Islamic University of Gaza Faculty of Nursing Chapter 5 General Assessment Including Vital Signs

Equipment needed: Beam balance scale, Tape measure, Thermometer, Sphygmomanometer Stethoscope. Subjective data : current health, current age, height, and weight, recent weight changes, fever, history of hypotension, hypertension, difficulty breathing, changes in pulse or heart rate.

Objective data head to toe examination to note any gross abnormalities in appearance or behaviors Assess vital signs, temperature, pulse, respirations, and blood pressure Weigh the client and measure for height

Procedure Observe: Behavior: (cooperative or uncooperative). Mood: steady or anxious. Appearance: well dressed or dress bizarre or inappropriate. Body movements: coordinated, or uncoordinated, shaky and unsteady

Vital signs Assessment of temp., pulse, respiration and blood pressure are known as life signs Indicators of the body’s physiologic status and response to physical, environmental and physiologic stressors. Temperature: Rectal temp is the most accurate. Unless contraindicated as in a client with a severe cardiac arrhythmia, a rectal temp is often preferred

Axillary/Forehead (°F) Comparison of temperatures in Fahrenheit by method Axillary/Forehead (°F) Oral (°F) Rectal/Ear (°F) 98.4-99.3 99.5-99.9 100.4-101 99.4-101.1 100-101.5 101.1-102.4 101.2-102 101.6-102.4 102.5-103.5 102.1-103.1 103.6-104.6 103.2-104 104.7-105.6

Comparison of temperatures in Centigrade by method Axillary/Forehead (°C) Oral (°C) Rectal/Ear (°C) 36.9-37.4 37.5-37.7 38-38.3 37.5-38.4 37.8-38.5 38.4-39.1 38.5-38.9 38.6-39.1 39.2-39.7 39-39.5 39.8-40.3 39.6-40 40.4-40.9 Comparison of temperatures in Fahrenheit by method Axillary/Forehead (°F) Oral (°F) Rectal/Ear (°F) 98.4-99.3 99.5-99.9 100.4-101 99.4-101.1 100-101.5 101.1-102.4 101.2-102 101.6-102.4 102.5-103.5 102.1-103.1 103.6-104.6 103.2-104 104.7-105.6

Palpate the radial pulse &count for at least "30" second. Vital signs… cont… Pulse: "60-80 b/m" regular Palpate the radial pulse &count for at least "30" second. If the pulse is irregular, count for full minute. Note is the pulse is strong or weak, bounding or thready . bounding pulse: feel strong and powerful pulse

Vital signs… cont. Respiration: "16-20/minut"e (for healthy adult person Count the No. of respiration, in full minute. Note rhythm and depth of breathing. Blood pressure: Measure Blood Pressure in both arms. Palpate the systolic pressure before using the stethoscope Apply cuff firmly, if too loose it will give falsely high reading. Use cuff in appropriate size. Note position of client When measuring blood pressure. Monitor blood pressure after client is seated or supine quietly for "10" minute.

Instrument needed for physical assessment Ophthalmoscope: "lighted instrument for visualization of the eye". Otoscope: for examination of the ear. Snellen eye chart: used as a screening test for vision. Nasal speculum, for assessment of the nose. Vaginal speculum: examination of the vaginal canal and cervix. Tuning fork: for testing auditory function and vibratory perception. Percussion hammer: “reflex hammer” to test reflexes and determine tissue density. Neuralgic hammer: to test reflexes during the neuralgic assessment

Positions for physical Examination Assessment positions e.g.: (Standing position, Supine position, Sitting position, Dorsal recumbent position, Sims position, Prone position, Knee chest position, and Lithotomy position) Each position has it's specialty for parts of examination

Six Possible Client Position During an Examination

I. Sitting position Areas Assessed: Head and neck, back, posterior thorax and lungs, anterior thorax , breasts, axillae, heart, vital signs, and upper extremities Limitations: Physically weakened client may be unable to sit

II. Supine position Most normally relaxed position Areas Assessed: Head and neck anterior thorax and lungs, breasts, axillae, heart, abdomen, extremities, pulses Limitations: Not use for client SOB, you may need to raise head of bed

III. Dorsal Recumbent position Areas Assessed: Head and neck, anterior thorax and lungs, breasts, axillae, heart. Limitations: Not used for abdominal assessment because it promotes contracture of abdominal muscles

IV. Lithotomy Position Areas Assessed: Female genitalia and genital tract. * Limitations: This position is embarrassing & uncomfortable, so examiner minimizes time that client spends in it. Client is kept well draped. This position not used for Client with severe arthritis or other joint deformity

V. Sims’ position: Areas Assessed: Rectum and vagina. * Limitations: Joint deformities may prevent client’s ability to Bend hip and knee VI. Prone position: * Areas Assessed: Musculoskeletal system. * Limitations: don’t use this position for client with respiratory difficulties

VII. Knee-chest position Areas Assessed: Rectum. Limitations: This position is embarrassing and uncomfortable. Don’t use this position for Clients with arthritis or other joint deformities. Assess for Crepitus (crackling sensation & noise caused by rubbing of bone fragments).

