NCM 101 : HEALTH ASSESSMENT

 At the end of the lecture discussion and return

demonstration, students will be able to :
1. Describe the procedures used to assess vital signs
2. Identify factors that can influence each vital sign
LEARNING 3. Identify the equipment routinely used for the vital sign
procedures
OBJECTIVES 4. Perform vital signs and interpret the findings
5. Discuss the nursing actions and interventions related to
findings
6. Document the findings obtain from each vital sign
procedure.
 Vital Signs reflect the body’s physiologic status and provide information critical to evaluating homeostatic balance.

1. Temperature

2. Pulse Rate

3. Respiratory Rate

4. Blood Pressure

5. Oxygen Saturation Rates

VITAL SIGNS ( CARDINAL SIGNS )

*** Pain Scale Assessment
  Nurses are responsible for :

ROLE
1. Recognizing patient’s symptoms
OF 2. Taking measures within the scope of nursing practice
to administer medications
3. Providing other measures for symptom alleviation
VITAL
4. Collaborating with other members of the health care
team to optimize patient’s comfort and families’
SIGNS understanding and adaptation
  Provides the general status of the body’s vital or life
PURPOSE sustaining functions

OF  Help assess the general physical health of a person

VITAL
Gives clues to possible diseases
SIGNS
Show progress towards wellness and recovery
  Name the equipment needed for your vital signs
1. Temperature
2. Pulse
??? 3. Blood Pressure
4. Respiratory Rate
5. Oxygen Saturation ( o2 Sat )
  On Admission

 Change in the Patient’s Health Status or reports symptoms

of chest pain or fainting

TIMES Before and after administration of medications that can

TO affect BP and Respiratory Rates
ASSESS
VITAL Before and After Surgery or any Invasive Diagnostic
SIGNS Procedures

Before and After any Nursing Intervention that can affect

the vital signs

According to Hospital and /or Unit Policy and Regulations

 It is the hotness or coldness of the body

Balance between heat production and heat loss

Normal Body Temperature : 37 Celsius or 98.6 Farenheit

Conversion from Celsius to Fahrenheit

Formula : ( Centigrade Reading x 9/5 ) +32 = Fahrenheit

Conversion from Fahrenheit to Celsius

Formula : ( Fahrenheit Reading -32 ) x 5/9 = Celsius

TEMPERATURE
 CORE SURFACE
TEMPERATURE TEMPERATURE
2

KINDS Temperature of internal organs Temperature of the skin,

and remains constant ( 37 C ) subcutaneous tissue and fat cells
with range of ( 36.5-37.5 ) and it RISES AND FALLS in
OF response to the environment

BODY Temperature of deep tissues of

the body

TEMPERATURE It does not indicate internal

Remains relatively CONSTANT
measure with thermometer. physiology
• Normal Body Temperature is 37 Celsius

Abnormal Body Temperature due to HYPERTHERMIA ( High Temperature

) or HYPOTHERMIA ( Low Temperature )

Slight Fever ( 37.5 C )

Pyrexia or Fever ( 38 C - 40 C )

Hyperthermia : very high fever ( 40 C up )

Hypothermia ( 34 C- 35 C )

ALTERATIONS IN BODY
TEMPERATURE
  INTERMITTENT FEVER

COMMON Body temperature alternates at regular intervals between periods of

fever and periods of normal or subnormal temperatures
REMITTENT FEVER
TYPES Wide range of temperature fluctuation ( more than 2 degrees Celsius )
occurs over a 24 hour period, all of which are above normal
RELAPSING FEVER
OF Short febrile periods of a few days are interspersed with periods of 1-
2 days of normal temperature

FEVER  CONSTANT FEVER

Body temperature fluctuates minimally but always remains above
normal
  AGE

CIRCADIAN RHYTHM

FACTORS
EXERCISE
AFFECTING

TEMPERATURE HORMONES

STRESS

ENVIRONMENT
 SITES
FOR
OBTAINING
TEMPERATURE
  Put the thermometer under the tongue
ORAL Leave for 3-5 minutes in place
TEMPERATURE  It is the most common site for temperature measurement
 NOT recommended for unconscious patients, infants, children, patient
with mouth sores and persistent cough

