HEALTH ASSESSMENT

Aimee C. Agudo RN, MAN

Course Description:
The course deals with concepts, principles
& techniques of history taking using various
tools, physical examination (head to toe),
psychosocial assessment and
interpretation of laboratory findings to arrive
at a nursing diagnosis on the client across
the lifespan in community and hospital
settings.
Course Credit:
3 units lecture (54 hours), 2 units RLE
(102 hours)

Contact Hours/Sem:
36 lecture hours, 51 RLE hours

Time:
8:00am-11:30am (BSN 1A)
1:30pm-4:30pm (BSN 1B)
Course Objectives:
At the end of the course and given simulated & actual
conditions/situations, the student will be able to:

1. Differentiate normal from abnormal assessment

findings;
2. Utilize concepts, principles, techniques and
appropriate assessment tools in the assessment of
individual client with varying age group and
development; and,
3. Observe bioethical concepts/
principles and core values and
nursing standards in the care of clients.
Back Ground

• The nursing process is based on a nursing

theory developed by Ida Jean Orlando.

• She developed this theory in the late

1950's as she observed nurses in action.
She saw "good" nursing
and "bad" nursing.
• From her observations she learned that
the patient must be the central character.
– Nursing care needs to be directed at
improving outcomes for the patient, and not
about nursing goals.
– The nursing process is an essential part of
the nursing care plan.
The Nursing Process is:

A systematic, rational method of

planning and providing individualized
nursing care.
5 components of the Nursing Process:

1.Assessment
2.Diagnosis
3.Planning
4.Implementing
5.Evaluating
I. Assessment
Is collecting, validating,
organizing and recording data about
the patient's health status.

* Purpose: To establish a data base.

• Activities During Assessment:
1. Collecting Data
- This involves gathering information
about the patient considering the
physical, psychological, emotional,
socio-cultural, and spiritual factors that
may affect his/or her health status.
• Types of Data:
a.) Subjective Data. Those that can be
described only by the person
experiencing it.

b.) Objective Data. Those that can be

observed and measured.
• Methods of Collection of Data:
a.) Interview. Is a planned, purposeful
conversation
Example:
- Collection of data for health history,
- Admission of patient to a healthcare facility
b.) Observation.
Example:
- Use of senses ( vision, hearing, touch,
smell)
- Use units of measure (mmHg, lbs. or kg,℃)
- Physical Examination techniques (IPPA)
- Interpretation of laboratory results
• Source of Data:

a.) Primary Source: Patient

b.) Secondary Source: Family members,

friends and significant others, Patient's
record/chart, etc.
II. DIAGNOSING
Is a process which results to a
diagnostic statement or Nursing Diagnosis.
It is the clinical art of identifying problems.
To diagnose in nursing, it means to analyze
assessment.
Purpose: To identify the patient's health care
needs and to prepare diagnostic
statements.
• Nursing Diagnosis:

Is a statement of patient's
potential or actual alteration of health
status. Is uses critical-thinking skills of
analysis and synthesis.
• Nursing Diagnosis uses PRS/PES format.

P - Problem
R - related to factors
S - Signs and Symptoms

P - Problem
E - Etiology
S - Signs and Symptoms
• Activities During Diagnosing:
1.) Organizing Data. Clustering facts into
groups of information.

a. Data about patient's Nutritional Status

- Subjective Data
- Objective Data

b. Data about patient's Fluid Balance Status

- Subjective Data
- Objective Data
2. Comparing Data gathered during
assessment against standards.
- Standards are acceptable norms, measures,
or patterns for purposes of comparison.

Examples:
- The standard color of the skin is pinkish
- The standard rbc level is 4.5M - 5.5M/cu.mm.
- The standard pulse rate of an adult is 60-100 bpm.
- The standard urine output is
30-60mls/hour
3. Analyzing data after comparing with
standards.

Examples:
- Passage of frequent watery stool may lead
to loss of electrolyte like potassium, sodium
- Poor appetite to eat, weight loss of 10lbs.,
weakness indicate inadequate nutritional
intake
4. Identifying gaps and inconsistencies in
data.

Example:
- Patient claims she is gaining too much
weight but actually, she is underweight.
5. Determining the patient's health problems,
health risks, and strengths.

Examples:
- Inadequate Nutrition
- Altered body image
6. Formulating Nursing Diagnoses
statements.

