HEALTH ASSESSMENT #LETLENILEAD

Assessing General Health Status and Vital Signs

GENERAL SURVEY- requires the nurse to If abnormalities observed- need to perform

use all observational skills while interviewing an in depth assessment of the body area
& interacting with the client. that appears to be affected; assess clients
level of consciousness; level of comfort;
- Provides the nurse with an overall
behavior; body movements; affect; facial
impression on the client’s whole being.
expression; speech and mental acuities.
GENERAL HEALTH STATUS includes:
TEMPERATURE
1. Physical development & body build
2. Gender & sexual development • Taken at various anatomic sites
3. Apparent age as compared to (approximate reflection of the body core
reported age temperature)
4. Skin condition & color Adult Normal Temperature 97 F to 99 F
5. (Dress condition & color) not sure
wara sa libro Babies and children normal temp 97.9 F to 100.4 F
6. Dress & hygiene
7. Posture & gait • Lowest in early morning (4 AM -6 AM)
8. Level of consciousness • Highest late in the evening (8PM-
9. Behaviors, body movement, and midnight)
affect
10. Facial expression
11. Speech
12. Vital signs

OVERALL IMPRESSION OF THE CLIENT

First time to meet the client- remember

certain obvious characteristics/ significant
abnormalities:

• Skin color
• Dress hygiene
• Posture • HYPOTHERMIA- lower than 36.5 oC or
• Gait 96.9 oF
• Physical development
• Body build • HYPERTHERMIA- higher than 38oC or
• Apparent age 100o F
• Gender
• HYPERPYREXIA- higher than 40oC or
Observe the client & environment quickly 104oF
before interacting with the client.
HEALTH ASSESSMENT #LETLENILEAD
Assessing General Health Status and Vital Signs

SEVERAL FACTORS THAT AFFECT THE Normal PR 60-100 Bpm

TEMPERATURE: Bradycardia Below 60 bpm
• Strenuous exercise Tachycardia Above 60 bpm
• Stress
• Ovulation

These can cause the temperature to rise.

To convert temperature in degrees Celsius

to Fahrenheit.
𝟗
℉ = (℃𝒙 ) + 𝟑𝟐
𝟓

To convert temperature in degrees

Fahrenheit to Celsius.

℃ = (℉ − 𝟑𝟐)𝒙 𝟓/𝟗

Anatomic sites:

• TEMPORAL
• AXILLARY
• RECTAL (RECTUM)
• ORAL (MOUTH)
• TYMPANIC (EAR)

PULSE RATE RESPIRATORY RATE

CHARACTERISTICS OF THE PULSE THAT Observe/watch chest movement while
SHOULD BE ASSESSED: continuing to palpate the radial pulse.

• Rate Normal: Adult= 12-20 breath per minute

• Rhythm infants= 20-40 breaths per minute
• Amplitude Eupnea- normal respiration
0- Absent
1+- Weak, diminished (easy to Tachypnea- greater that 20 breaths per
obliterate) minute
2+- Normal (obliterate with Bradypnea- less that 12 breaths per minute
moderate pressure)
3+- Bounding (unable to obliterate Apnea- no breathing
or requires firm pressure)
Hyperpnea- deep breathing
• Contour
• Elasticity Hypopnea- shallow breathing
HEALTH ASSESSMENT #LETLENILEAD
Assessing General Health Status and Vital Signs

Dyspnea- difficulty breathing

Orthopnea- difficulty breathing while lying

down

Cheyne-Stokes – increase in depth and

rate followed by a decrease, resulting in
apnea. Seen in dying patient.

BLOOD PRESSURE
- Reflects the pressure exerted on the wall
of the arteries.
- It is measurement of the pressure of the
blood in the arteries when the ventricles
are contracted (systolic bp) & when the
ventricles are relaxed (diastolic bp)
- It is expressed as the ratio of the systolic
pressure over diastolic pressure.

AFFECTED BY TH FOLLOWING FACTORS:

• Cardiac output
• Elasticity of the arteries
• Blood volume
• Blood velocity (heart rate)
• Blood viscosity (thickness)

Varies throughout the day due to external

factors (time of the day, caffeine or nicotine
intake, exercise, emotions, pain,
temperature)

Pulse Pressure- the difference between the

systolic and diastolic pressure
- determine after measuring the BP because
it reflects the stroke volume (volume of the
blood ejected with each heartbeat) PAIN
Pain- an unpleasant sensory & emotional
experience, which we primarily associate
with tissue damage or describe in terms of
such damage.
HEALTH ASSESSMENT #LETLENILEAD
Assessing General Health Status and Vital Signs

• “Pain is whatever the person says it is”

(McCaffery & Pasero; 1999)

PAIN ASSESSMENT TOOLS

• Visual Analog Scale

• Numeric Rating Scale
• Numeric Pain Intensity Scale
• Verbal Descriptor Scale
• Graphic Rating Scale
• Verbal Rating Scale
• Faces Pain Scale