 Advantage : Easy Access and Patient Comfort

Disadvantage : False reading if patient has taken hot/ cold drinks

or smoked. Wait for 10-15 mins after meals or
smoking
 CONTRAINDICATIONS ORAL TEMPERATURE
 Patients who cannot follow instructions to keep their mouth closed
Child below 7 years old
Epileptic or Mentally Ill Patients
Unconscious
Patients with Oxygen
Patients with persistent cough
Uncooperative Patients or in severe pain
Mouth Surgery
Nasal Obstruction
Nasal or gastric tubes in place
 RECTAL TEMPERATURE

 Insertion of thermometer into the rectum or anus

Reliable measurement and reflects CORE BODY TEMPERATURE

Hold the thermometer in place 3-5 minutes

More accurate and most reliable higher than oral temperature

Disadvantage : Injure the rectum, needs privacy

 CONTRAINDICATIONS FOR RECTAL TEMPERATURE

 Patients with diarrhea

Patients who had rectal or perineal surgery

Patients with rectal infection

 AXILLARY TEMPERATURE

 Safe and Noninvasive

Recommended for infants and children

Disadvantage : Longer time

Least accurate and reliable

Route of choice if temperature measurement cannot be obtained by

other routes.
TEMPERATURE VALUES

Axillary : 36.5-37.5
Tympanic : 36.8-37.5
Rectal : 36.6-37.9
Oral : 36.4-37.5
PULSE
 Pulse is a wave of blood created by the contraction of the left
ventricle

Pulse reflects heartbeat

Pulse Rate is regulated by the Autonomous Nervous System

Peripheral Pulse is located in the periphery of the body

Central Pulse ( Apical Pulse ) : Apex of the Heart

Pulse Rate ( PR ) is expressed in beats / min ( BPM )

Pulse Deficit : Difference between Peripheral Pulses and

Central Pulse or Apical Pulse ( PP- CP or AP = PD = ZERO )

PULSE
  NORMAL HEART RATES

 AGE GROUPS AWAKE SLEEPING

NORMAL
HEART  Neonate
 Infant
100-205
100-180
90-160
90-160
RATES  Toddler 98-140 80-120
 Preschool 80-120 65-100
 School Age 75-118 58-90
 Adolescent 60-100 50-90
  PULSE RHYTHM
Refers to patterns and interval
between the beats ( regular in
interval )
Dysrhythmia : random irregular
beats
 ELASTICITY OF THE ARTERIAL WALL

PULSE RATE  PULSE VOLUME

A healthy, normal artery feels, straight, smooth,
soft and easily bent
ASSESSMENT It reflects the patient’s vascular system

Force of blood with each beat

Each heartbeat consist of 2 sounds ( LUB –DUB )
Normal pulse can be felt with
moderate pressure
S1 : Closure of the MITRAL and TRICUSPID
VALVES separating the atria from the ventricles
Description of Pulse Rate
Full or forceful bounding pulse S2 : Closure of the Pulmonic and Aortic Valves

Weak, feeble pulse

 Pulse Rate assessed by Rate, Rhythm, Volume and Elasticity
of the Arterial Wall

It is assessed by Palpation ( feeling )

Pulse Rate :

Normal ( 60-100 BPM )

Adult PR > 100 BPM ( Tachycardia )
Adult PR < 60 BPM ( Bradycardia )

PULSE
  AGE
 SEX
After puberty, the average males PR slightly lower than female
 AUTONOMIC NERVOUS SYSTEM ACTIVITY
Parasympathetic ( Decrease PR )
FACTORS Sympathetic ( Increase PR )
AFFECTING  EXERCISE
PULSE  FEVER
RATES  HEAT
 STRESS
 POSITIONAL CHANGES ( Decrease BP Increase PR )
 MEDICATIONS ( Digoxin : Decrease PR / Diuretics : Increase PR/
Atropine : Increase PR / Propanolol : Decrease Heart Rate )
  TEMPORAL  FEMORAL
Pulse Temporal Bone Area Along Inguinal ligament used for
infants and children
 CAROTID
Side of the Neck
 POPLITEAL
 APICAL
PULSE Left Midclavicular Line 5 th
Behind the knee

SITES
Intercostal Space ( Mitral Valve )
 BRACHIAL  POSTERIOR TIBIA
Inner aspect of Bicep Muscle of Medial Surface of the ankle
the arm or elbow crease
 RADIAL  DORSALIS PEDIS
Thumb side inner aspect of the Dorsum ( Upper Surface of the
wrist Foot )
 RESPIRATION RATE ( RR ) : Act of Breathing ( Intake of Oxygen +
Removal of Carbon Dioxide

VENTILATION : Movement of air in and out of the lungs

HYPERVENTILATION : Very deep, rapid respiration

HYPOVENTILATION : Very Shallow Respiration

EUPNEA: Normal, good, healthy and unlabored breathing

BRADYPNEA: Abnormally slow breathing < 12/ minute

TACHYPNEA: Abnormally shallow rapid breathing > 20/minute

APNEA : Cessation of Breathing

As age decreases, respiratory rates increase.