Examples:
- Fluid volume deficit related to frequent
passage of watery stool
- Alteration in nutrition: less than body
requirements related to poor apetite to eat.
• Summary of Steps of Nursing Diagnosis
A. Cluster of Data
- Diarrhea of 10 days
- Distended abdomen
B. Compare with standards
- Soft, formed stool, daily
- Abdomen soft, non-distended
C. Make a Reasoned Conclusion
- Bowel elimination problem
D. Nursing Diagnosis
- Alteration in Bowel Elimination
(Diarrhea) related to food intolerance
III. Planning
Involves determining beforehand the
strategies or course of action to be taken
before implementation of nursing care.
Purpose:
- To identify the patient's goals and
appropriate nursing intervention.
- To direct patient care activities.
- To promote continuity of care.
- To allow delegation of specific activities.
IV. Implementation
Is puting the nursing care plan into
action.

Purpose: To carry out planned nursing

interventions to help the patient attain
goals and achieve optimal level of health.
• Activities:

- Reassessing
- Set Priorities
- Perform Nursing Interventions
- Record Actions
V. Evaluation
Is assessing the patient's response to
nursing interventions and then comparing
the response to predetermined standards
or outcome criteria.

Purpose:
- To appraise the extent to which goals and
outcome criteria of nursing
care have been achieved.
THE INTERVIEW
• Purpose of Interview:
a.) Gather organized, complete, and accurate data
about the patient's health state, including the
description and chronology of any signs and
symptoms of illness.

b.) To establish rapport and trust so the patient feels

accepted and thus feel free to share all relevant
data.
c.) Teach the patient about the health state
so that he/she can participate in identifying
problems and planning for health care.

d.) Build rapport for a contunuing nurse-

patient therapeutic relationship; this
rapport facilitates future diagnoses,
planning and treatment.

e.) Begin teaching for health

promotion and disease
prevention.
• The Process of Communication

1.) Sending

2.) Receiving
• Internal Factors that Affect
Communication

- Liking Others

- Empathy

- The Ability to Listen

• External Factors that Affect
Communication

- Ensure Privacy
- Refuse Interruption
- Physical Environment
- Dress
- Note-Taking
- Tape and Video Recording
• Phases of the Interview

1.) Preparatory Phase

- Occurs before the nurse meet the patient.

2.) Introductory Phase

- Also known as orientation phase. It begins
when the nurse and the
patient meet.
3.) Maintenance Phase
- Also known as working phase
- The nurse and patient work toward
achieving the specific task or goal agreed
on in the introductory phase.

4.) Concluding Phase

- Also known as Termination phase
• Techniques of Communication

1.) Facilitation of General Leads

- There responses encourage the patient to
say more, to continue with the story.

2.) Silence
- The patient is able to collect
his/her thoughts.
3.) Reflection
- This response echoes the patient's words.
It is repeating part of what the patient has
just said.

4.) Empathy
- Empathetic response recognizes a feeling
and puts into words. This makes the
patient feel accepted and can deal with the
feeling openly.
5.) Clarification
- This is used when the person's word
choice is ambiguous confusing.

6.) Confrontation
- The nurse gives his/her honest feedback
about what he/she sees or feels.
7.) Interpretation
- It is based on influence or conclusions.

8.) Explanation
- Provides information to the patient. It
shares factual and objective information.

9.) Summary
- The final review of what the
nurse understand the
patient has said.
• 10 Traps of Interviewing

1.) Providing False Assurance or

Reassurance
2.) Giving Unwanted Advice
3.) Using Authority
4.) Using Avoidance Language
5.) Engaging in Distancing
6.) Using Professional Jargon
7.) Using Leading or Biased Questions
8.) Talking too much
9.) Interrupting
10.) Using "Why" Questions
• Space and Distance

 4 Distance Zones are as follows:

a.) Intimate Zone (0 to 1 1/2 feet)

- Visual distortions occurs
- Best for assessing breath and other body
odors.
b.) Personal Distance ( 1 1/2 feet to 4
feet)

- No visual distortion
- Voice is moderate
- Body odors inapparent
- Much of physical assessment occurs at the
distance.
c.) Social Distance (4 feet to 12 feet)

- Used for impersonal business transactions

- Perceptual information much less detailed
- Much of the interview occurs at this
distance.
d.) Public Distance ( 12 feet and more)
- Interaction with others is impersonal
- Speaker's voice must be protected
- Subtle facial expressions are imperceptible
Health History
• Health History
- Provides the subjective
database of assessment.

