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Health Assessment
Group 1:
Vital Signs
Submitted by:
Leader: Jamisola, Maria Maristel G.
Members: Abdullah, Abdul Majid V.
Agbay, Kryshna Kaye B.
Cala, Rovan Jon Antony T.
Enriquez, Deborah Chloe B.
BSN1-C
Submitted to:
Ms. Nikki Rae Cayanan
December 9, 2019
Cebu Doctors’ University
College of Nursing
Cebu,Philippines
Health Assessment
Vital Signs
1.1 Vital signs – the most frequent and routine measurements obtained by
health care providers are those of temperature, pulse, blood pressure (BP),
respiratory rate and oxygen saturation.
• Systolic blood pressure – The pressure when the heart beats pumping
blood.
• Diastolic blood pressure – The pressure when the heart is at rest
between beats
• Pulse pressure – The difference between systolic and diastolic pressure.
• Hypertension – Disorder characterized by an elevated blood pressure.
• Hypotension – Abnormal lowering of blood pressure that is inadequate
for normal perfusion and oxygenation of tissues. (less than 90/60).
• Orthostatic hypotension – Abnormally low blood pressure occurring
when a person stands. Dehydration, blood loss, and anemia are the most
common reasons to develop low blood pressure when standing.
• Arterial blood pressure – The blood pressure in the system of arteries
in the body.
• Korotkoff’s sound – Sound heard during the taking of blood pressure
using a sphygmomanometer and stethoscope.
• Auscultatory gap – Disappearance of sound when obtaining a blood
pressure; typically occurs between the first and second Korotkoff sounds.
• Mean blood pressure – mean actual pressure = 2 x diastolic + systolic /
3 ex. BP of 130/80 : 130 + 160 = 290 / 3 = 96.7MAP
• Vasodilatation – Increase in the diameter of a blood vessel caused by
inhibition of its vasoconstrictor nerves or stimulation of dilator nerves.
2)Enumerate the importance of taking vital signs.
1.Provides baseline data of usual health of patient
2.Provides data for nursing interventions, and evaluation of the outcome
of care.
3.Understand risk to patient’s health and wellness.
4.Useful in establishing presence of disease, and monitoring of chronic
disease.
5.Basis for clinical decision making and problem solving.
2.Physics
Knowledge of the correct amount of pressure the Bp Cuff needs to place
on the arm in order to correctly close/open the brachial artery.
3. Pharmacology
Knowledge of guidelines on medication allows the medical team to analyze
the vital signs data, in order to determine whether or not the patient is
suitable/ is in need for certain medications.
4. Psychology
Use of various techniques to make the patient less anxious, so that they
aren’t producing variability to their normal values.
5. Immunology/ Microbiology
Pyrogens, acting as antigens, trigger immune system response, altering
patient’s temperature.
5. Guidelines for Taking Vital Signs
Guidelines Rationale
The nurse caring for the client is To review vital sign data, interpret
responsible for vital signs their significance, and critically think
measurement. through decisions about intervention
The nurse should verify and When vital signs appear abnormal, it
communicate significant changes in may help to have another nurse
vital signs. or a physician repeat the
measurement.
6.1 TEMPERATURE
6.1.1 Physiology
● Heat Production
Temperature regulation depends on normal heat production processes. Heat
produced by the body is a by-product of metabolism - chemical reaction in all
body cells. Food is the primary fuel source for metabolism.
Heat production occurs during:
➢ rest
➢ Voluntary movements
➢ Involuntary shivering
➢ Nonshivering thermogenesis
➢
● Heat Loss
The structure of the skin and exposure to the environment result in constant
normal heat loss through:
➢ Radiation - the transfer of heat from the surface of one object to the
surface of another without direct contact between the two.
➢ Conduction - the transfer of heat from one object to another with direct
contact. Solid, liquid, gases conduct heat through contact.
➢ Convection - the transfer of heat away by air movement.
➢ Evaporation - the transfer of heat energy when a liquid is changed to
gas.
➢ Diaphoresis - visible perspiration primarily occurring on the forehead and
upper thorax, although can be seen in other places of the body.
● Skin
Skin regulates temperature through insulation of the body, vasoconstriction,
temperature sensation. The skin, subcutaneous tissue, and fat keep heat inside
the body.
● Behavioral Control
Healthy individuals are able to maintain comfortable body temperature when
exposed to temperature extremes. The ability of a person to control body
temperature depends on:
➢ The degree of temperature extreme
➢ The person’s ability to sense feeling comfortable or uncomfortable
➢ Thought processes or emotions, and
➢ The person’s mobility or ability to remove or add clothes.
➢ Individuals are unable to control body temperature if any if these abilities
are lost.
● Exercise - any form of exercise increases metabolism and heat production and
thus body temperature.
