on the inside of the arm. Then find the radial pulse on the arm to which the blood pressure cuff has been applied. The bottom of the cuff should be 1 to 2 inches above the elbow. There are different sizes of blood pressure cuffs for adults, children and infants.

Narrow cuffs are for taking children's blood pressures, and extra-large cuffs are for obese adults. Cuffs that are too small may give falsely high readings, and cuffs that are too large may give falsely low readings. Be sure to use a cuff of the correct size for your patient.

INFLATE THE CUFF:

Place the indicator dial (the gauge) in a position where you can easily see the movement of the indicator needle. Make certain that the adjustable valve is closed by turning the knob clockwise to close the valve. This knob is located on the bulb. Inflate the cuff to a point where you can no longer feel the radial pulse. Note this point on the gauge and continue to inflate the cuff 30 mm of mercury beyond this point.

OBTAIN & RECORD THE SYSTOLIC PRESSURE:

Slowly deflate the cuff, noting the reading at which the radial pulse returns. This reading is the patient's systolic pressure. Record your findings as, for example, "blood pressure 140 by palpation" or "140/P" and the time of the determination. (You cannot determine a diastolic reading by palpation.) If you are not certain of a reading, repeat the procedure. You should use the other arm or wait one minute before re-inflating the cuff. Otherwise, you will tend to obtain an erroneously high reading. If you are still not sure of the reading you are getting, try again or get some help. Never make up vital signs! A blood pressure can be obtained on patients (clients) more than 3 years old. Blood pressures on infants and children younger than 3 years are difficult to obtain with any accuracy outside of a health care institution. In the field, client's home, or midwife's or health care provider's office, you can get more helpful information about the condition of an infant or very young child by observing for conditions such as a sick appearance, respiratory distress, or unconsciousness. Vital signs are usually taken more than once. How frequently they should be repeated depends on the condition of the patient and the patient care interventions you are performing. Stable patients need repeat vital signs at least

every 15 minutes. Unstable patients need repeat vital signs at least every 5 minutes. You should also repeat vital signs after every medical intervention. Record every reading of the vital signs. To become skilled in taking blood pressures, take every opportunity to practice on as many healthy, uninjured people as possible. Try to take blood pressures of both children and elderly patients; do not spend all your time with young, healthy adults. This practice will help prepare you to measure the blood pressure of a serious ill or injured person, if the situation arises.

HEALTH ASSESSMENT AND PHYSICAL EXAMINATION Purpose . The purposes for a physical assessment are: To obtain baseline physical and mental data on the patient. To supplement, confirm, or question data obtained in the nursing history. To obtain data that will help the nurse establish nursing diagnoses and plan patient care. To evaluate the appropriateness of the nursing interventions in resolving the patient's identified pathophysiology problems.

SKILLS OF PHYSICAL ASSESSMENT INSPECTION A method of systematic observation. Inspection should begin with general observation of the patient progressing to specific body areas. Inspection is a physical assessment technique that is often used but seldom thought about.

PALPATION

Palpation is used as part of a physical examination in which an object is felt (usually with the hands of a healthcare practitioner) to determine its size, shape, firmness, or location.

Process of examining patients by application of the hands. Used to determine: The consistency of tissue directly or indirectly with the palms of the hands or finger pads.

Alignment and intactness of structures (such as the nasal septum or extremities).

Presence of thrills. Thrills are fine vibrations and can sometimes be felt over aneurysms or Grade IV or stronger heart murmurs.

Symmetry of body parts and movement.

Transmission of sound through vibration (known as tactile fremitus).

Areas of warmth and tenderness.

PERCUSSION Percussion is the act of striking the body surface to elicit sounds that can be heard or vibrations that can be felt. Two types of percussion: Direct percussion The nurse strikes the area to be percussed directly with pads of two, three, or four fingers or with the pad of the middle finger.

The strikes are rapid, and the movement is from the wrist. Indirect percussion The striking of an object held against the body area to be examined. The middle finger of the nondominant hand, reffered to as pleximeter, is placed firmly on the clients skin. Using the tip of the flexed middle finger of the other hand, called plexor, the nurse strike the pleximeter, usually at the distal interphalangeal joint.

Percussion indicates such as the liver, spleen or heart. Resonance a hollow sound such as that produced by lungs.

Hyperresonance not produced in the normal body. It is described as booming and can be heard over an enphysematous lung. Tympany a musical or drumlike sound produced from air- filled stomach.

AUSCULTATION (Assessment using sense of hearing) Is the process of listening sounds produced within the body. based on the Latin verb auscultare "to listen. is performed for the purposes of examining the circulatory system and respiratory system, as well as the gastrointestinal system. May be direct or indirect: o Direct Auscultation is the use of unaided ear. o Indirect Auscultation is the use of stethoscope (used primarily to listen to the sounds within the body) Auscultated sounds are described according to their pitch, intensity, duration and quality. o Pitch refers to the frequency of the vibrations. o Intensity is softness and loudness of sounds. o Duration of the sound is the length. o Quality is the subjective description of the sound.

It is important that a nurse learns to listen effectively, so that not only what a client says is registered but also the tone of voice, which often conveys a great deal. A nurse must also learn how to recognize abnormal sounds. In client care, recognizing abnormal sounds involves the ability to detect: Abnormalities of breathing: for example, respirations that are wheezing, or noisy or distressed Abnormalities of heart sounds, blood pressure, bowel sounds or fetal heart sounds, when using stethoscope Manifestation of a clients distress for example, coughing, expectorating sputum, vomiting, crying or moaning Changes in the sound or rhythm of technical equipment such as suction artificial ventilation apparatus OFFACTION (Assessment using the sense of smell) A well-developed sense of smell enables a nurse to detect odors that are characteristic of certain conditions. Some alterations in body functions and certain bacteria create characteristic odors, for example: The fishy smell of infected urine The ammonia odor associated with concentrated or decomposed urine The musty or offensive odor of an infected wound The offensive rotting odor associated with gangrene (tissue necrosis) The smell of ketones on the breath of ketoacidosis (accumulation of ketones in the body) The smell of alcohol on the breath due to ingestion of alcohol Halitosis (offensive breath) accompanying mouth infections; for example, gingivitis of certain disorders of the digestive system; for example, appendicitis The foul odor associated with steatorrhea (abnormal amount of fat in the feces) The characteristic odor associated with malaens (abnormal black tarry stool containing blood)

PREPARATION FOR EXAMINATION Environment It is important to prepare the environment before starting the assessment. The time for the physical assessment should be convenient to both the client and the nurse. The environmental needs to be well lighted and the equipment should be organized for

efficient use. A client who is physically relaxed will usually experience little discomfort. The room should be warm enough to be comfortable for the client. Providing privacy is important. Most people are embarrassed if their bodies are exposed or if others can overhear or view them during assessment. Culture, age, and gender of both the client and the nurse influence how comfortable the client will be and what special arrangements might be needed. For example, if the nurse and client are off different genders, the nurse should ask if it is acceptable to perform the physical examination of if the nurse of the same gender is preferred. Family and friends should not be present unless the client asks for someone. Nurses assess clients in a special examination room or at the bedside. Regardless of the assessment location, the area should have easy access to a restroom; a door or curtain that ensures privacy; adequate warmth for client comfort; a padded, adjustable table or bed; sufficient room for moving to either side of the client; adequate lighting; facilities for hand hygiene; a clean counter or surface for placing examination equipment; and a lined receptacle for soiled articles the area should have easy access to a restroom a door or curtain that ensures privacy adequate warmth for client comfort a padded, adjustable table or bed sufficient room for moving to either side of the client adequate lighting facilities for hand hygiene a clean counter or surface for placing examination equipment a lined receptacle for soiled articles

Equipment SUPPLIES PURPOSE To assist viewing of the pharynx and cervix and to determine the reaction of the pupil of the eye To permit visualization of the lower and middle turbinates; usually, a penlight is used for illumination

Flashlight or penlight

Nasal Speculum

Othoscope Ophtalmoscope Percussion (reflex) hammer Tuning fork Vaginal speculum Cotton applicators Gloves Lubricant Tongue blades (depressors) Client

A lighted instrument to visualize the eardrum and external auditory canal (a nasal speculum may be attached to the othoscope to inspect the nasal cavity) A lighted instrument to visualize the interior of the eye An instrument with a rubber head to test reflexes. A two-prolonged metal instrument used to test hearing acuity and vibratory sense To access the cervix and the vagina To obtain specimen To protect the nurse To ease insertion of instruments (e.g., vaginal speculum To depress the tongue during assessment of the mouth and pharynx.