- It consist of what the patient tells

you, what the patients perceives
and what the patients thinks is
important.
Subjective data is consist of:
• Sensations/Symptoms
• Feelings
• Desires
Interview
• Preferences
• Beliefs
• Ideas
• Values
Non Verbal Communication
• Appearance • Silence
• Demeanor • Listening
• Attitude
 Communication to Avoid
• Excessive/Insufficient eye contact
• Distance/Distraction
• Standing
• Reading questionnaires
Communication in Anxious Patient
• Simple and organize
• Avoid becoming anxious like the client
• Do not hurry
• Decrease external stimuli
Communication in Angry Patient

• Approach client in a calm

manner.
• Allow to ventilate
feelings.
• Avoid arguing
 Communication in Depressed
Patient

• Express interest and understanding.

 Communication in
Manipulative Patient

• Provide structure and

set limits.

• Differentiate
manipulation and
reasonable request.
 Communication in a Seductive
Patient

• Set firm limits

• Ignore the behavior
 Communication when discussing
sensitive issues (Dying, Spirituality)
• Ask non judgemental questions
• Allow time for ventilation of feelings as
needed.
 Types of Health History

• Complete (includes biographical data)

• Focused (complaint)

Which type do you do?

• Patient’s condition
• Amount of time
Medical Versus Nursing History
How does a medical history differ from
nursing?
Medical
Focuses on diagnosis and treatment of
illness
Nursing
Focuses on diagnosis
and treatment of human
responses to health problems
 Key Points to Remember When
Obtaining Health History.
• Listen to what your patient is
telling you both verbally and
non verbally.
• Don’t Rush
• Ensure confidentiality
• Provide private, quite
comfortable environment.
• Do not be so concerned about
completing documents that you neglect
your paatient.
• Start with what the patient perceives as
the problem.
• Attend any acute problems (pain) before
obtaining history.
• Quality is more important than quantity
of information gathered.
Components of the
Health History
 A. Biographical Data
What can the biographical data tell you?
• Name
• Address & phone
• Contact
• Age, birth date
• Gender
• Social Security number
• Referral source
• Source of history and reliability
• Race/ethnicity
• Religion
• Marital status
• Education
• Occupation
• Insurance
• Advanced directives
B. History of Present Illness
What can the patient’s reasons for seeking
health
care and the patient’s current health status tell
you?
• Primary Level of Health Care — usual state
of health, major health problems, usual
patterns of care, and any health concerns
• Secondary or Tertiary Levels of Health Care
— perform a symptom analysis
 C. Past Health History
What can the past health history tell you?

• Hospitalizations
• Serious injuries
• Allergies
• Transfusions
• Military service
• Surgeries
• Immunizations
• Medications
• Recent travel
• Childhood illnesses
 Symptom Analysis

P= Precipitating / palliative factors

Q= Quality / quantity of symptom
R= Region / radiation / related symptoms
S= Severity
T = Timing
 D. Family History
What can the family history tell you?
• Patient
• Children
• Siblings
• Grandparents
• Spouse
• Parents
• Aunts and uncles
Genogram
 E. Review of Systems
What can the review of systems tell you?

• General health status

• Endocrine
• Genitourinary
• Reproductive
• Musculoskeletal
• Neurological
• Immune
• Hematological
• Integumentary
• HEENT
• Respiratory
• Cardiovascular
• Breasts
• Gastrointestinal
 Review of Systems
Content of a complete review of systems.

• General/Constitutional
Average weight, weight loss or gain,
general state of health,, strength, ability to
conduct usual activities, exercise tolerance
• Skin/Breast
• Rash, itching, pigmentation, moisture or
dryness, texture, changes in hair growth or
loss, nail changes
• Breast lumps, tenderness, swelling, nipple
discharge
Eyes/Ears/Nose/Mouth/Throat
• Headaches (location, time of onset,
duration, precipitating factors), vertigo,
lightheadedness, injury
• Vision, double vision, tearing, blind
spots, pain
• Nose bleeding, colds, obstruction,
discharge
• Dental difficulties, gingival bleeding,
dentures
• Neck stiffness, pain, tenderness, masses
in thyroid or other areas
• Cardiovascular

