HEALTH ASSESSMENT – PRELIMS Normal Range: 36.

7’C –
38.3’C or 98.0F – 100.9F
VITAL SIGNS Client Type: all clients
- Measurements of the body’s most except with ear
foundation infection or ear pain
- Body’s indicator of health Advantage: Easy and
- Also knows as “Cardinal Signs.” quick to obtain.
- First step in physical assessment Disadvantage: There is
- Common, noninvasive physical assessment no research to support
procedure that most clients are accustomed accuracy of this method
to RECTAL Normal Range: 36.3’C-
37.9’C or 97.4’F- 100.3’F
FOUR MAIN VITAL SIGNS Client type: Adults who
require a very accurate
core temperature.
 Body Temperature Advantage: Most
 Pulse Rate indicative of core body
 Respiratory Rate temperature
 Blood Pressure Disadvantage: Cannot
be used with clients
TIME TO ASSESS VITAL SIGNS who have had rectal
surgery, abscesses,
diarrhea, low WBC, or
 On admission to a health care agency to obtain cardiac disease.
baseline data. ORAL Normal Range: 35.9’C-
 When clients have a change in health status 37.5’C or 96.6’F- 99.5’F
report symptoms such as chest pain or feeling Client type: Older
hot or faith. children and adults who
 Before and after surgery or an invasive are awake, cooperative,
procedure. alert, and oriented.
 before and after the administration of a Advantage: Easy and
accurate
medication that could affect the respiratory or
Disadvantage: Cannot
cardiovascular system.
be used if client has had
 Before and after any nursing intervention that oral surgery, if the client
could affect the vital signs. is a smoker, or if the
TEMPERATURE client is mouth
breather.
- Is a measurement of our body’s ability to
make or expel heat. AXILLARY Normal Range: 35.4’C-
- THERMOREGULATION CENTER: 37’C or 95.6’F98.5’F
HYPOTHALAMUS Client type: Infants,
young children, and
anyone with an altered
COMPENSATORY MECHANISM OF OUR BODY: immune system,
because this technique
- When you are too warm, your body’s blood is noninvasive.
vessels widen to carry heat to your skin’s Advantage: Easy to take
surface. You may begin to sweat to help your Disadvantage: Takes a
body cool. very long time while
- When you are cold, your body’s blood vessels nurse holds
constrict, reducing blood flow to your skin so thermometer under
that your organs remain warm and working. client’s arm. Not as
You may start to shiver to help your body create accurate as oral or
heat. rectal

CHOOSING THE CORRECT ROUTE TO MEASURE

BODY TEMPERATURE WHY IS NORMAL BODY TEMPERTATURE IMPORTANT?
TEMPORAL Normal Range: 36.3’C –  Normal body temperature is required for the
37.9’C or 97.4’F –
important enzyme in our body to function.
100.3F
 Extreme high or low temperatures cause
Client Type: All clients,
metabolic imbalances and can result in life-
unless sweating
profusely. threatening emergencies.
Advantage: Easy and FACTORS AFFECTING BODY TEMPERATURE
quick to obtain.
- Age
Disadvantage: Sweating
- Exercise
can interfere with
- Hormonal Level
accurate reading.
- Circadian rhythm (the lowest body temp.
 occurs between 1 and 4 hours and the body 2+ Normal and Expected
attain the maximum temp. at 18 hours) 3+ Full or Strong
- Environment 4+ Bounding
- Illness or infection - Temporal
- Carotid
- Apical
TYPES OF HEAT TRANSFER - Brachial
- Ulnar
- Radial
Conduction – transfer of heat from one molecule to a
- Femoral
molecule of lower temperature.
- Popliteal
Radiation – transfer of energy in the form of waves and - Posterior tibial
particles. - Dorsalis pedis

Convection – is the dispersion of heat by air currents.

Vaporization/Evaporation – is a continuous evaporation
of moisture from the respiratory tract and from the
mucosa of the mouth and from the skin.
TYPES OF FEVERS
TERMINOLOGIES
Pulse rhythm – is the regularity of the heartbeat.
- There are regular intervals between beats.
Dysrhythmia – irregular heartbeat

Pulse volume - is a measurement of the strength or

Intermittent – alternates at regular intervals between amplitude of force exerted by the ejected blood against
periods of fever and periods of normal/subnormal the arterial wall with each contraction.
temperature.
Arterial elasticity – artery feels straight, resilient, and
Remittent – wide range of temperature fluctuations all springy.
of which are above normal.
Bradycardia – is a heart rate of less than 60 beats per
Relapsing – short febrile periods of a few days are minute in an adult may be normal in well – conditioned
interspersed with periods of 1 or 2 days of normal clients.
temperature.
Tachycardia – is a heart rate more than 100 per minute
Constant – fluctuates minimally but always remains in an adult.
above normal.
RESPIRATORY RATE
NURSING INTERVENTIONS DURING FEVER 12-20 BEATS PER MINUTE
 Monitor vital signs and skin color. - The act of breathing
 Encourage fluid intake. - Rate and character are additional clues to
 Tepid sponge bath the client’s overall health status.
 Dry clothing and linens
 Antipyretics
NORMAL RESPIRATORY RATE RANGES
 Monitor lab values.
AGE BREATS/MINUTE
PULSE RATE
Newborn to 6 weeks 30-60
- A shock wave produced by the contraction
Infant (6weeks to 6m) 25-40
of the heart and forceful pumping of blood
Toddler (1-3) 20-30
out of the ventricles into the aorta.
Young children (3-6) 20-25
- Commonly called the arterial or peripheral
Older children (10-14) 15-20
pulse.
- Is an indirect measurement of cardiac Adult 12-20
output obtained by counting the number of
apical or peripheral pulse waves over a TERMINOLOGIES
pulse point.
- A normal pulse rate for adults is between 60 Bradypnea – less than 12 beats/min
and 100 beats per minute.
Tachypnea – greater than 20 beats/min