Most people need an explanation of the physical examination. Often clients are anxious about what the nurse will find. They can be reassured during the examination by explanations at each step. The nurse should explain when and where the examination will take place, why it is important, and what will happen. Instruct the client that all information gathered and documented during the assessment is kept confidential in accordance with the Health Insurance Portability and Accountability Act (HIPAA). This means that only those health care providers who have a legitimate need to know the clients information will have access to it. Health examinations are usually painless; however, it is important to determine in advance any positions that are contraindicated for a particular client. The nurse assists the client as needed to undress and put the gown. Clients should empty their bladders before the examination. Doing so helps them feel more relaxed and facilitates palpation of the abdomen and public area. If a urinalysis is required, the urine should be collected in a container for that purpose. When assessing adults it is important to recognize that people of the same age differ markedly. The following provides special considerations for assessing adults, especially elders.

Health assessment of the Adult Be aware of normal physiologic changes that occur with age. Be aware of stiffness of muscles and joints from aging changes or history of orthopedic surgery. The client may need modification of the usual positioning necessary for examination and assessment. Expose only areas of the body to be examined in order to avoid chilling. Permit ample time for the client to answer your questions and assume the required positions. Be aware of cultural differences. The client may want a family member present during disrobing. Arrange for an interpreter if the clients language differs from that of the nurse. Ask client how they wish to be addressed, such as Mrs. or Miss. Adapt assessment techniques to any sensory impairment; for example, make sure the eyeglasses or hearing aids are nearby. If clients are elderly/or frail it is wise to plan several assessment times in order not to overtire them.

The sequence of the assessment differs with children and adults. With children, always proceed from the least invasive or uncomfortable to the more invasive. Examinations of the head and neck, lungs and heart, and range of motions can be done early in the process, while the ears, mouth, abdomen, and genitals should be left for the end of the exam.

NURSING HISTORY FORM OR HEALTH HISTORY first part and one of the most significant aspects in case studies a systematic collection of subjective and objective data, ordering and a step-by-step process in collating detailed information in determining clients history, health status, functional status and coping pattern provides a conceptual baseline data utilized in developing nursing diagnosis, subsequent plans for individualized care and for the nursing process application as a whole

COMPONENTS OF NURSING HEALTH HISTORY BIOGRAPHIC DATA includes clients name, address, age, sex, marital status, occupation, religious preference, health care financing, and usual source of medical care. CHIEF COMPLAINT OR REASON FOR VISIT the clients answer to the question What brought you to the hospital? or What is troubling you? is expressed in the clients own words. HISTORY OF PRESENT ILLNESS includes the onset of symptoms, when the symptoms started, if its development was sudden or gradual, severity and frequency of occurrence, the site or exact location of distress; the character of the complaint, its intensity or quality of discharge, sputum, etc.; activity of the client which may be involved in the development of the problem, phenomena or symptoms associated with the chief complaint, and the factors that aggravate or alleviate the problem. PAST HISTORY includes childhood illnesses, immunizations, allergies to drugs, animals, or other environmental agents, accidents and injuries, hospitalizations for serious illnesses, and medications currently used. FAMILY HISTORY OF ILLNESS to ascertain risk factors for diseases. Particular attention should be given to disorders such as diseases of the heart, tuberculosis, cancer, diabetes, hypertension, obesity, allergies, arthritis, bleeding, alcoholism, and any mental disorders. LIFESTYLE includes personal habits, diet, sleep/ rest patterns, activities of daily living, instrumental activities of daily living, recreation or hobbies. SOCIAL DATA pertains to quality of family relationships/friendships, ethnic affiliation, educational background, occupational history, economic status, home and neighborhood conditions. PSYCHOLOGICAL DATA major stressors experienced by the client and their perception of them, how they cope up with these stressors, their communication to relay appropriate emotion. PATTERNS OF HEALTH CARE includes all the health care resources that the client is currently using and has used in the past.

PURPOSE The history aids the patient and health care provider by supplying essential information that will assist with diagnosis, treatment decisions, and establishment of trust and rapport between patient and medical professional. The information also helps determine the patient's baseline, or what is normal and expected for the patient.

HEALTH AND PHYSICAL ASSESSMENT

A. Neck and head assessment focuses on the cranium, face, thyroid gland, and lymph node structures contained within the head and neck

1. THE HEAD the framework of the head is the skull, which can be divided into two subsections: the cranium and the face

a. CRANIUM houses and protects the brain and major sensory organs consisting of eight bones: frontal, parietal, temporal, occipital, ethmoid, and sphenoid in the adult client, the cranial bones are joined together by immovable sutures: the sagittal, coronal, squamosal, and lambdoid sutures b. FACE its shape is prearranged by the facial bones

consists of 14 bones: maxilla, zygomatic (cheek), inferior conchae, nasal, lacrimal, palatine, vomer, and mandible (jaw) a normal head size is referred to as normocephalic consists of many muscles that produce facial movement and expressions the temporal artery, a major artery, is located between the eye and the top of the ear two other important structures located in the facial region are the parotid glands which are located on each side of the face, anterior, and inferior to the ears and behind the mandible; and the submandibular glands which are located inferior to the mandible, underneath the base of the tongue many disorders cause a change in facial shape or condition as of the following: -- hyperthyroidism can cause exophthalmos, a protrusion of the eyeballs with elevation of the upper eyelids, resulting in a startled or starting expression hypothyroidism or myxedema can cause a dry, putty face with dry skin and coarse features and t hinning of scalp hair and eyebrows -increased adrenal hormone production or administration can cause a round face with reddened cheeks, referred to as moon face, and excessive hair growth on the upper lips, chin, and sideburn areas -- prolonged illness, starvation, and dehydration can result in sunken eyes, cheeks, and temples --

Figure 1.1 Bones of the head

2. THE NECK examination of the neck includes the muscles, lymph nodes, trachea, thyroid gland, carotid arteries, and jugular veins

a. MUSCLES AND CERVICAL VERTEBRAE movement the resistance the sternomastoid (sternocleidomastoid) and trapezius muscles are two of the paired muscles that allow and provide support to the head and neck Sternomastoid muscle rotates and flexes the head Trapezius muscle shoulders extends the head and moves the

the eleventh cranial nerve is responsible for muscle movement that permits shrugging of the shoulders by trapezius muscles and turning the head against by the sternomastoid muscles these two major muscles also form two triangles that provide important landmarks for assessment: the anterior triangle is located under the mandible, anterior to the muscle; and the posterior triangle is

sternomastoid

located between the muscles

trapezius

and

sternomastoid

b. BLOOD VESSELS the internal jugular veins and carotid arteries are located bilaterally, parallel and anterior to the sternomastoid muscles the external jugular vein lies diagonally over the surface of these muscles

Blood vessels - organic conduits carrying blood to the heart and organs. Connective tissue - tissue that connects and supports. Smooth muscle tissue - smooth muscle. Endothelium - cellular tissue covering the wall of an artery.