• Pain, substernal distress, palpitations,

syncope, dyspnea on exertion, orthopnea,
nocturnal paroxysmal dyspnea, edema,
cyanosis, hypertension, heart murmurs,
varicosities, phlebitis.
• Respiratory
• Pain (location, quality,
relation to respiration),
shortness of breath,
wheezing, cough (time of
day,of productive,amount
in tablespoons or cups per
day and color of sputum), hemoptysis,
respiratory infections, tuberculosis (or
exposure to tuberculosis), fever or night
sweats
• Gastrointestinal

• Appetite, dysphagia,
indigestion, abdominal
pain, heartburn,nausea,
vomiting, hematemesis,
jaundice, constipation, or diarrhea, abnormal
stools (clay-colored, tarry, bloody, greasy, foul
smelling), flatulence, hemorrhoids, recent
changes in bowel habits
• Genitourinary

• Urgency, frequency, dysuria,

nocturia, hematuria, polyuria,
oliguria, unusual (or change in)
color of urine, stones,
infections, nephritis, hesitancy,
change in size of stream,
dribbling, acute retention or
incontinence, libido, potency,
genital stores, discharge,
venereal disease
• (Female) Age of onset of menses,
regularity, last period, dysmenorrhoea,
vaginal discharge/, post-menopausal
bleeding, dyspareunia, number and results
of pregnancies (gravida, para)
• Musculoskeletal
• Pain, swelling, redness or
heat of muscles or joints,
l;imitation, of motion,
muscular weakness,
atrophy, cramps
• Neurologic/Psychiatric
• Convulsions, paralyses, tremor,
incoordination, difficulties with memory of
speech, sensory or motor disturbances, or
muscular coordination (ataxia, tremor)
• Predominant mood "nervousness",
emotional problems, anxiety, depression,
previous psychiatric care, unusual
perceptions, hallucinations
• Allergic/Immunologic/Lymphatic/Endocrine
• Reactions to drugs, food, insects, skin
rashes, trouble breathing .
• Anemia, bleeding tendency, previous
transfusions and reactions, Rh incompatibility
• Local or general lymph node enlargement or
tenderness. -Polydipsia, polyuria, hormone
therapy, growth, secondary sexual
development, intolerance to heat or cold
 F.Developmental Considerations

Consider:
• Past developmental stages
• Current developmental stages
 G. Developmental Theories
• Freud • Peck
• Erikson • Havighurst
• Maslow • Cumming & Henry
• Piaget • Duvall
• Kohlberg • Butler
• Gilligan
 H. Psychosocial History
What can the psychosocial history tell you?
• Activity & exercise
• Sleep/rest patterns
• Personal habits
• Health practices & beliefs
• Occupational health patterns
• Socioeconomic status
• Environmental health patterns
• Role, relationships, self-concept
• Cultural influences
• Religious/spiritual influences
• Nutritional patterns
• Recreation, pets, hobbies
 I. Pattern of Health Care
• Includes all health care resources:
hospitals, clinics, health centers, family
doctors
 J. Lifestyle
• Include personal habits, diets, sleep or
rest patterns, activities of daily living,
recreation or hobbies.
 K. Psychological data

• Information about the client’s emotional state.

Physical Assessment
( Objective)
• Use of senses to collect data.
• Important to know normal findings to
appreciate abnormal.
• Objective collection of data.
• May ask questions upon assessment
(ROS).
 Components
• General survey (appearance, behavior)
• Measurements
– Vital signs
– Height
– Weight
– Pulse oximetry
• Head-to-toe, including all
systems assessments.
Thermometer
Doppler
Penlight
Otoscope
Stethoscope
Visual Acuity Charts
Ophthalmoscope
Tape Measure
Triceps Skin Fold Calipers
Scale
Tongue Depressor
Gloves
 Physical Assessment
Techniques

Inspection
Palpation
Percussion
Auscultation
 Inspection

Types:
Direct - direct looking at the patient.
Indirect - using equipment to
enhance visualization.
Senses Sight, Smell

What can inspection tell

you?
– Surface characteristics
– Symmetry
– Gross abnormalities or signs of distress
– Unusual odors
 Palpation
Types Single-handed, Bimanual

Senses Touch

 Light: < 1/2 inch (temperature, texture,

shape, size, pulse)
 Deep: > 1/2 inch (assess organ size,
tenderness)
– Ballottement:
-used to assess partially free-
floating objects
(fetal assessment, assess fluid in
patella)
 Parts of Hand Used for
Palpation
Dorsal aspect
Best for temperature

Ulnar surface of hand

Best for vibrations

Fingertips
Best for fine sensations
 Percussion
Used to assess density of underlying structures.