PULSE DEFICIT - condition in which the apical pulse rate
is greater than the radial pulse rate.
- A deficit or a discrepancy may present heart
condition such as atrial fibrillation.
- A pulse deficit results from the ejection of a
volume of blood that is too small to initiate a
peripheral pulse wave.
ASSESSMENT OF PULSE
0- ABSENT
1+ Diminished or barely palpable
Apnea – no respiration for several seconds
Hyperventilation – Increased rate and depth of
respiration
Hypoventilation – decrease rate and depth of
respiration.
Cheyne-Stokes – alternating patterns of depth
separated by periods of apnea and hyperventilation.
Kussmaul’s – Deep and labored, increased rate
Biot’s respiration - 2-3 abnormally shallow breaths that has two focuses.
followed by an irregular period of apnea.

BLOOD PRESSURE  Establishing rapport and trusting relationship

120/80 mmHg with the client to elicit accurate and meaningful
information.
 Gathering information on the clients that can be
enhanced through nurse-client collaboration.
ARTERIAL BLOOD PRESSURE – the force exerted on the
walls of an artery by the pulsing blood under pressure Four basic phases of Interview
when pumped by the heart.

Systolic pressure – maximum peak pressure during PREINTRODUCTORY PHASE

ventricular contraction.
- reviews the medical record before meeting with
Diastolic pressure – minimal pressure during ventricular the client.
relaxation. - Knowing some of the client’s already
documented biographical information.

INTRODUCTORY PHASE

- The nurse explains the purpose of the

interview, discusses the types of questions that
will be asked, explains the reason for taking
notes, and assures the client that confidential
information will remain confidential.

WORKING PHASE
FACTORS AFFECTING ARTERIAL BLOOD PRESSURE - the nurse elicits the client’s comments about
- Age major biographical data, reasons for seeking
- Stress care, history of present health concern, past
- Ethnicity health history, family history, review of body
- Gender systems (ROS) for current health problems,
- Daily variation lifestyle and health practices, and development.
- Medication
- Activity weight SUMMARY PHASE
- Smoking - Identifies and discusses possible plans to
- Diet resolve the problem with the client.
- summarizes information obtained during the
OXYGEN SATURATION
95%-100% working phase and validates problems and
- The amount of oxygen that is in the blood goals with the client.
carried to the extremities of the body COMMUNICATION DURING THE INTERVIEW
(fingers, ears, nose, toes)

NONVERBAL VERBAL
COMMUNICATION COMMUNICATION
COLLECTING SUBJECTIVE DATA - appearance - Open-ended
- is an integral part of interviewing the client - Demeanor questions
to obtain a nursing health history. - Facial expression - Close-ended
- Consist of: - Attitude questions
1. Sensations or symptoms - Silence - Laundry list
2. Feeling, perception - Listening - Rephrasing
3. Desires, preference - Well-placed
4. Beliefs, ideas phrases
5. Values - Inferring
6. Personal information - Providing
information

SUBJECTIVE DATA – can be elicited and verified only by

the client. C – character

- Provide clues to possible physiological, O- onset

psychological, and sociologic problems. L – location
INTERVIEWING – Obtaining valid nursing health history D – duration
requires professional, interpersonal, and interviewing
skills. S – severity

The nursing interview is a communication process P – pattern

A – associated factors - assessment of posture, gait & balance.

PAIN ANALYSIS MNEMONIC SITTING/FOWLERS POSITION (SEMI 30-45 degrees, HIGH

90 degrees)
P – provocative/palliative
- : Head, neck, posterior and anterior thorax,
Q – quality
breast, axillae, heart, vital signs, upper
R – radiates extremities lower, extremities and reflexes.

S – severity DORSAL RECUMBENT

T – timing - The client lies down on the examination table or

COLLECTING OBJECTIVE DATA: THE PHYSICAL
EXAMINATION
- A systematic way of collecting objective
data from a client using the four
examination techniques.
- To assess or identify current health status
bed with the knees bent, the legs separated,
and the feet flat on the table or bed.
SUPINE
- head, neck, axillae, anterior thorax, lungs,
abdomen, extremities, peripheral pulses.

PRONE POSITION
BASIC KNOWLEDGE IN 3 AREAS A NURSE MUST - The client lies down on the abdomen with the
HAVE!
head to the side.

SIMS POSITION
EQUIPMENT
- The client lies on the right or left side with the
- Prior to examination, collect the necessary lower arm placed behind the body and the
equipment and place it in the area where the upper arm flexed at the shoulder and elbow.
examination will be performed. The lower leg is slightly flexed at the knee while
the upper leg is flexed at a sharper angle and
pulled forward.
- assessment of rectum and vagina.

LITHOTOMY POSITION

- The client lies on the back with the hips at the

edge of the examination table and the feet
supported by stirrups.

KNEE CHEST POSITION

- The client kneels on the examination table with

the weight of the body supported by the chest
and knees. A 90-degree angle should exist
between the body and the hips. The arms are
placed above the head, with the head turned to
one side.

PERFORMANCE OF THE 4 ASSESSMENT TECHNIQUES

- Inspection
- Palpation
- Percussion
- Auscultation

POSITIONING YOUR CLIENT

STANDING/ERECT POSITION