Epithelial cell - cell of the endothelium. Valve - tissue that prevents the blood from flowing backwards. White blood cell - free-floating blood cell that plays an important role in the immune system. Red blood cell - free-floating blood cell that carries nutriments to the organs. Capillary - small blood vessel that connects arteries to veins and allows exchange with the cells. Vein - blood vessel that carries blood from the organs to the heart. Artery - blood vessel that carries blood from the heart to the organs.

c. THYROID GLAND largest endocrine gland in the body produces thyroid hormones that increase the metabolic rate cells of most body

surrounded by several structures that are important to palpate for accurate location of the thyroid gland consists of two lateral lobes that curve posteriorly on both sides of the trachea and esophagus and are mostly covered by the sternomastoid muscles these two thyroid lobes are connected by an isthmus that overlies the second and third tracheal rings below the circoid cartilage

3. LYMPH NODES OF THE HEAD AND NECK a clear substance composed mostly of excess tissue fluid, after the lymphatic vessels collect it but before it returns to the vascular system (this filtering action removes bacteria and tumor cells form the lymph) lymphocytes and antibodies are produced in the lymph nodes as aa defense against invasion by foreign substance its size and shape vary but most are less the 1 cm long and are buried deep in the connective tissue, which makes them nonpalpable in normal situations and usually appear in clusters that vary in size from 2 to 100 individual nodes

the most common head and neck lymph nodes are referred to as follows:

preauricular - located anterior to the auricle of the ear postauricular - describes the area behind the auricle, or external part of the ear tonsillar - pertaining to the palatine tonsil occipital - the unpaired bone constituting the back and part of the base of the skull submandibular - pertaining to the area beneath the mandible, or lower jaw submental - the superficial cervical nodes located inferior to the chin superficial cervical - lymph nodes that lie near the surface of the neck

posterior cervical - located on the neck which is responsible for draining and filtering lymphatic fluid from different areas of the head and neck deep cervical - a group of lymph nodes situated around or near the internal jugular vein. Includes two groups, superior and inferior, based on the point where the omohyoid muscle crosses the vein supraclavicular - pertaining to the area above the clavicle, or collar bone

ASSESSMENT OF THE NECK

A. PLANNING Delegation Assessment of the neck is not delegated to UAP. However, many aspects are observed during usual care and may be recorded by persons other than the nurse. Abnormal findings must be validated and interpreted by the nurse. Equipment None

B. IMPLEMENTATION Performance 1. Prior to performing the procedure, introduce self and verify the clients identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate. Discuss how the results will be used in planning further care or treatment. 2. Perform hand hygiene and observe appropriate infection control procedures. 3. Provide for client privacy.

4. Inquire if the client has any history of the following: problems with neck lumps; neck pain or stiffness; when and how any lumps occurred; previous diagnoses of thyroid problems; and other treatments provided. ASSESSMENT NORMAL FINDINGS DEVIATIONS NORMAL FROM

Neck muscles 5. Inspect the neck muscles (sternocleiodomastoid and Muscles equal in size; head trapezius) for abnormal centered swellings or masses. Ask the client to hold the head erect. Coordinated, smooth 6. Observe head movements with no movement. Ask client to: discomfort Move the chin to the chest. Rationale: This determines function of the Head flexes 45o sternocleidomastoid muscle Move the head back so that the chin points upward. Rationale: This Head hyperextends 60o determines function of the trapezius muscle. Move the head back so that the ear is moved toward the shoulder on each side. Rationale: This Head laterally flexes 40o determines function of the sternocleidomastoid muscle.

Unilateral neck swelling; head tilted to one side (indicates presence of masses, injury, muscle weakness, shortening of sternocleidomastoid muscle, scars) Muscle tremor, spasm, or stiffness Limited range of motion; painful movements; involuntary movements (e.g., up-and-down nodding movements associated with Parkinson's disease)

Head hyperextends than 60o

less

Head laterally flexes less than 40o

Turn the head to the right and to the left. Rationale: This determines function of Head laterally rotates 70o the sternocleidomastoid muscle. 7. Assess muscle strength. Ask the client to turn the head to one side against the resistance of your hand. Repeat with the Equal strength other side. Rationale: This determines the strength of the sternocleidomastoid muscle. Ask the client to shrug the shoulders against the resistance of your hands. Equal strength Rationale: this determines the strength of the trapezius muscles. Lymph Nodes 8. Palpate the entire neck Not palpable for enlarged lymph nodes. Face the client, and bend the client's head forward slightly or toward the side being examined. Rationale: This relaxes the soft tissue and muscle. Palpate the nodes using the pads of the fingers. Move the fingertips in a gentle rotating motion.

Head laterally rotates less than 70o

Unequal strength

Unequal strength

Enlarged, palpable, possibly tender (associated with infection and tumors)

When examining the submental and submandibular nodes place the fingertips under the mandible on the side nearest the palpating hand, and pull the skin and subcutaneous tissue laterally over the mandibular surface so that the tissue rolls over the nodes. When palpating the supra clavicular nodes, have the client bend the head forward to relax the tissues of the anterior neck and to relax the shoulders so that the clavicles drop. Use your hand nearest to be examined when facing the client. Use your free hand to flex the client's head forward if necessary. Hook your index and third fingers over the clavicle lateral to sternocleidomastoid. When palpating the anterior cervical nodes and posterior cervical nodes, move your fingertips slowly in a forward circular motion against the sternocleidomastoid and trapezius muscles, respectively. To palpate the deep cervical nodes, bend or hook your fingers around the sternocleidomastoid muscle.

Trachea 9. Palpate the trachea for lateral deviation. Place your fingertip or thumb on the trachea in the Deviation to one side, suprastenal notch and then Central placement in indicating possible neck move your finger laterally midline of neck; spaces are tumor; thyroid enlargement; to the left and the right in equal on both sides enlarged lymph nodes spaces bordered by the clavicle, the anterior aspect if the sternocleidomastoid muscle, and the trachea. Thyroid Gland 10. Inspect the thyroid gland: Stand in front of the client. Observe the lower half of the neck overlying the Not visible on inspection. thyroid gland for symmetry and visible masses. Ask the client to extend the head and swallow. If necessary, offer a glass a water to make it easier for the client to swallow. Gland ascends during Rationale: This action swallowing but is not visible determines how the thyroid and cricoid cartilages move and whether swallowing causes a bulging of the gland.

Visible diffuseness or local management.

Gland is not fully movable with swallowing.

11. Palpate the thyroid gland for smoothness. Note any areas of enlargement, masses, or nodules. Stand in front of or behind the client and ask the client to lower the chin slightly. Rationale: Lowering the chin relaxes the neck muscles, facilitating palpation. Posterior Approach Place your hands around the client's neck with your fingertips on the lower half of the neck over the trachea. Ask the client to swallow and feel for any enlargement of thyroid isthmus as it rises. The isthmus lies across the trachea, below the croid cartilage. To examine the right thyroid lobe, have the client lower the chin slightly and turn the head slightly to the right. With your left fingers, displace the trachea slightly to the right thyroid lobe. Have the client swallow while you are palpating. Anterior Approach

Lobes may not be palpated. If palpated, lobes are small, smooth, centrally located, painless, and rise freely with swallowing.

Place the tips of your index and middle fingers over the trachea, and palpate the thyroid isthmus as the client swallows. To examine the right thyroid lobe, have the client lower the chin slightly and turn the head slightly to the right. With your right fingers, displace the trachea slightly to the client's right. With your left fingers, palpate the right thyroid lobe. To examine the left thyroid lobe, repeat the above step in reverse. 12. If enlargement of the gland is suspected, ausculate over the thyroid area for a bruit. Use the bell of the stethoscope. Absence of bruit Rationale: The bell transmits this law frequency sound better than the diaphragm. 13. Document findings in the client record using forms or checklists supplemented by narrative notes when appropriate.