RESPIRATION
  INFANT 30-53 cycles/min

 TODDLER 22-37 cpm

RESPIRATORY
RATES  PRESCHOOL 20-28 cpm

 SCHOOL AGE 18-25 cpm

 ADOLESCENT 12-20 cpm

  AGE
Normal growth from infancy to adulthood results in larger lung capacity.
As lung capacity increases, lower respiratory rates are sufficient for the
exchange.
 MEDICATIONS
Narcotics decrease respiratory rate and depth.
 STRESS
FACTORS Strong emotions increases the rate and depth of respirations
AFFECTING  EXERCISE
RESPIRATION Increases the rate and depth of respirations
 ALTITUDE
Higher altitudes increases the rate and depth of respirations to improve the
oxygen supply available to the body tissues
 GENDER
Men have lower respiratory rates than women due to larger lung capacity
 FEVER
Increases respiratory Rates
 BLOOD
PRESSURE  It is the force exerted by the blood against the
walls of the arteries in which it is flowing

 It is expressed in terms of millimeters of

mercury ( mmHg )
 SYSTOLIC PRESSURE DIASTOLIC PRESSURE

 Maximum Pressure against

the wall of the vessel
2
 Minimum Pressure of the blood
following ventricular
contraction against the walls of vessels
TYPES following ventricular relaxation

OF  TOP NUMBER referring to

 BOTTOM NUMBER referring
BLOOD the amount of pressure
experienced by the arteries to the amount of pressure in the

PRESSURE while the HEART IS arteries while the HEART IS

BEATING. RESTING BETWEEN
HEARTBEATS.

 SYSTOLIC PRESSURE is a  SYSTOLIC PRESSURE – DIASTOLIC

better INDICATOR OF PRESSURE = PULSE PRESSURE
HEART RISK
  MEDICATIONS
AGE
OBESITY
Women lower BP than men before
menopause. After menopause BP Predisposition to Hypertension
increases. POSITIONS
EXERCISE Sitting, Standing or Lying Down position
cause variations in BP
Physical Activity increases Cardiac

FACTORS
Output, Increases BP DIURNAL VARIATIONS
STRESS Pressure is lowest early in the morning,
AFFECTING Stimulation of Sympathetic Nervous
when metabolic rate is low, BP is low. Then
rises throughout the day and peaks in the
BLOOD System, increases Cardiac Output and
cause vasoconstriction, BP is increased
late afternoon or evening.

PRESSURE RACE
MEDICAL CONDITIONS
Any health condition affecting cardiac
African Americans have higher BP than output, blood volume, blood viscosity has
direct effect in the BP
European Americans
 TEMPERATURE
SEX
Increased metabolic rate=Increase BP
Females have lower BP than males due to
hormonal variations. But after External Heat =vasodilation= low BP
menopause BP increases Cold= vasoconstriction= high BP
 SITES
FOR
MEASURING
BLOOD
PRESSURE
  A persistently high BP, measured for greater than three
times is called HYPERTENSION and that persistently less
than the normal is called HYPOTENSION.
 Because many factors affect and influence BP, a single
measurement is not necessarily significant to confirm
FACTS hypertension
ABOUT
BLOOD TYPES OF HYPERTENSION :
PRESSURE
Primary or Essential Hypertension : Unknown Cause
Secondary Hypertension : Known Cause
1. To obtain baseline measure of arterial blood pressure
for subsequent evaluation

2. To determine the patient’s hemodynamic status

3. To identify and monitor changes in the blood pressure

PURPOSE OF ASSESSING
BLOOD PRESSURE
o TODDLER 86/42 TO 106/63

PRESCHOOL 89/46 TO 112/72

SCHOOL AGE 97/57 TO 115/76

PREADOLESCENT 102/61 TO 120/ 80

ADOLESCENT 110/ 64 TO 131/83

OTHER BP READINGS