● Stress - Individuals dealing with chronic stress may experience a sudden spike in
body temperature. This fever is a biological reaction to an emotional event or
ongoing trauma. The condition is typically treated with anti-anxiety medications
and therapy.
"
● Intermittent - fever spikes interspersed with usual temperature levels
(Temperature returns to acceptable value at least once in 24 hours.
"
● Remittent - fever spikes and falls without a return to acceptable temperature
levels
"
"
6.1.4 Different Sites in Taking Temperature and its normal body temperature range
● Digital thermometers
● Pacifier thermometer
6.2 PULSE
6.2.1 Physiology
The pulse is the palpable bounding of blood flow generated by the opening and
closing of the aortic valve in the heart. Blood flows through the body in a
continuous circuit. The pulse is an indirect indicator of circulatory status which
can be felt by applying firm fingertip pressure to the skin at sites where the
arteries travel near the skin’s surface; it is more evident when surrounding
muscles are relaxed.
● Cardiac output - refers to the volume of blood pumped by the heart during 1
minute and the product of Heart Rate (HR) and Stroke Volume (SV) of the
ventricle.
CO = HR x SV
● Heart Rate - is the speed of the heartbeat measured by the number of
contractions (beats) of the heart per minute (bpm) and the most common way to
change cardiac output.
● Stroke Volume - volume of blood pumped by each ventricle in one contraction
and is usually remains relatively constant.
6.2.2 Factors Influencing Pulse Rates
FACTOR INCREASES PULSE RATE DECREASE PULSE
RATE
Exercise Short-term exercise H conditioned by long-
term exercise, resulting
in lower resting pulse
and quicker return to
resting level after
exercise
The pulse rate, rhythm, strength, and equality are assessed when palpating
pulses.
● Rate. Pulse rates refers to the number of pulsing sensations occuring in 1
minute. It is exactly equal to the heartbeat, as the contractions of the heart cause
the increases in blood pressure in the arteries that lead to a noticeable pulse.
Taking the pulse is, therefore, a direct measure of heart rate. The pulse rate is
counted by starting at one, which correlates with the first beat felt by your fingers.
Count for thirty seconds if the rhythm is regular (even tempo) and multiply by two
to report in beats per minute. Count for one minute if the rhythm is irregular.
● Rhythm. The normal pulse rhythm is regular, meaning that the frequency of the
pulsation felt by your fingers follows an even tempo with equal intervals between
pulsations.
● Strength. The pulse force is the strength of the pulsation felt when palpating the
pulse. The force is important to assess because it reflects the volume of blood,
the heart’s functioning and cardiac output, and the arteries’ elastic properties.
Remember, stroke volume refers to the volume of blood pumped with each
contraction of the heart (i.e., each heart beat). Thus, pulse force provides an idea
of how hard the heart has to work to pump blood out of the heart and through the
circulatory system.
Pulse force is recorded using a four-point scale:
➢ 3+ Full, bounding
➢ 2+ Normal/strong
➢ 1+ Weak, diminished, thready
➢ 0 Absent/non-palpable
● Equality. Pulse equality refers to whether the pulse force is comparable on both
sides of the body. For example, palpate the radial pulse on the right and left wrist
at the same time and compare whether the pulse force is equal. Pulse equality is
assessed because it provides data about conditions such as arterial obstructions
and aortic coarctation.
● Tachycardia
Tachycardia means that your heart is beating too fast. For example, a normal
heart beats 60 to 100 times per minute in adults. Tachycardia is any resting heart
rate over 100 beats per minute (BPM).
● Bradycardia
If you’re bradycardic, it means you have a slow heart rate (less than 60 BPM).
Bradycardia generally occurs when the electrical signals traveling from the atria
to the ventricles become disrupted. Some athletes have slower heart rates
because they are in excellent physical condition, and this isn’t usually the result
of a heart problem.
6.3 RESPIRATION
6.3.1 Physiology
Assessment of ventilation
• Respiration is the easiest to assess yet needs to be accurately measured.
• Do not let the patient know that you are assessing respirations. Keep in mind
the patient’s usual ventilatory rate and pattern
• The objective measurements are the rate and depth of breathing, and rhythm
of ventilatory movements.
• The respiratory rate varies with age. RR above 27 breaths/min is an important
risk for cardiac arrest.
• Ventilatory Rhythm. Observe the chest or abdomen. Healthy men and children
usually demonstrate diaphragmatic breathing while women use thoracic
muscles. longer expiration phase is evident when the outward flow of air
is obstructed. With normal breathing, a regular interval occurs after
every respiratory cycle. Infants tend to breathe less regularly. Estimate
the time interval after each respiratory cycle.
Assessment of diffusion and perfusion
Evaluate the respiratory process of diffusion and perfusion by
measuring the oxygen saturation of blood. Blood flow through the
pulmonary capillaries delivers red blood cells for oxygen attachment. The
percentage of hemoglobin that is bound with oxygen in the arteries is the
percent of saturation on hemoglobin or SaO2 . It is usually 95-100%.
