Unit 2C.3: Objective Data | Vital Signs & Physical Assessment

Vital Signs

Provide‬‭ data ‬‭that‬‭ reflect ‬‭status‬‭ of‬‭ several‬‭ body‬ systems ‬‭including ‬‭but‬‭ not ‬‭limited ‬‭to‬‭ cardiovascular,‬ neurological,‬‭ peripheral‬‭vascular,‬‭ and‬‭ respiratory‬ systems‬

1. Temperature (TEMP)

2. Pulse/Heart Rate (PR)

3. Respiratory Rate (RR)

4. Blood Pressure (BP)

What is the typical sequence for vital signs?

1. RR

2. PR (using stethoscope)

3. TEMP

4. NO BP (unless in NICU or PICU)

What is the sequence for vital signs for pediatric clients?

36.5-37.5 degrees Celsius

Normal Range Adult Temperature

35-36.4 degrees Celsius

Normal Range Elderly Adult Temperature

Diurnal

Temperature has ___ variation, varying throughout the day.

4 AM - 6 AM

When is a persons temperature the lowest?

8 PM -12 AM

When is a persons temperature the highest?

Pulse Rate (PR)

Shock‬‭ wave produces‬‭ when ‬‭heart‬‭ pumps ‬‭blood ‬‭out‬ of ventricles into aorta‬

Arterial/Peripheral Pulse

What is PR also called?

60-100 bpm

Normal Range for PR

1. Temporal

2. Carotid

3. Apical

4. Radial

5. Brachial

6. Popliteal

7. Femoral

8. Dorsalis Pedis

What are the sites for PR?

1. Carotid

2. Apical

What sites is PR commonly taken for adults?

1. Radial

2. Brachial

What sites is PR commonly taken for pediatric clients?

False (Nurse MUST take RR without alerting the client since they may aleter their vital sign)

True or False: The nurse must alert the client prior to taking the RR.

12-20 cpm

Normal Value for RR

Dominant Arm

Where should BP be measured first?

1. Take on both arms

2. Subsequent readings taken in arm with highest measurement

What must be done regarding BP if it is the client's first time?

90-120 mmHg

Normal Value for Systolic BP

60-90 mmHg

Normal Value for Diastolic BP

Pulse Pressure

Is the difference between systolic and diastolic BP

30-60 mmHg

Normal Value for Pulse Pressure

decreases

When pulse pressure decreases, cardiac output ___

1. Heart is beating faster than normal

2. Heart attack

A decrease in pulse pressure are signs that…

Systolic: Less than 120 AND

Diastolic: Less than 80

According to the DOH, what is in the Normal Category (systolic and diastolic BP)?

Systolic: 120-129 AND

Diastolic: Less than 80

According to the DOH, what is in the Elevated Category (systolic and diastolic BP)?

Systolic: 130-139 OR

Diastolic: 80-89

According to the DOH, what is in the High BP Stage 1 Category (systolic and diastolic BP)?

Systolic: 140 or higher OR

Diastolic: 90 or higher

According to the DOH, what is in the High BP Stage 2 Category (systolic and diastolic BP)?

Systolic: Higher than 180 AND/OR

Diastolic: Higher than 120

According to the DOH, what is in the Hypertensive Crisis Category (systolic and diastolic BP)?

1. Head-to-Toe (Cephalocaudal)

2. Body Systems

3. Functional Health Patterns

4. Human Response Pattern

4 Components of Physical Assessment

Inspection, Palpation, Percussion, Auscultation (IPPA)

Physical Examination Techniques

Inspection

One of the Physical Examination Techniques

Involves‬‭ using ‬‭senses ‬‭of‬‭ vision,‬‭ smell,‬‭ and‬‭ hearing‬ ‭to observe and detect any normal findings‬

‭May ‬‭use ‬‭special ‬‭equipment‬‭ (e.g.,‬ ophthalmoscope)‬

1. Room is at a comfortable temperature to ensure skin appearance is accurate

2. Room is has good lighting to ensure skin appearance is accurate

3. Look and observe prior to touching since appearance may be altered

4. Draping properly

5. Compare appearance of symmetric body parts

Guidelines for Inspection

SSS CLOMB PC

Acronym for 10 things that should be noted for in Inspection

1. Size

2. Symmetry

3. Sounds

4. Color

5. Location

6. Odor

7. Movement

8. Behavior

9. Patterns

10. Consistency

What 10 things should be noted for in Inspection?

Palpation

One of the Physical Examination Techniques

Involves using of hand to touch and feel

SSS MM TT DC

Acronym for 9 things that should be noted for in Palpation

1. Texture (Rough or Smooth)

2. Temperature (Hot or Cold)

3. Moisture (Dry or Wet)

4. Mobility (Fixed/Movable/Still/Vibrating)

5. Consistency (Soft/Hard/Fluid Filled)

6. Strength of Pulses (Strong/Weak/Thready)

7. Size (S/M/L)

8. Shape (Well-Defined/Irregular)

9. Degree of Tenderness (Pain upon palpation?)

What 9 things should be noted for in Palpation?