Presence of bruit

B. Integument includes the skin, hair, and nails the examination begins with a generalized inspection using a good source of lighting, preferably indirect natural daylight

1. SKIN the assessment of the skin involves inspection and palpation Pallor result of inadequate circulating blood or hemoglobin subsequent reduction in tissue oxygenation and

* In clients with dark skin, is usually characterized by the absence of underlying red tones in the skin and may be most readily seen in the buccal mucosa. In brown-skinned clients, pallor may appear as a yellow-tinge. In black-skinned patients, the skin may appear ashen gray. Pallor in all people is usually most evident in areas with the least pigmentation such as the conjunctiva, oral mucous membranes, nail beds, palms of the hand, and soles of the feet. Cyanosis most evident in the nail beds, lips, and buccal mucosa

* In dark-skinned patients, close inspection of the palpebral conjunctiva and palms and soles may also show evidence of cyanosis. Jaundice may be first evident in the sclera of the eyes and then in the mucous membranes and the skin. Erythema is a redness associated with a variety of rashes. Vitigilo caused by the destruction of melanocytes in the area Edema is the presence of excess interstitial liquid which appears to be swollen, shiny, and taut and tends to blanch the skin color or, if accompanied by inflammation, may redden the skin. Generalized edema is most often an indication of impaired venous circulation and in some cases reflects cardiac dysfunction or venous abnormalities. Primary skin lesions those that appear initially in response to some change on the external or internal environment of the skin Secondary skin lesions those that do not appear initially but result from modifications suchas chronicity, trauma, or infection of the primary lesion

ASSESSMENT OF THE SKIN Physical assessment of the skin begins with a general inspection followed by a detailed examination. When preparing to assess the skin, wear gloves

if the patient has any lesions, complains of itching skin, or if the mucous membranes are to be examined. Color: Note the color of the skin first. Depending upon the persons race the skin should be flesh-toned appropriate for the person. Jaundice can indicate biliary tract disease or a liver problem; pale yellow skin can indicate a renal problem. A flushed, red face can indicate excessive ETOH intake, fever, localized inflammation, or even embarrassment. Persons who have eaten excessive amounts of yellow or orange vegetables can exhibit pale yellow skin from carotene overload. However, a person with carotene overload will not have yellow colored sclera as is evident in true jaundice. Temperature Turgor: Use the back of the hand to assess skin temperature for coolness or warmth. When pinched between the thumb and index finger for a few seconds, normally hydrated, taut skin will snap back into place when released. Dehydrated skin or the skin of the elderly patient will form a small tent shape before gradually assuming its normal position. Moisture: Dry skin can be caused by irritating soap, excessive bathing, or hypothyroidism; dry skin is normally found in elderly people. Odor: Note any unusual body odor, smell of ETOH, and breathe odor. Scars: Assess for cause, location, appearance (color and size), and degree of tenderness. Masses: Note location, size, depth, and presence of tenderness.

2. NAILS inspected for nail plate shape, angle between the nail and the nail (fingernails), nail texture, nail bed color, and th intactness of the tissues around the nails Nail plate normally colorless and has a convex curve; the angle between the fingernail and the nail bed is normally 160 degrees. * Koilonychia (spoon shape) wherein the nail curves upward from the nail bed which is usually seen in clients with iron deficiency anemia

* Clubbing a condition in which the angle between the nail and the nail bed is 180 degrees or greater which may be caused by a long-term lack of oxygen Nail texture normally smooth * excessively thick nails can appear in elders, in the presence of poor circulation, or in relation to a chronic fungal infection * excessively thin nails or the presence of grooves or furrows can reflect prolonged iron deficiency anemia * Beaus lines horizontal depressions in the nail that can result from injury or severe illness Nail bed highly vascular, a characteristic that accounts for its color * bluish or purplish tint to the nail bed may reflect cyanosis, and pallor may reflect poor arterial circulation * PARONYCHIA an inflammation of the tissues surrounding a nail (ingrown nail) where tissues appear inflamed and swollen, and tenderness is usually present * BLANCH TEST a type of test which can be carried out to test the capillary refill, that is, peripheral circulation.

ASSESSMENT OF THE NAILS a. Observe the shape and configuration of the nail Normal findings: Dorsal nail surface: slightly convex Nail thickness: 0.3-0.65 mm Angle at nail base: 160 degrees (skin-nail interface)

Deviations from normal: Abnormal shape may indicate malnutrition

Spooning: concave nail plates; associated with iron deficiency anemia Clubbing

b. Note the color of the nails. Normal findings: Pinkish Bluish hue in dark-skinned people

Deviations from normal: Nail lesions may alter the color of nail plate Cyanosis

c. Squeeze the nail between the thumb and the forefinger to determine capillary in refill time. Normal findings: Capillary refill less than 3 seconds

Deviations from normal: Capillary refill more than 3 seconds indicates poor tissue perfusion

d. Examine the nails for presence of lesions or other abnormalities. Nail Abnormalities: Onycholysis - characterized by a spontaneous separation of the nail plate starting at the distal free margin and progressing proximally Beaus Lines - deep grooved lines that run from side to side on the fingernail Splinter hemorrhages - associated with infection of the heart valves endocarditis and may be caused by vessel damage from swelling of the blood vessels tiny clots that damage the small cap vasculitis or tiny clots that damage the small capillaries

3. HAIR a thread of keratin formed from cells at the base of a single follicle although hair covers the entire body, its amount, distribution, color, and texture vary considerably among males and females, infants and adults, and ethnic groups prevents heat loss Sebaceous glands release sebum, an oily secretion that adds weight to the shafts of hair, causing them to flatten against the skull the texture, elasticity, and porosity of hair are inherited characteristics influenced by the amount of keratin and sebum produced ASSESSMENT OF THE HAIR a. Inspect the hair to evaluate color and pigmentation Normal findings: Hair color is influenced by genetic makeup. Pigment uniform in hair shaft gray hair represents normal age distribution is

Deviations from normal: alteration in color pigmentation may indicate nutrition alterations transverse depigmentation of the hair indicating nutrient deficiency, especially copper and protein

b. Inspect the quantity of hair. Pull gently a few strands whether it comes out easily. Normal findings: hair quantity varies among healthy persons on both sexes

Male balding occurs as anterior regression is considered normal (genetics)

Deviations from normal: easy pluckability and sparse hair may indicate protein deficiency alopecia may occur with anemia, heavy metal poisoning, and hypopituitarism

c. Move a few strands of hair between your thumb and forefinger to evaluate texture Normal findings: coarse or silky (varies in race)

Deviations from normal: very coarse hair hypothyroidism very fine hair hyperthyroidism

d. Survey general hygiene of the hair and scalp (also, inspect the back of the head and neck) Normal findings: free of lice infestations and nits

Deviations from normal: flakiness sores infestations

4. TEETH
hard, calcified structures embedded in the bone of the jaws of vertebrates that

perform the primary function of mastication An adult human normally has 32 teeth 16 in each jaw. The upper jaw has on each side two incisors, one canine, two premolars and, at the back, three molars. The same is true of the lower jaw.

