Health Assessment and Vital Signs

HEALTH ASSESSMENT AND VITAL SIGNS
PHYSICAL EXAMINATION
 Modes of Assessment
o Inspection, Palpation, Percussion, Auscultation
(IPPA)
 Inspection visual examination
 Palpation examination of the body using
the sense of touch
• Two types of palpation: light and deep
 Percussion striking the body surface to
elicit sounds
• Five types of sound (percussion tone):
tympany (musical or drum-like);
resonance (hollow sound);
hyperresonance (booming sound);
flatness (extremely dull); dullness
(thud-like sound)
 Auscultation examination of the body
using the sense of hearing
• Two types of auscultation: direct
(unaided ear) and indirect (use of
stethoscope)
o Abdominal: Inspection, Auscultation, Percussion,
Palpation (IAPePa)
o Physical examination of the abdomen (sequence
of methods): RLQ, RUQ, LUQ, LLQ
o Position (abdomen physical examination): dorsal
recumbent
 Positions
o Dorsal recumbent back-lying with knees flexed
and hips externally rotated
o Dorsal/Supine back-lying position
o Sitting back unsupported and legs hanging
freely
o Fowlers
 Semi HOB elevated at 15-30 degrees
angle
 High HOB elevated at 80-90 degrees angle
o Lithotomy back-lying position with feet
supported in stirrups
o Genupectoral/knee-chest kneeling position with
torso at 90 degrees angle to hips
o Lateral side-lying position
o Sim’s semi-prone
o Prone face-lying position; abdomen-lying
position
VITAL SIGNS
 Temperature, Pulse, Respirations, and Blood Pressure

 Pain is considered as the fifth vital sign
o Body temperature:
 2 types: (1) Core temperature of deep
tissues of the body; (2) Surface
temperature of the skin
 Heat production: basal metabolic rate,
muscle activity, thyroxine, epinephrine,
norepeniphrine and sympathetic stimulation,
fever
 Common sites:
• Oral accessible and convenient
allow 30 minutes to elapse if a client
has been taking cold or hot food or
fluids or smoking
• Rectal reliable; accurate
contraindicated for clients with
myocardial infarction due to vagal
stimulation
• Axilla safe preferred site for
measuring temperature in newborns
 pat dry the axilla (avoid rubbing)
• Tympanic readily accessible and
reflects the core temperature risk of
injuring the tympanic membrane
(eardrum) if the probe is inserted too
far
 Heat loss:
• Radiation transfer of heat from one
surface to one object to the surface of
another without contact between two
objects
• Conduction transfer of heat from
one surface to another
• Convection dissipation of heat by air
currents
• Evaporation continuous vaporization
of moisture from the skin
 Alterations in body temperature:
• Pyrexia (hyperthermia/fever) body
temperature above the usual range
• Hyperpyrexia very high fever, 41 °C
and above
• Hypothermia core body temperature
below the lower limit of normal
 Types of fever:
• Intermittent temperature fluctuates
between periods of fever and periods
of normal/subnormal temperature
• Remittent  wide range of
temperature fluctuations occurs over
the 24-hour period which are above
normal
• Relapsing fever few days alternated
with 1 or 2 days of normal
temperature
• Constant consistently high
temperature that fluctuates minimally
o Pulse
 Controlled by Autonomic Nervous System
(ANS)
 Created by the contraction of the left
ventricle
 Peripheral pulse pulse located away from
the heart
 Apical pulse located at the apex of the
heart  8 cm (3 in.) to the left of the
sternum
 Neonate: 120-160 beats/minute
 Adult: 60-100
 During CPR:
• Adult assess the carotid pulse
• Infant assess the brachial pulse
 NO THUMB USE during pulse
measurement
 Pulse deficit discrepancy between two
pulse rate rates (apical-radial pulse)
normally, the apical and radial rates are
identical
o Respirations
 Three (3) processes: ventilation, diffusion,
perfusion
 Medulla oblongata primary respiratory
center
 Neonate: 30-60 cycles/minute
 Adult: average is 12-20
 2 types of breathing: costal (thoracic) and
diaphragmatic
 Newborns complete nose breathers
 Infants and young children diaphragmatic
breathers
o Blood pressure (BP)

 Systole contraction of the ventricles (100-
140 mm Hg)
 Diastole ventricles are at rest (60-90 mm
Hg)
 Pulse pressure difference between
diastolic and systolic pressures normal
range is 30-40 mm Hg
 Hypertension BP that is above normal in
two readings at different times (above
140/90 mm Hg)
• Diuretics (thiazides) first line of
treatment for HPN
 Hypotension abnormally low BP, systolic
pressure below 100/60 mm Hg
• Flat position for 10 minutes initial
management for hypotension
 Allow 30 minutes to elapse if the client had
engaged in exercise or had smoked or
ingested caffeine
 Korotkoff’s sound series of sounds heard
when taking BP using stethoscope
 Read lower meniscus of the mercury level of
the sphygmomanometer at eye level to
prevent ERROR OF PARALLAX
 Wait 1-2 minutes before making further
determinations

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HEALTH ASSESSMENT AND VITAL SIGNS

 Temperature, Pulse, Respirations, and Blood Pressure

o Blood pressure (BP)

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