Entails striking a body surface with quick light blows

and eliciting vibrations and sounds.
Types
– Direct (immediate)
*directly tapping the body surface to elicit a
sound.
– Indirect (mediate)
* done by placing non dominant hand over a
body surface.
– Fist or blunt
* Used to assess organ tenderness. Striking
with an Ulnar surface of your fist.
Senses
– Touch
– Hearing

HINTS:
* In percussion, examiner
must trim his/her nails.
* Do not percuss over bone.
 Percussion Sounds
• Resonance
- hollow
* Normal Lung Sound
• Tympany
- Drum like sound
* Intestinal Air/Gastric Air Bubble
• Dullness
- Thudlike sound
* Liver, Full Bladder,
Pregnant uterus
• Hyper resonance
- Very loud intensity
- Very Long duration
* Hyperinflated Lung
(emphysema)
• Flatness
- Short duration
- Muscle
 Auscultation
Types
Direct: Listening to sound without
stethoscope
Indirect: With Stethoscope
Senses Hearing
What can auscultation tell you?
– Heart sounds
– Lung sounds
– Bowel sounds
Examination Positions
Sitting
Supine
Dorsal Recumbent
Sims
Prone
Knee Chest
Standing
 Approach to Assessment

• System or region
• Be systematic.
• Minimize position change.
• Expose only the area being assessed.
 Approach to Assessment
• Explain as you go.
• Share findings with patient and teach.
• Ensure privacy and confidentiality.
• Consider developmental level of patient.
• Consider cultural background of patient.
 General Survey
• Age • Gender
• Race • Affect
• Level of • Dress
consciousness • Speech
• Obvious • Posture
abnormalities or
signs of distress
 Vital Signs and
Anthropometric Measurements
• Temperature • Pulse
• Respirations • Blood pressure
• Height • Weight
Vital Signs
 Temperature
• Difference • Hypothermia – below
between heat normal
produced and • Hyperthermia (fever)
heat loss. – above normal.
2 Types of Body Temperature
• Core Temperature • Surface Temperature
- temperature of the -temperature of the
deep tissues of the skin, subcutaneous
body. tissue and fat.
- Measured by taking - Measured by taking
oral and rectal axillary temperature.
temperature.
 • Body heat is primarily produced by
metabolism.

• The heat regulating centre is found in

hypothalamus.
Factors Affecting Heat Production
• 1. Basal Metabolic Rate (BMR)
- the younger the person, the higher the BMR;
the older, the lower the BMR .

Therefore, the older persons have lower body

temperature than young ones.

BMR = 655 + (9.6 x weight in kg) + (1.8 x height in cm) – (4.7 x age in Yrs) To
determine your total daily calorie needs, multiply your BMR by the
appropriate activity factor, as follows: If you are sedentary (little or no
exercise) : Calorie-Calculation = BMR x 1.1.
2. Muscle Activity
( Exercise)
- Increase cellular
metabolic rate therefore
increase body heat
production.

3. Thyroxine Output
- Increase cellular metabolic
rate. (Hyperthyroidism)
4. Epinephrine and Sympathetic Stimulation.

5. Increased Temperature of Body Cells

 Processes of Heat Loss
1. Radiation
- transfer of heat from one object to another
without contact.
Eg. Warm in crowded room

2. Conduction
- transfer of heat from one
object to another with contact.
Eg. TSB
3. Convection
- Dissipation of heat by air currents.
Eg. Exposure of skin to electric fan.

4. Evaporation
- Continous vaporization of moisture from
skin.

Eg. Insensible heat loss

Factors Affecting Temperature

1. Age
- Infant: dependent to the environment
- Adult: Risk for hypothermia decreased
thermoregulatory control
Decreased SQ fats
Inadequate diet
Sedentary activity
2. Diurnal Variations
- Highest temp: 8pm-12mn
- Lowest temp: 4am-6am.

3. Exercise
- Strenuous exercise increases metabolic
rate and temperature.
4. Hormones
- Progesterone, Thyroxine, epinepherine
increases body temperature.
- Estrogen decreases body temperature.