3. THORAX AND LUNGS

a. Anterior 1. mid sternal line - vertical - down center of sternum 2. right and left midclavicular line - midpoint of clavicle 3. right and left anterior axillary line 4. suprasternal notch - top of sternum 5. sternal angle area where the manubrium and sternum meet. 6. xiphoid process - distal to sternum b. Lateral 1. right and left anterior axillary line 2. mid axillary - vertical from apex of axilla 3. posterior axillary line - vertical from posterior axillary fold c. Posterior 1. right and left posterior axillary lines 2. right and left scapula line - vertical from inferior angle of scapula 3. vertebral line - vertical along spinous processes d. Lungs 1. apex 2-4 cm above inner one-third of clavicle 2. inferior anterior border - crosses 6th rib at midclavicular line and 8th rib at mid axillary line 3. inferior posterior border - at level of 10th thoracic spinous process (T-12 at deep inspiration) 4. tracheal bifurcation - left and right mainstem bronchus at sternal angle (anterior) and T-4 (posterior)

5. Five lobes of the lungs - left upper lobe (LUL), left lower lobe (LLL), right upper lobe (RUL), right middle lobe (RML), and right lower lobe (RLL). These will vary in position and size during phases of respiration. 6. Lingula - part of the lung that lies adjacent to the heart. ASSESSMENT OF THE THORAX AND LUNGS

Posterior Thorax

1. Prior to performing the procedure, introduce self and verify the clients identity

using agency protocol. Explain to the client what you are going to do, why it is necessary, how he or she can cooperate. Discuss how the results will be used in planning further care or treatments.
2. Perform hand hygiene and observe appropriate infection control procedures. 3. Provide for client privacy. In women, drape the anterior chest when it is not

being examined.
4. Inquire if the client has any history of the following: family history of illness,

including cancer, allergies, tuberculosis; lifestyle habits such as smoking and occupational hazards; medications being taken; current problems.
5. Inspect the shape and symmetry of the thorax form the posterior and lateral

views. Compare the anteroposterior diameter to the transverse diameter. Normal findings: Asnteroposterior to transverse diameter in ratio of 1:2 Chest symmetric Deviations form Normal: Barrel chest; increased anteroposterior to transverse Diameter 6. Inspect the spinal alignment for deformities. Have the client stand. From a lateral position, observe the three normal curvatures: cervical, thoracic, and lumbar. Normal Findings: (test for scoliosis) Spinal column is straight, right and left shoulders and hips are at the same height

Deviations from normal: Spinal column deviates to one side, often accentuated when bending over 7. Palpate the posterior thorax. For clients who have no respiratory complaints, rapidly assess the temperature and integrity of all chest skin Normal findings: Skin intact; uniform temperature Deviations from normal: Skin lesions; areas of hyperthermia 8. Palpate the posterior chest for respiratory excursion. Place the palms of both your hands over the lower thorax with your thumbs adjacent to the spine and your fingers stretched laterally. Normal Findings: Full and symmetric chest expansion Deviations from normal: Asymmetric and/or decreased chest expansion 9. Palpate the chest for vocal (tactile) fremitus, the faintly perceptible vibration felt through the chest wall when the client speaks Normal findings: Bilateral symmetry of vocal fremitus Fremitus is heard most clearly at the apex of the lungs Deviations from normal: Decreased or absent fremitus Increased fremitus 10. Percuss the thorax. Percussion of the thorax is performed to determine whether underlying lung tissue is filled with air, liquid, or solid material and to determine the positions and boundaries of certain organs. Because percussion penetrates to a depth of 5 to 7 cm, it detects superficial rather than deep lesions. Ask the client to bend the head and fold the arms forward across the chest. Percuss in the intercostal spaces at about 5 cm intervals in a systematic sequence. Compare one side of the lung with the other.

Percuss the lateral thorax every few inches, starting at the axilla and working down to the eighth rib. 11. Percuss for diaphragmatic excursion. Normal findings: Excursion is 3 to 5 cm (11/2 to 2 inches) bilaterally in women and 5 to 6 cm (2 to 3 inches) in men Deviations from normal: Restricted excursion Ask the client to take a deep breath and hold it while you percuss downward along the scapular line until dullness is produced at the level of the diaphragm. Mark this point with a marking pencil, and repeat the procedure on the other side of the chest. Ask the client to take a few normal breaths and then expel the last breath upward from the marked point to assess and mark the diaphragmatic excursion during deep expiration on each side. 12. Measure the distance between the two marks.

Ausculate the chest using the flat-disc diaphragm of the stethoscope. Normal findings: vesicular and bronchovesicular breath sounds Deviations from normal: adventitious breath sounds Use the systematic zigzag procedure used in percussion

Ask the client to take slow, deep breaths through the mouth. Listen at each point to the breath sounds during a complete inspiration and expiration. Compare findings at each point with the corresponding point on the opposite side of the chest. Anterior Thorax 13. Inspect breathing patterns. Normal findings: quiet, rhythmic, and effortless respirations 14. Inspect the coastal angle and the angle at which the ribs enter the spine. Normal findings: Costal angles is less than 90 o, and the ribs insert into the spine at approximately a 45o angle

Deviations from normal: Costal angle is widened 15. Palpate the anterior chest 16. Palpate the anterior chest for respiratory excursion. Normal findings: full symmetric excursion; thumbs normally separate 3 to 5 cm Deviations from normal: asymmetric and/or decreased respiratory excursion Place the palms of both your hands on the lower thorax, with your fingers laterally along the lower rib cage and your thumbs along the coastal margins. Ask the client to take a deep breath while you observe the movement of your hands 17. Palpate tactile fremitus in the same manner as for the posterior chest and using the sequence shown in. Normal findings: Same as posterior vocal fremitus; fremitus is normally decreased over heart and breast tissue Deviations from normal: Same as posterior fremitus 18. Percuss the anterior chest systematically. Normal findings: Percussion notes resonate down to the sixth rib at the level of the diaphragm but are flat over the areas of heavy muscle and bone, dull on areas over the heart and the liver, and tympanic over the underlying stomach. Deviations from normal: Asymmetry in percussion notes Begin above the clavicles in the supraclavicular space, and proceed downward to the diaphragm. Compare one side of the lung to the other. Displace female breasts for proper examination.

19. Ausculate the trachea. Normal findings: Broinchial and tubular breath sounds Deviations from normal: Adventitious breath sounds

20. Ausculate the anterior chest. Use the sequence used in percussion, beginning over the bronchi between the sternum and the clavicles. Normal findings: Bronchovesicular and vesicular breath Deviations from normal: Adventitious breath sounds 21. Document findings in the client record using forms or checklists supplemented by narrative notes when appropriate.

D. Heart

Nurses assess the heart through observations (inspection), palpation and auscultation. The heart is usually assessed during an initial physical assessment; periodic reassessments may be necessary for long-term or at-risk clients or those with cardiac In the average adult, most of the heart lies behind and to the left of the sternum, The upper portion (both atria) of the heart and referred to as the its base, lies toward the back. The lower portion, (the ventricles), referred to as its apex. Heart

A hollow, muscular, four chambered (left and right atria nad left and right ventricles) organ located in the middle of the thoracic cavity between the lungs in the mediastinum.

Point of Maximal Impulse (PMI) The point where the apex touches the anterior chest wall is known as the The precordium, the area of the chest overlying the heart is inspected and palpated for the presence of abnormal pulsations or lifts or heaves.

Superior and Inferior vena cava Return blood to the right atrium from the upper and lower torso respectively. Lift and Heave Often used interchangeably, refer to a rising along the sternal border with each heartbeat. Systole The period in which the ventricles contract. It begins with S 1 and ends with S2. Diastole The period in which the ventricles relax. It starts with S 2 and ends with the subsequent S1. S3 and S4 Extra heart sounds during diastole. Both sounds are low in pitch. S 3 occurs early in diastole right after- and sounds like lub-dub-ee or Kentuc-ky. S4 is rarely heard in young adults. CENTRAL VESSELS Carotid arteries Supply blood to the head and neck.

Bruit

Is created by turbulence of blood flow due either to a narrowed arterial lumen or to a condition such as anemia or hyperthyroidism, which elevates cardiac output.