Muscle assessment Assess muscle strength & tone when doing Range of motion. * Tone: Muscular resistance felt by examiner as the relaxed extremity is passively moved through its range of motion. * Ask client to relax or hang limb, support & move it through Range of motion. * Assess for increase tone “hyper tonicity” or decrease tone “hypo tonicity Strength of dominant side is more than non dominant, and it is normally for specific ratio

Assessment of general Appearance Body builds, posture and gait. Note proportion of height weight "Weight = height – “100” = ---- +/- 10kg". Hygiene, grooming: (Note cleanliness, body odors, appropriate dress for age and environment). Signs of illness.: (Note posture, skin color, respirations, and nonverbal communications of pain or distress). Affect. Attitude, mood. (Note speech, facial expressions, ability to relax, eye contact, behavior. Cognitive process. (Note speech content and patterns, orientation, appropriate verbal responses). Height and weight: Weigh client without shoes, and without extra clothing.

Assessment of skin, Hair, and nails Skin infection, rashes, lesions, itching. ( Precipitating factors: stress, weather, drugs, exposure to allergens. Changes in skin color, lesions, and bruising. Amount of sun exposure (type of lotions used). SCALP lesions, itching, and infections. SCALP ”Skin Connective Tissue Aponeurotica Loose Connective Tissue Pericranium” Changes in texture and amount of hair. Changes in nails and Nail breaking, and inflammation. ** The examination of skin includes, inspections of skin color moisture, temperature, and thickness, and turgor. Vascular changes, edema, and any lesions are noted. Skin odors are usually noted in the skin folds.

Color of skin varies from body part to body part and from person to person. * Normal changes in skin color my occur with aging Assessment first involves area, of skin not exposed to the sun e.g. palms of the hands. Pallor easily perceived in the buccal “mouth” mucosa particularly in individuals with dark skin. Cyanosis seen in areas, e.g. lips, nail beds conjunctiva, and palm. Jaundice: seen in client’s sclera. Erythema may indicate circulatory changes

Moisture of skin Moisture in the skin: related to the degree of client’s hydration and the condition of the outer lipid layer of the skin surface. Skin is normally smooth and dry. Skin folds e.g. axillae are normally moist. Assessment of skin done by palpation. In presence of skin lesions: nurse must wear gloves to prevent exposure to infections. Temperature: Temp of skin depends on the amount of blood circulating through dermis. Palpation of skin with dorsum of the hand. Assessment of skin is critical point in some conditions e.g. after cast application, or tight bandage, or after vascular surgery.

Texture : Character of skin surface and the feel of deeper portion are its texture. Texture of skin normally smooth, soft and flexible. If any abnormalities in texture, Ask the client is he exposed to any recent injury to the skin? Turgor: Is the skin elasticity which can be diminished by edema or dehydration, (done by pinching skin between the thumb and forefinger and released) Normally skin return immediately to its position. Failure of this process means dehydration. Vascularity : Assessment of circulation of skin. E.g. petechiae may indicate serious blood clotting disorders, drug reactions. Or liver disease

Edema: "Build up of fluid in tissues". Edematous areas should be inspected for location, color, and shape. Edema separates the skin’s surface from the pigmented and vascular layers masking skin color. palpates areas of edema to determine mobility, consistency, and tenderness. Lesions: If lesion present inspection must done for color, location, size, shape type, grouping, and distribution. N.B: cancerous lesions frequently undergo changes in color and size

Hair and SCALP Assess for lesions or lice are probable, the nurse wears disposable gloves to avoid infection. Types of hair covering the body: - Terminal hair (long, coarse, thick) and easily visible on the SCALP, axillae, and pubic areas. - Vellus hair” small, soft, tiny” covering the whole body except palms and soles. Assessment done for distribution, thickness, texture, and lubrication of the hair. Some events which affect the distribution of hair over the body e.g. client with hormone disorders, woman with hirsutism.

Hair and SCALP cont... Normal color of terminal hairs: black, red, yellow, or variations of these colors. Older men lose facial hair; but older women may develop hair on chin and upper lip. Amount of hair covering extremities may be reduced as a result of aging and arterial insufficiency especially in lower limbs. Scaliness or dryness of the SCALP is frequently caused by dandruff or psoriasis.

Nails Assessment Nails reflect an individual's general state of health, state of nutrition, and occupation. Vascularity of the nail bed creates the nails underlying color. Nails are normally transparent, smooth, and convex. The surrounding cuticles are smooth, intact and without inflammation. Nail bed is normally firm on palpation. Nails normally grow at a constant rate. Hemorrhage, transverse band, and abnormal thickness.

Nails Assessment cont… N.B: "vitamins, proteins and electrolytes changes can result in various lines or band forming on the nail beds". **The color of nails is an indicator of blood oxygenation: Bluish color means cyanosis. White or pallor means anemia Palpation of the nails determines the adequacy of circulation or capillary refill. Calluses are commonly found on the toes or fingers

Some Abnormalities of the nails Paronychia: inflammation surrounding the nail. Anonachia: complete absence of nail. Platunychia : flatting of the nails. Kolilonychia: nails spoon like shape. Racketnail: flattened and expanded nails (signs of secondary syphilis) Onycholysis: nails separated from nail bed. Leukonychia white nails (entire plate). Melanonychia: brown color in nails plate

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