Exercise
-increases rate and depth to meet the need of the body for
additional oxygen and to rid the body of carbon dioxide.
Acute pain
-Pain alters rate and rhythm of respirations; breathing becomes
shallow.
-Patient inhibits chest wall movement when the pain is in the chest
area of chest or abdomen.
Anxiety
-Anxiety increases respiration rate and depth as a result of
sympathetic stimulation.
Smoking
-Chronic smoking changes pulmonary airways, resulting in
increased rate of respirations at rest when not smoking
Body position
-A straight, erect posture promoted full chest expansion.
-A stooped or slumped position impairs ventilatory movement.
-Lying flat prevents full chest expansion.
Medications
-Opioid analgesics, general anesthetics, and sedative hypnotics
depress rate and depth
- Amphetamines and coccaine sometimes increase rate and depth.
- Bronchodilators slow rate by causing airway dilation.
Neurological Injury
- Injury to brainstem impairs respiratory center and inhibits
respiratory rate and rhythm.
Hemoglobin function
-Decreased hemoglobin levels (anemia) reduce oxygen-carrying
capacity of the blood, which increases respiratory rate
-Increased altitude lowers amount of saturated hemoglobin, which
increases respiratory rate and depth.
Tachypnea
- Rate of breathing is regular but abnormally rapid (greater than 20
breaths/min)
Hyperpnea
- Respirations are labored, increased in dephy, and increased in rate
(occurs normally during exercise)
Apnea
-Respirations cease for several seconds. Persistent cessation results
in respiratory arrest.
Hyperventilation
-Rate and depth of respirations increase.
Hypoventilation
-Respiratory rate is abnormally low, and depth of ventilation is
depressed.
Cheyne-Stokes Respiration
- Respiratory rate and depth are irregular, characterized by
alternating periods of apnea and hyperventilation. Respiratory cycle
begins with slow, shallow breaths that gradually increase to
abnormal rate and depth. The pattern reverses.
Kussmaul’s respiration
-Respirations are abnormally deep, regular, and increased in rate.
Biot’s respiration
-Respirations are abnormally shallow for two to three breaths,
followed by irregular period of apnea.
• Cardiac output
The BP depends on the cardiac output. When the blood volume
increases, the pressure rises. Cardiac output increases due to an
increase in :HR, heart muscle contraction, and increase in blood
volume.
• Peripheral Resistance
The BP depends on the peripheral vascular resistance. The size of
the arteries and arterioles changes to adjust blood flow to the
needs of local tissues. The smaller the lumen, the greater the
peripheral vascular resistance. As resistance rises, BP rises.
• Blood volume
An increase in blood volume exerts more pressure in the arterial
walls. When the blood volume falls, the BP falls.
• Viscosity
Hematocrit determines blood viscosity. When hematocrit rises and
blood flow slows, arterial BP rises. The heart contracts more
forcefully to move viscous blood through the system
• Elasticity
As pressure within the arteries increases, vessel walls diameter
increases. However, in certain diseases such as arteriosclerosis, the
vessels lose their elasticity which results in greater resistance.
Age
-Normal BP levels vary throughout life. BP increases during
childhood. Evaluate the BP level with respect to body size and age.
The heavier or taller the children, the higher BP they obtain.
Stress
-Anxiety, fear, pain, and emotional stress result in sympathetic
stimulation, which increases HR, cardiac output, and vascular
resistance. Anxiety increases BP as much as 30 mmHg.
Ethnicity
- Genetic and environmental factors are often contributing factors.
Hypertension-related deaths are also higher among African-
Americans.
Gender
-After puberty, males tend to have higher BP readings. After
menopause, women tend to have higher BP than men of similar
age. Yet, there is no clinically significant difference in BP levels
between boys and girls.
Daily variation
-BP varies throughout the day, with lower during sleep between
midnight and 3 am. Between 3am and 6am, there is a slow and
steady rise in BP. When the patient awakens, there is an early-
morning surge.
Medications
-Before BP assessment, ask whether the patient is receiving
antihypertensive, diuretic, or other cardiac medications, which
lower BP. Vasoconstrictors and excess volume of IV fluids increase
it.
Smoking
-Smoking results in vasoconstriction, a narrowing of blood vessels.
Auscultation
• The best environment is a quiet room and comfortable
temperature.
• Sitting is the preferred position, although the patient may lie or
stand.
• Before obtaining BP, attempt to control facotrs for artificially high
reading such as pain, anxiety, or exertion.
• During the initial assessment, obtain and record the BP in both
arms. Normally there is a difference of 5-10 mmHg
between the arms. In subsequent assessments, measure
the arm with the higher pressure.