Thrill Accompanies a bruit. It is a vibrating sensation that is also a turbulent blood flow. Jugular veins Drain blood from the head and neck directly into the superior vena cava and right side of the heart. NORMAL HEART SOUNDS Sound Description or Phase S1 Aortic Pulmonic Less intensity than S2 Tricuspid Apical

a dull, low Less pitched and intensity longer than than S2 S2; sounds like lub Normally silent interval between S1, S2 Higher than S1 pitch Louder than S1

Louder Louder than or than or equal to S2 equal to S2

Systole

S2

Louder than S 1; abnormal if louder than the aortic in S2 adults over 40 years of age

Less intensity than or equal to S1

Less intensity than or equal to S1

Diastole

Normally silent interval between Less intensity than or equal to S2

and S1

ASSESSING THE HEART AND THE CENTRAL VESSELS A. PLANNING Heart examinations are usually performed while the client is in semi-reclined position. The practitioner stands at the clients right side, where palpation of the cardiac area is facilitated and optimal inspection allowed.

ASSESSMENT 5. Simultaneously inspect and palpate the precordium for the presence of abnormal pulsations, lifts of heaves. To locate the valve areas of the heart, here are the following procedures:

NORMAL FINDINGS

DEVIATION NORMAL

FROM

Inspect and palpate No pulsations the aortic and pulmonic areas observing them at an angle and to the side, to note the presence of pulsations. Observing these areas at an angle increases the likelihood of seeing pulsations.

No pulsations

Inspect and pulpate the area for pulsation, noting its specific location (it may displaced laterally or lower) and diameter. If displaced laterally, record the distance between the apex and MCL in centimeters.

Pulsations visible in 50% PMI displaced laterally or of adults and palpable in lower (indicates enlarged most PMI in fifth LICS at heart) or medial to MCL. Diameter over 2 cm Diameter of 1 to 2 cm (indicates enlarged or (1/3 to inches). aneurysm) No lift or heave Diffuse lift or heave lateral to apex (indicates enlargement or over activity of left ventricles Bounding pulsations aneurysm) abdominal (e.g aortic

Inspect and palpate Aortic pulsations the epigastric area at the base of the sternum for the abdominal aortic pulsations.

6. Auscultate the heart in S1: Usually heard at all Increase or decrease all four anatomic sites: sites. intensity Varying intensity aortic, pulmonic, with different beats Usually louder at apical

Equipment Stethoscope Centimeter ruler

B. IMPLEMENTATION Performance 1. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate. Discuss how the results will be used in planning further care or treatments. 2. Wash hands and observe appropriate infection control procedures. 3. Provide for client privacy. 4. Inquire if the client has any history of the following: family history of incidencel and age of the heart disease, high cholesterol levels, high blood pressure, stroke, congenital heart disease, arterial disease, hypertension and etc.

Auscultation of the heart LIFESPAN CONSIDERATIONS Infants Physiologic splitting of the second heart sound may be heard when the child takes a deep breath and the aortic valve closes a split second before the pulmonic valve. If splitting is heard during normal respirations, it is abnormal and may indicate an atrial-septal defect.

Children

Elders

Heart sounds are louder because of the thinner chest wall. A third sound best heard at the apex, is present in about one-third of all children. The PMI is higher and more medial in children under 8 years old.

If no disease is present, heart size remains the same throughout life. Cardiac output and strength of contraction decrease, thus lessening the older persons activity tolerance. The heart rate returns to its resting rate more slowly after exertion than it did when the individual is younger. S4 heart sound is considered normal in older adults. Extra systoles commonly occur. Ten or more systoles per minute are considered abnormal. Sudden emotional and physical stresses may result in cardiac arrhythmias and heart failure.

E. Peripheral Vascular System

A. PLANNING

Delegation Due to the substantial knowledge and skill required, assessment of the peripheral vascular system is not delegated to unlicensed assisstive personnel. A. IMPLEMENTATION Performance 1. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate. Discuss how the results will be used in planning further care or treatments. 2. Wash hands and observe appropriate infection control procedures. 3. Provide for client privacy. 4. Inquire if the client has any history of the following:

past history of heart disorders varicosities arterial disease hypertension lifestyle habits such as exercise patters activity patterns asnd tolerance smoking use of alcohol

Assessment

Peripheral Pulses 5. Palpate the pheriperal pulses ( except the carotid pulse ) in both sides of the clients body individually, simultaneously, systematically to determine the symmetry or pulse volume.

Normal findings: Symmetric pulse volumes Full pulsations

6. Inspect the peripheral veins in the arms and legs for the presence and/or appearance of superficial veins when limbs are elevated.

Normal findings: In dependent position, presence of distention and nodular bulges at calves

7. Assess the peripheral leg veins for signs of phlebitis. Normal findings: Limbs not tender Symmetric in size Pheriperal Perfusion 8. Inspect the skin of the hands and feet for color, temperature, edema, and skin changes. Normal findings: skin color pink Skin temperature not excessively warm or cold No edema skin texture resilient and moist 9. Access the adequacy of arterial flow if arterial insufficiency is susected. Normal findings: Burgers test: Original color returns in 10 seconds; veins in feet or hands fill in about 15 seconds. Capillary test: Immediate return of color. 10. Document findings in the client record using forms or checklists supplemented by narrative notes when appropriate. Evaluation Perform detailed follow- up examination of the heart or central vessels, integument, or other systems based on findings that deviated from expected or normal for the client. Relating findings to previous assessment data if available. Report significant deviations from normal to the physician f. Breasts

The breasts of men and women need to be inspected and palpated. Men have some glandular tissue beneath each nipple, a site for malignancy, whereas mature women have glandular tissue throughout the breast, In females, the largest portion of glandular breast tissue is located in the upper outer quadrant of each breast. In this quadrant, there is a projection of breast tissue into the axilla called the axillary tail of Spence The majority of breast tumors are located in the upper outer breast quadrant and in the tail of the Spence. During assessment, the nurse can localize specific findings by using the division of the breast into quadrants and axillary tail. Clients need to be instructed to do a breast self-examination (BSE) once a month. They should also be informed about the breast health guidelines.

BREAST HEALTH GUIDELINES Women ages 20 to 39 Monthly breast self-exam Clinical breast exam by a health professional every 3 years

Women ages 40 and older Monthly breast self-exam Clinical breast exam by a health professional every year Screening mammogram every year

ASSESSING THE BREASTS AND AXILLAE A. PLANNING

Delegation Assessment of the breasts and axillae is not delegated to unlicensed assistive personnel. However, persons other than the nurse may record aspects observed during usual care. Abnormal findings must be validated and interpreted by the nurse. Equipment Centimeter ruler

B. IMPLEMENTATION Performance 1. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate. Inquire whether the client has ever had a clinical breast exam previously. Discuss how the results will be used in planning further care or treatments. 2. Observe appropriate infection control procedures. 3. Provide for client privacy. 4. Inquire if the client has any history of the following: breast self-examination; medication history; any discharge of the nipple, history of breast masses and etc.

Palpation of the breast ASSESSMENT NORMAL FINDINGS DEVIATION NORMAL FROM

5. Inspect the breasts for Females: Rounded Recent change in breast size, symmetry and shape; slightly unequal in size, swellings; marked contour or shape while size; generally symmetric symmetry the client is in sitting

position.

Males: Breasts even with the chest wall; if obese, may be similar in shape to female breasts Skin uniform in color Localized discolorations (same in appearance as or hyperpigmentation skin of abdomen or back) Retraction or dimpling Skin smooth and intact (result of scar tissue or an invasive tumor) Diffuse symmetric horizontal or vertical Unilateral, localized vascular pattern in light- hypervascular areas skinned people (associated with increased blood flow) Striae (stretch marks); moles and nevi Swelling or edema

6. Inspect the skin of the breast for localized discoloration or hyperpigmentation, retraction or dimpling, localized hypervascular areas, swelling or edema

7. Emphasize any retraction by having the client. Raise the arms above the head. Push the hands together, with elbows flexed. Press the hands down on the hips. 8. Inspect the areola area for size, shape, symmetry, color, surface characteristics and any masses or lesions.