5. Stress
- Stimulation of sympathetic nervous
system
 Types of Fever
1. Intermittent Fever
- Temperature fluctuates with episodes
of normal.
2. Remittent
- Temperature fluctuates over 24 hours
but remains above normal.
3. Relapsing Fever
- Temperature is elevated for few days
alternated with normal temp for 1-2 days.

4. Constant Fever
- Very high temperature (41-42 degree
Celsius)
 Decline of Fever
1. Crisis/Flush/Defervescent
- sudden decline of fever
- Indicates hypothalamus impairment.

2. Lysis
- Gradual change of fever
 Clinical Signs
Onset Course
Increased HR Absence of chills
Increased RR Warm skin
Shivering Increased thirst
Pale, Cool skin Restlessness
Cyanotic nail bed Convulsions
Complains of feeling Loss of appetite
cold Malaise
Cessation of sweating Muscle pain
 Temperature Routes
• Oral • Rectal
NV: 36.5-37.5 ˚C NV: 37-38.1 ˚C

- Most accesible and - more reflective to core

convenient temperature.
- Time: 2-3 min - most accurate
CI: Time:2 minutes
unconscious, confused CI:
or with seizures,oral hemorrhoids. surgery,
lesions/surgery diarrhea.
• Tympanic • Axillary
NV: 36.8-37.9 ˚C NV:35.8-37˚C

- safe, good for - safe, good for

children children and
newborns.
- inaccurate Time: 9 min. (adult)
sometimes. 5 min (Infant)
• Forehead
NV: 34.4 ˚C

- Safe and easy but

least accurate.
 Conversion

• ˚F to ˚C (˚F – 32) x 5/9= ˚C

• ˚C to ˚F ( ˚C x 9/5) + 32= ˚F
 Pulse
• Wave of pressure as • Bradycardia – below
blood circulates. normal range.
• Of different sites.
- Temporal • Tachycardia – above
- Carotid normal range.
- Apical
- Brachial
- Radial
-Femoral
- Posterior tibial
-Popliteal
- Dorsalis pedis
NV:
Newborn: 120-160 bpm
3 y o: 80-125 bpm
10 y o: 70 – 110 bpm
16 y o: 55-100 bpm
Adult: 60- 100 bpm
 Respirations
• Checking for rate, • Eupnea – normal
rhythm and depth range
of inspiration and • Bradypnea – below
expiration. normal.
NV: • Tachypnea – above
NB: 30-80rpm normal range.
3 y o:20 -30rpm • Apnea – absent
10 y o: 16-22rpm breathing.
16 y o :15 – 20 rpm • Dyspnea – difficulty
Adult: 12-20 rpm of breathing
 3 Process of Respiration
1. Ventilation
- movement of gases in and out of lungs.
Inspiration
Expiration
2. Diffusion
-Exchange of gases from an area of higher
pressure to an area of lower pressure.

3. Perfusion
- Movement of blood
for transport of gases
and nutrients.
 2 Types of Breathing
1. Costal ( Thoracic)
- involves chest
movement.

2. Diaphragmatic
(Abdominal)
-Involves movement
of abdomen
Medulla Oblongata – respiratory center.
 Blood Pressure
• Pressure on the vascular system as the
heart contracts and relax.
NV:
Newborn:
Systolic: 50-52mmHg
Diastolic: 25-30 mmHg

3 year old:
Systolic: 78-114 mmHg
Diastolic: 46-78 mmHg
• 10 year old: Systolic: 90- 132 mmHg
Diastolic: 75-86 mmHg

• 16 year old: Systolic: 104 – 108 mmHg

Diastolic: 60-92 mmHg

• Adult: Systolic: < 120

Diastolic: < 80
• Hypotension – below normal (< 90/60)

• Hypertension – above normal(>140/90).

• Pulse pressure – difference between

systolic and diastolic.

• Korotkoff sound – determine BP

measurement.

Blood Pressure
Animation Heart disease risk factors.mp4
 Blood Pressure Tips
• Narrow cuff – false high BP
• Too wide cuff – false low reading
• Loosely wrapped – false high
• Arm above heart level upon reading –
false low reading.
• Muscle contracted – false high
 Avoid doing BP on:
• Arm with injury/cast.
• Arm with IV site
• Post mastectomy
patient
• Arm with vascular
access.
 When Vital Signs Are Assessed
• Temperature, pulse, respirations, and
blood pressure are usually assessed at the
same time at set intervals.
• A set of vital signs is taken when the
patient is admitted to the facility and then
as prescribed by the physician or as policy
dictates.
• Example: every 4 hours; once a shift;
weekly
• The more ill the patient, the more frequently
vital signs are taken.
• Vital signs are interrelated.

