HSA vital signs, temp, and physical assesment

temperature

measurement of core body heat

• balance between heat produced and heat lost

febrile

with fever

afebrile

without fever

methods to measure temp

• oral

• rectally

• axillary

• tympanic (aural)

• temporal

oral

by mouth

rectally

by rectum, most accurate

axillary

• under arm, in the armpit

tympanic (aural)

• in ear

temporal

• across the forehead

types of thermometers

• digital electronic

• thermoscan

digital electronic

to be used for oral, rectal, and axillary

thermoscan

digital used for tympanic or temporal artery

norms

oral - 97.6-99.6

rectally - 99.6-100.6

axillary - 96.6-98.6

tympanic - 97.6-99.6

temporal - 99.6-100.6

norms

body temp is lowest in morning

temperature is affected if you eat, drink, or smoke within 15 min of taking temp

when taking rectal and axillary temps

• always hold thermometer in place

• always use lubricant with rectal temps

• always removing clothing from axilla

hypothermia

-abnormal low body temp

hyperthermia

• abnormally high body temp

F

farenheit

C

celsius

O

oral

Ax

axillary

T

tympanic

TA

temporal artery

history and physical (H&P)

• physicians record findings, in the patients chart

• provides the data on which the physician bases their diagnosis and treatment

H&P info

• date, demographic info, source of referral, chief complaint, history of present illness, medical history, current health status, family history of illness, psychosocial history, review of all systems

date

day H&P is done

demographic

• age, gender, race, place of birth, marital status, occupation, religion

source of referral

• was patient referred from another doctor

chief complaint

primary problem from the patient’s point of view

history of present illness

when did the person first start, hot frequently it occurs, how long it lasts, description, location, what relieves the problem

history

general state of patients health and any previous physical or psychosocial illness, accidents, injuries, surgeries, and hospitalizations

current health status

• list of allergies and immunizations - normal activity level and diet

• current medications (over the counter or prescription)

• tobacco or alcohol used, sleep pattern disturbances

family history of illness

age and health or cause of death of parents, siblings, spouse, and children

family history of specific disease conditions

psychosocial history

home, work, stress life

support structure

significant into affecting care of the patient

lifestyle: diet, smoking, drinking, exercise

review of all systems

• weight, height, vital signs, and review of each body system

• head to toe asessment

general physical surgery (head to toe)

• overall impressions

• posture, distress body proportion, color of skin, odors from body or breath, character of speech, height, weight, level of consciousness, verbal and motor response, vital signs

vital signs

• pules, respiration, blood pressure, temperature

psychosocial observations

inspection, auscultation, palpatation, percussion

inspections

use of your senses of visions and smell for patient condition

auscultation

• listening to sounds inside body with stethoscope

palpatation

using hands and finger on exterior of body to detect evidence of abnormalities of internal organs

percussion

using fingertip to lightly tap on exterior of the body to determine position, size, and consistency of underlying structures.