Round or oval bilaterally the same

and

Color varies widely from light pink to dark brown Irregular placement of sebaceous glands on the surface of the areola ( Montgomerys tubercles)

9. Inspect the nipples for Round, everted and Asymmetrical size, shape, position, equal in size; similar in

size

and

color, discharge lesions.

and color; soft and smooth; color both nipples point in the Presence of discharge, same direction crusts or cracks No discharge, except from pregnant or breast- Recent inversion of one or both nipples feeding females Inversion of one or both Tenderness, masses, or nipples that is present nodules from puberty No tenderness, masses or nodules

10. Palpate the axillary, subclavicular and supraclavicular lymph nodes while the client sits with the arms abducted and supported on the nurses forearm. Use the flat surfaces of all fingertips to palpate the four areas of the axilla: The edge of the greater pectoral muscle (musculus pectoralis major) along the anterior axillary line The thoracic wall in the midaxillary area The upper part of the humerus, and The anterior edge of the latissimus dorsi muscle along the posterior axillary line. 11. Palpate the breast for No tenderness, masses, Tenderness, masses, tenderness and nodules or nipple nodules or any discharge from the

masses, nipple

nipples.

discharge

discharge

12. Palpate the areola No tenderness, masses, Tenderness, and the nipples for nodules or nipple nodules or masses. Compress each discharge discharge nipple to determine the presence of any discharge. Assess any discharge for amount, color, consistency, and odor. 13. Teach the client the technique of breast selfexamination 14. Document findings in the client record using forms or checklist supplemented by narrative notes when appropriate

masses, nipple

LIFESPAN CONSIDERATIONS Infants Newborns up to two years of age may have breast enlargement and white discharge from the nipples (witchs milk)

Children Female breast development begins between 12 and 13 years of age and occurs in five stages. One breast may develop more rapidly than the other. Stage 1 Elevation of the nipple Stage 2 Enlargement of the areola Stage 3 Enlargement of the breast Stage 4 Projection of the areola and the nipple

Stage 5 Recession of the areola by about age 14 or 15, leaving only the nipple projecting Boys may have some breast development in early adolescence. Gynecomastia, enlargement of breast tissue in males, can occur during puberty and may affect only one breast.

Pregnant Females Breast, areola and nipple size increase. The areolae and nipples darken, may become more erect Superficial veins become more prominent and jagged linear stretch marks may develop. A thick yellow fluid (colostrum) may be expressed from the nipples after the third trimester.

Elders In the postmenopausal female, breasts change in shape and often appear pendulous or flaccid; they lack the firmness they had in younger years. The presence of breast lesions amy be detected more readily because of the decrease in connective tissue. General breast size remains the same.

G. Abdomen

The nurse locates and describes abdominal findings using two common methods of subdividing the abdomen: quadrants and regions.

To divide the abdomen into quadrants, the nurse imagines two lines: a vertical line from the xiphoid process to the pubic symphysis, and a horizontal line across the umbilicus. These quadrants are labeled (1) right upper quadrant, (2) left upper quadrant, (3) right lower quadrant and (4) left lower quadrant. Using the second method, division into nine regions, the nurse imagines two vertical lines that extend superiorly from the midpoints of the inguinal ligaments, and two horizontal lines, one at the level of the edge of the lower ribs and the other at the level of the iliac crests. Assessment off the abdomen involves all four methods of examination (inspection, auscultation, palpation and percussion).

ASSESSING THE ABDOMEN

A. PLANNING

Ask the client to urinate since an empty bladder makes the assessment more comfortable. Ensure that the room is warm since the client will be exposed.

Equipment Examining light Tape measure (metal or unstretchable cloth) Water-soluble skin-marking pencil Stethoscope

B. IMPLEMENTATION Performance 1. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate. Discuss how the results will be used in planning further care or treatments. 2. Observe appropriate infection control procedures. 3. Provide for client privacy. 4. Inquire if the client has any history of the following: incidence of abdominal pain; bowel habits; incidence of constipation or diarrhea; change in appetite; previous problems and treatment and etc. 5. Assist the client to a supine position, with the arms placed comfortably at the sides. Place small pillows beneath the knees and the head to reduce tension in the abdominal muscles. Expose only the clients abdomen from chest line to the public area to avoid chilling and shivering which can tense the abdominal muscles. ASSESSMENT INSPECTION OF THE ABDOMEN 6. Inspect the abdomen Unblemished skin for skin integrity Uniform color Presence of rash or other lesions NORMAL FINDINGS DEVIATION NORMAL FROM

Tense, glistening skin Silver-white striae (may indicate ascites, (stretch marks) or

surgical scars 7. Inspect the abdomen for contour and symmetry:

edema)

Flat, rounded (convex), Distended Observe the or scaphoid (concave) abdominal contour (profile line from the rib margin to the public bone) while standing at the clients side when the client is supine.

evidence of Evidence of enlargement Ask the client to take a No deep breath and to hold enlargement of liver or of liver or spleen spleen it. Assess the symmetry of contour while standing at the foot of the bed. If distention is present, measure the abdominal girth by placing a tape around the abdomen at the level of the umbilicus. 8. Observe abdominal movements associated with respiration, peristalsis or aortic pulsations. Symmetric contour Asymmetric contour,e.g., inguinal ligament or scars

Symmetric movements Limited movement due to caused by respiration pain or disease process Visible peristalsis in very Visible peristalsis lean people nonlean clients (with bowel obstruction) Aortic pulsations in thin persons at epigastric Marked aortic pulsations area

9. Observe the vascular No visible pattern pattern

vascular Visible venous pattern (dilated veins) is associated liver disease,

scites, and obstruction AUSCULTATION THE ABDOMEN OF

venocaval

10. Auscultate the abdomen for bowel Audible bowel sounds sounds, vascular sounds, Absence of arterial bruits and periptoneal friction Absence of friction rub rubs.

Absent, hypoactive or hyperactive bowel sounds Loud bruit over aortic area (possible aneurysm)

PERCUSSION OF THE ABDOMEN 11. Percuss several over the Large dull areas areas in each of the four Tympany quadrants to determine stomach and dullness tympany (gas in stomach and intestines) and dullness (decrease, absence or flatness of resonance over solid masses or fluid. PERCUSSION OF THE LIVER 12. Percuss the liver to 6 to 12 cm determine its size PALPATION ABDOMEN OF THE Enlarged size (associated with liver disease) and

No tenderness; relaxed Tenderness abdomen with smooth, hypersensitivity consistent tension 13. Perform light Superficial masses palpation first to detect Localized areas areas of tenderness or increased tension muscle guarding.

of

14. Perform deep Tenderness may be Generalized or localized palpation over all four present near xiphoid areas of tenderness quadrants process, over cedum,

and over sigmoid colon PALPATION LIVER OF THE May not be palpable

Mobile or fixed masses

Enlarged Smooth but nodular or hard tender,

15. Palpate the liver to detect enlargement and Border feels smooth tenderness PALPATION BLADDER OF THE

16. Palpate the area above thee public Not palpable symphysis if the clients history indicates possible urinary retention.

Distended and palpable as smooth, round, tense mass

LIFESPAN CONSIDERATIONS Infants The abdomen of the newborn and infant is round.