– A rise in temperature of 1° F may cause an

increase in pulse rate of 4 beats per minute.
– Respiratory rate and blood pressure readings
increase with a rise in temperature.
– Blood pressure falls because of hemorrhage,
the pulse and respirations increase and the
temperature usually decreases.
 Recording Vital Signs
• Graphic Flow Sheet
– Used for charting vital signs
– R indicates a rectal temperature
– Ax indicates an axillary temperature
– Blood pressures are always written with the
systolic first and the diastolic beneath.
• Example: 120/80
– Apical pulse is indicated with an
“ap” after next to the number.
• Example: 78 ap
 Recording Vital Signs
• Any abnormal findings are reported to the
nurse-manager or physician immediately.
• Any accompanying or precipitating signs
and symptoms such as chest pain, vertigo,
shortness of breath, flushing, and
diaphoresis should be recorded as well.
• The nurse documents any interventions
initiated as a result of vital sign
measurement, such as tepid sponging.
 Height and Weight
• Helps assess normal growth and
development
• Aids in proper drug dosage calculation
• May be used to assess the effectiveness
of drug therapy, such as diuretics
• Significant loss of weight
may be a sign of an
underlying disease
 Height and Weight
• Height
– Patient should remove shoes
and stand erect.
– A measuring stick or tape may
be attached vertically to the
weight scales or wall.
– Standing scales may have a
metal rod, which is attached to
the back of the scale and
swings out over the top of the
patient’s head.
 Height and Weight
• Weight
– Types of scales
• Standing scales
• Chair scales; lift scales
– Used for patients who cannot stand.
– Patients should be weighed at the same time
of day, on the same scale, and in the same
type of clothing to allow an objective
comparison of subsequent weighing.
– Patient should void before weighing.
Types of scales. A, Standing scale. B, Chair scale. C, Lift scales.
 Nursing Process
• Assessment
– Normal daily fluctuations
– Factors likely to interfere with accuracy of vital
sign reading
– Medications that may influence vital signs
– Factors that influence vital signs
– Conditions that precipitate fever, such as
infections
– Pertinent laboratory values
– Previous baseline vital signs from patient’s
record
 PAIN ASSESSMENT
• Pain – a subjective feeling.The fifth Vital sign
• Nociception – a process in which pain stimuli is
transmitted to CNS and perceived as pain .
• Process of Pain
- Transduction
- Transmission
- Perception
 Types of Pain
• Acute • Chronic Pain
- self limiting < 6 months - > 6 months
- a protective - Arthritis
mechanism in
response to threat to
injury.
Example: Trauma
Labor
minor
burns
• Cancer • Chronic Non Cancer
pain/Malignant Pain

- associated with - Associated with

malignancy. chronic disease or no
identifiable cause.
- Ex. Low back pain
Nerve
compressions.
• Chronic Pain Syndrome
- associated with prolonged stress, anxiety
or depression.
• Referred Pain • Radiating Pain
- is felt from the site - begins in one area
other than the site of and extends to other.
origin.
 Examples of Referred Pain
• Appendicitis – Umbilical region
• Angina Pectoris – arm, jaw
• Pleuritis – shoulder
• GERD – Chest
• Cholecystitis – Right shoulder
 ‘PQRST’ in Pain Assessment
• Precipitating/Provocative
• Quality
• Region
• Severity
Pain Scale
• Timing
How long?
How often?
OLDCART in Pain Assessment
Onset – When?
Location- Where?
Duration – How Long?
Characteristics – What does it Feel?
Aggravating – What make it worst?
Radiation
Treatment- What relieves?
 Pain Rating

• 1-10 rating
• Faces Pain Rating
 Assignment:
Differentiate the following sensory words.

• Burning • Sharp
• Crushing • Shooting
• Drilling • Wrenching
• Penetrating
• Piercing
• Scalding
• Searing
 Head-to-Toe
Physical Assessment
• Integumentary • HEENT
• Breast • Respiratory
• Gastrointestinal
• Cardiovascular • Neurological
• Musculoskeletal
• Genitourinary
• Reproductive
 Documentation
• Accurately
• Concisely
• Objectively
• Record by systems
• Chart pertinent negatives