• Ask the patient to state his or her usual BP, inform him after
measuring. This is a good opportunity to educate the
patient about the optimal values of BP and risk factors.
• The first onset of the sound corresponds to the systolic pressure.
• The second sounds is a blowing sound, while the third is more
intense tapping.
• The fourth becomes muffled and low pitched; this sound is the
diastolic pressure in infants and children
• In adolescents and adults, the fifth silent sound corresponds to
the diastolic pressure.
• Note the arm used in measuring (e.g., right arm [RA] 130/70)
and the patient’s position (e.g., sitting)
Assessment in children
-Children 3 years of age through adolescence need to have BP
checked atleast annually because of the changes in growth and
development. Help parents understand the importance of this routine
screening to detect children who are at risk of hypertension. They are
difficult to measure due to different arms sizes, restlessness, and low
amplitude of sound.
Ultrasonic stethoscope
-allows you to hear low frequency systolic sounds.
Palpation
-This method is useful for patients whose arterial pulsations are too
weak to create sounds. You can assess the systolic BP by palpation. The
diastolic is difficult to determine.
8.1.1 Temperature
Assessment
• Assess for signs and symptoms of temperature alterations and factors that
accompany body temperature alterations.
Planning
• Identify patient using two identifiers (e.g., name and birth date, or medical
record number)
• Explain route by which temperature will be taken and importance of
maintaining proper position until reading is complete
Implementation
Equipment and Supplies
• Electronic thermometer
• appropriate probe (blue oral probes are used for axillary temperatures);
disposable probe cover
• paper and pen
• patient’s medical record
• tissue
• waste container
Method
• Perform hand hygiene.
• Greet and identify the patient.
• Explain the procedure. If the patient is a child, explain the procedure to
both the parent and child.
• Remove the electronic thermometer from its charging base, select the
appropriate probe, and attach a disposable probe cover.
• Ask the patient to expose the axilla (under the arm).
• Using a tissue, pat the axilla dry of any perspiration. Do not rub the area.
• Place the probe with cover into the axillary space.
• Ask the patient to remain still and to hold the arm tightly next to the body
while the temperature registers.
• When the thermometer signals completion, remove the thermometer and
discard the probe cover in a waste container.
• Record the temperature in the patient’s medical record, making sure to
note that the temperature was obtained via the axillary route (AX) and
which side was used.
• Return the thermometer probe to its appropriate storage location, and
then return the entire unit to the rechargeable base.
• Perform hand hygiene.
Evaluation
• If temperature is assesses for the first time, establish temperature as
baseline if it is within normal range.
8.1.2 Pulse
Assessment
• Determine need to assess radial or apical pulse:
Planning
• Identify patient using two identifiers (e.g., name, medical record number)
• Explain that you will assess pulse rate or heart rate. Encourage patient to
relax and not speak. If patient was active, wait 5 to 10 minutes before
assessing pulse.
Implementation
Paper and pen; patient’s medical record; watch with second hand
Evaluation
• Compare readings with previous baseline and/or acceptable ranges of
heart rate for patient's age.
• Compare peripheral pulse rate with apical rate and note discrepancy.
• Compare radial pulse equality and note discrepancy.
• Correlate pulse rate with the data obtained from blood pressure and
related signs and symptoms (palpitations, dizziness)
Planning
• Identify patient using two identifiers (e.g. name and birth date or name
and medical record number)
• Plan to assess respirations after measuring pulse in adult.
Implementation
To take respiration rate:
Method
• Perform hand hygiene.
• Greet and identify the patient.
• Assist the patient into a comfortable position.
• Place your hand on the patient’s wrist in position to take the pulse, or
place your hand on the patient’s chest or back.
• Count each breathing cycle by observing or feeling the rise and fall of the
chest, back, or upper abdomen. Count breaths (inhale + exhale = 1
respiration) for one minute.
• Count for 1 full minute (60 seconds) using a watch with a second hand. If
the rate is a typical or unusual in any way, count respirations again for
another minute.
• Record the respiratory rate in the patient’s medical record, noting any
abnormality in rate, rhythm, and depth.
• Perform hand hygiene.
Evaluation
• If assessing respirations for the first time, establish rate, rhythm, and
depth as baseline if within normal range.
• Compare respiratory rate, depth, and rhythm with data obtained from
pulse oximetry and ABG measurements of available.
Assessment
• Determine need to assess patient's BP
• Asses for factors that affect BP
• Determine best site for BP assessment.
• Determine previous baseline BP (if available) from patient's record.
• Determine if patient has latex allergy.
Planning
Identify patient using two identifiers
Implementation
To take blood pressure:
Method
Evaluation
• Compare reading with previous baseline and or/ acceptable value of BP for
patient's age.
• Compare BP in both arms and both legs.
• Correlate BP with data obtained from pulse assessment and related
cardiovascular signs and symptoms.