Children Elders The abdominal wall is slacker and thinner The pain threshold in elders is often higher Gastrointestinal pain may be located in the chest or abdomen. Decreased absorption of oral medications often occurs with aging The incidence of colon cancer is higher among older adults. Toddlers have a characteristic pot belly appearance. Peristaltic waves are usually more visible than in adults. Children may not be able to pinpoint areas of tenderness; by observing facial expressions the examiner can determine the areas of tenderness. The liver is relatively larger than in adults. If the child is ticklish, guarding or fearful, use a task that requires concentration to distract the childs attention.

H. Female Genitalia

.The examination of the genitals and reproductive tract of women includes assessment of the inguinal lymph nodes and inspection and palpation of the external genitals. Examination of the internal genitals involves (a) palpating Skenes and Bartholins glands, (b) assessing the pelvic musculature, (c) inserting a vaginal speculum to inspect the cervix and vagina, and (d) obtaining a Papanocolaou smear. A virgin or sexually inactive woman will probably require small speculum.

ASSESSING FEMALE GENITALS AND INGUINAL AREA A. PLANNING Equipment Examination gloves Drape Supplemental lighting, if needed

B. IMPLEMENTATION Performance 1. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate. Discuss how the results will be used in planning further care or treatments.

2. Wash hands, apply gloves, and observe appropriate infection control procedures. 3. Provide for client privacy. 4. Inquire if the client has any history of the following: age of onset of menstruation, last menstrual period (LMP), regularity of cycle, vaginal discharge, urgency and frequency of urination at night and etc. 5. Position the client supine with feet elevated on the stirrups of an examination table.

ASSESSMENT 6. Inspect the distribution, amount, and characteristics of pubic hair.

NORMAL FINDINGS There are wide variations; generally kinky in the menstruating adult, thinner and straighter after menopause Distributed in shape of an inverse triangle

DEVIATION NORMAL

FROM

Scant pubic hair (may indicate hormonal problem) Hair growth should not extend over the abdomen

7. Inspect the skin of the pubic area for parasites, inflammation, swelling and lesions. To assess pubic skin adequately, separate the labia majora and labia minora.

Pubic skin lesions

no Lice, lesions, scars, fissures, swelling, erythema, excoriations, Skin of vulva area slightly scars from episiotomies, darker than the rest of varicosities or leukoplakia the body Labia round, full and relatively symmetric in adult females

intact,

8. Inspect clitoris, urethral Clitoris does not exceed Presence of lesions orifice and vaginal orifice 1cm in width and 2 cm in Presence inflammation, when separating the labia length swelling or discharge. minora. Urethral orifice appears as small slit and is the same color as surrounding tissues No inflammation, swelling or discharge. 9. Palpate the inguinal No enlargement lymph nodes. Use the tenderness. pads of the fingers in the rotary motion noting any enlargement of tenderness. 10. Document findings in the client record using forms or checklist supplemented by narrative notes when appropriate. or Enlargement tenderness. or

LIFESPAN CONSIDERATIONS Infants Infants can be held in a supine position on the mothers lap with the knees supported in a flexed position and separated. The labia and clitoris may be edematous and enlarged. There may be a white vaginal discharge. Children Ensure that you have the parent or guardians approval to perform the examination. The girl has an increase in vaginal discharge if she is sexually active. The clitoris is a common site for syphilitic chancres in younger females.

Elders

Labia are atrophied and flatter in older females. The clitoris is a common site for cancerous lesions in older females. Because the vulva is more fragile, it is more easily irritated. The vaginal environment becomes drier. The cervix and uterus decrease in size. The fallopian tubes and ovary atrophy. Ovulation and estrogen production cease. Vaginal bleeding is abnormal. Older females may be arthritic and find examination uncomfortable. Prolapse of the uterus occurs, especially those who have had multiple pregnancies. Male Genitals

I.

Infants Foreskin (uncircumcised) normally tight Children Parent approval The cremasteric reflex causes the testes to ascend into the inguinal canal. 5 stages of development Elderly Penis decreases in size / firmness. Testosterone is produced in smaller amounts

More time to achieve erection Seminal fluid is reduced Problems with beginning and ending the urinary stream are usually result of prostatic enlargement. Client preparation Empty the bladder Emotionally prepared Explain the procedure Eye contact with the client Proper position Companionship Draping Warm hands Be gentle B. PLANNING Delegation Due to the substantial knowledge and skill required, assessment of the male genitals and inguinal area is not delegated to unlicensed assistive personnel. Equipment examination gloves C. IMPLEMENTATION Performance 1. Explain to the client what you are going to do, why it is necessary, and how he can cooperate. 2. Wash hands, apply gloves, and observe appropriate infection control procedures. 3. Provide for client privacy. 4. Inquire if the client has any history of the following: usual voiding patterns and any changes bladder control urinary incontinence, frequency, urgency abdominal pain any symptom of sexually transmitted disease any swelling that could indicate presence of hernia family history of nephritis malignancy of the prostate malignancy of the kidney

Assessment Pubic hair 5. Inspect the distribution, amount, and characteristics of pubic hair. Normal findings: Triangular distribution, often spreading up the abdomen. Penis 6. Inspect the penile shaft and glans penis for lesions, nodules, swellings, and inflammation. Normal findings: Penil skin intact Appears slightly wrinkled and varies in color as widely as other body skin Foreskin easily retractable from the glans penis Small amount of thick white smegma between the glans and foreskin 7. Inspect the urethral meatus for swelling, inflammation, and discharge. compress or ask the client to compress the glans slightly to open the urethral meatus to inspect it for discharge. Normal findings: Pink slit like appearance Positioned at the ti of the penis Assessment If the client has reported a discharge, instruct the client to strip the penis from the base to the urethra. 8. Palpate the penis for tenderness, thickening, and nodules. Use your thumb and first two fingers. Normal findings: Smooth and semi firm and is slightly movable over the underlying structures Scrotum 9. Inspect the scrotum for appearance, general size, and symmetry. To facilitate inspection of the scrotum during physical examination, ask the client to hold the penis out of the way. Inspect all skin surfaces by spreading the scrotum as needed to observe posterior surfaces.

Normal findings: Scrotal skin is darker in color than that of the rest of the body and is loose.

Size varies with temperature changes (the dartos muscles contract when the area is cold and relax when the area is warm.) Scrotum appears asymmetric ( left testis is usually lower than the right testis ) 1o. Palpate the scrotum to assess status of underlying testes, epididymis, and spermatic cord. Palpate both testes simultaneously for comparative purposes. Normal findings: Testicles are rubbery, smooth, and free to nodules and masses. Testis is about 2 x 4 cm ( 0.7 x 1.5 in. ) Epididymisis is resilient, normally tender, and softer than the spermatic cord Spermatic cord is firm Inguinal Area 11. Inspect both inguinal areas for bulges while the pateint is standing, if possible. First, have the client remain at rest. Next, have the client hold his breath and strain or bear down as though having a bowel movement. Bearing down may make the hernia more visible. Normal findings: No swelling or bulges 12. Palpate hermias Normal findings: No palpable bulge 13. Document findings in the client record using forms or checklists supplemented by narrative notes when appropriate. Evaluation Perform detailed follow- up examination of the heart or central vessels, integument, or other systems based on findings that deviated from expected or normal for the client. Relating findings to previous aessment data if available. Report significant deviations from normal to the physician. Palpating the scrotum Using your first two fingers and thumb, palpate each testis for size, consistency, shape, smoothness, and presence of masses. Palpate the epididymis between your thumb and index finger.

Palpate the spermatic cord between thumb and index finger. If swelling, irregularities, or nodules are detected during the scrotal examination, attempt to transilluminate the lesion. This is done by darkening the room and shining a flashlight behind the scrotum through the masses. Serous fluid causes the light to show with a red glow; tissue ir blood does not transilluminate. Describe all scrotal masses in terms of their size, shape, placement, consistency, tenderness, and presence of transillumination.