1. Fingerpads

2. Ulnar/Palmar Surface

3. Dorsal (Back) Surface

Parts of Hand to Use for Palpation

Fine discriminations (example: checking pulse, texture, size, consistency)

When should the Fingerpads of the hand be used in palpation?

Check vibrations, thrills, fremitus (vibration in chest wall)

When should the Ulnar/Palmar Surface of the hand be used in palpation?

Checking temperature

When should the Dorsal (back) Surface of the hand be used in palpation?

1. Light

2. Moderate

3. Deep

4. Bimanual

4 Types of Palpation

Light

One of the types of palpation

‭Little ‬‭or ‬‭no ‬‭depression ‬‭(<1‬‭cm);‬‭ used ‬‭to ‬‭feel‬‭ for‬ pulses, tenderness, texture, temperature and moisture

• pulses

• tenderness

• texture

• temperature

• moisture

When is Light Palpation used?

Moderate

One of the types of palpation

1 ‬‭cm ‬‭to ‬‭2‬‭ cm ‬‭depression;‬‭ used ‬‭to ‬‭feel ‬‭for‬‭ size,‬ consistency‬‭ and‬‭ mobility ‬‭of‬‭ masses

Checking ‬‭for‬ thyroid/breast exam

Size,‬ consistency‬‭ and‬‭ mobility ‬‭of‬‭ masses (including Thyroid and Breast exams)

When is Moderate Palpation used?

Deep

One of the types of palpation

2.5 ‬‭cm ‬‭to ‬‭5 ‬‭cm ‬‭depression;‬‭ used ‬‭to ‬‭feel ‬‭very ‬‭deep‬ organs covered by thick muscle‬

Deep organs covered by thick muscle

When is Deep palpation used?

Bimanual

One of the types of palpation

‭Using ‬‭two ‬‭hands‬‭ (one ‬‭hand ‬‭applies‬‭ pressure‬ and other feels structure examined)‬‭

Percussion

One of the Physical Examination Techniques

‭Involves ‬‭tapping ‬‭of ‬‭body ‬‭parts‬‭ to‬‭ produce‬‭ sound‬‭ waves ‬‭or‬ vibrations to

• Elicit pain

• Determine location, size, and shape‬

• Determine density (if organ is fluid or air filled)‬

• Detect abnormal masses‬

• Elicit reflexes‬

1. Elicit pain

2. Determine location, size, and shape‬

3. Determine density (if organ is fluid or air filled)‬

4. Detect abnormal masses‬

5. Elicit reflexes

5 Functions of Percussion

1. Direct

2. Blunt

3. Indirect/Mediate

3 Types of Percussion

Direct

One of the types of percussion

Tapping ‬‭body‬‭ part‬‭ with‬‭ one‬‭ or ‬‭two ‬‭fingertips;‬‭ may‬ also use‬ reflex hammer‬

Blunt

One of the types of percussion

Placing‬‭ one ‬‭hand ‬‭flat‬‭ on‬‭ body ‬‭surface ‬‭and‬‭ using ‬‭fist‬ of other hand to strike back of hand flat on body surface‬

Kidney Punch

Kidney Punch

Example of Blunt Percussion

Indirect/Mediate

One of the types of percussion

Commonly ‬‭used ‬‭method,‬‭ detects ‬‭density‬ of underlying structure‬

Putting pressure to listen‬

the pleximeter is the finger (usually the middle finger of the non-dominant hand) placed firmly on the body, acting as a stable surface to receive the percussion strike, while the plexor is the finger (typically the middle finger of the dominant hand) that delivers the controlled tap

1. Resonance (Hollow)

2. Hyperresonance

3. Tymphany (Drum-Like)

4. Dullness

5. Flatness

5 Types of Percussion Tones/Sounds

Resonance (Hollow)

One of the types of percussion tones/sounds

Normal lung

Hyperresonance

One of the types of percussion tones/sounds

Lung with emphysema

Usually if lung has too much air

Tymphany (Drum-Like)

One of the types of percussion tones/sounds

Puffed-out cheek,GI organs

Heard normally in stomach, not chest

Dullness

One of the types of percussion tones/sounds

Diaphragm, liver, pleural effusion

Heard over solid tissue

Flatness

One of the types of percussion tones/sounds

Muscle, bone

Auscultation

One of the Physical Examination Techniques

Requires ‬‭the ‬‭use ‬‭of‬‭ a ‬‭stethoscope ‬‭to‬‭ listen ‬‭for‬ heart ‬‭sounds,‬‭ movement‬‭ of‬‭ blood ‬‭through ‬‭vessels,‬ movement‬‭ of ‬‭the ‬‭bowel,‬‭ and‬‭ movement‬‭ of ‬‭air‬ through the respiratory tract‬

1. Eliminate distracting noises

2. Expose body part

3. Warm diaphragm/bell before placing on skin

Guidelines for Auscultation

1. Diaphragm

2. Bell

2 Parts of the Stethoscope

High-pitched sounds like

• normal heart sounds

• bowel sounds

• breath sounds

When is the Diaphragm of the stethoscope used?

Low-pitched sounds like

• murmurs

• bruits

When is the Bell of the stethoscope used?