Health Assessment Notes

Health Assessment (NCM 101)

Credit Units & Course Description

This course covers concepts, principles, and techniques for health history taking, physical examinations from head to toe, psychosocial assessments (using tools), and interpreting lab findings to determine a nursing diagnosis. Students will conduct holistic nursing assessments for adult clients. The credit units are broken down as follows:

• Theory: 3 units (54 hours)
• Laboratory: 2 units (102 hours, including 20-30 hours of independent study)

Instructions for Module Use

1. Study the module individually, following timelines set by the teacher.
2. Review learning objectives per unit.
3. Complete self-study guide questions after each topic, checking answers against module content. Write answers on short bond paper and submit to the teacher.
4. Proceed sequentially through units, repeating steps 2 and 3.
5. Attend follow-up conferences (text, message, call, video call) with the teacher for feedback.
6. Contact the teacher with any module questions.

Unit 1: Introduction to Health Assessment

Overview

Health assessment involves evaluating a patient's health through physical examination and health history. It's a plan identifying specific needs and how healthcare staff will address them using the nursing process.

Learning Objectives

• Describe the nursing process.
• Identify types of health assessment.
• Discuss the nurse's role in health assessment.

Overview of Nursing Process

The nursing process is a systematic, goal-directed, client-centered method for structuring nursing care delivery (Toney-Butler & Thayer, 2020). It is a systematic, continuous, and dynamic method of providing care, with sequential phases built upon preceding steps. Each phase logically leads to the next to achieve mutually determined outcomes. Nursing practice is directed by how nurses view the client, their environment, health, and the purpose of nursing (Parihar, 2019).

History of Nursing Process

• 1955: Lydia Hall introduced 3 steps: Observation, Administration of care, and Validation.
• 1967: Yura and Walsh added assessment, creating a four-phase process (APIE).
• Mid-1970s: The diagnostic phase was added, resulting in a five-step process (ADPIE).
• 1973: The American Nurses Association (ANA) started using the nursing process in Standards of Nursing Practice.
• 1991: Revisions incorporated outcome identification into the planning phase, creating a 6-step process (ADOPIE): Assessment, Diagnosis, Outcome Identification, Planning, Implementation, and Evaluation.

Characteristics of Nursing Process

It follows a GOSH approach, meaning it's goal-oriented, organized, systematic, and humanistic. These characteristics ensure efficient and effective care. In addition to GOSH the nursing process is:

• Cyclic and Dynamic: Data from each phase provides input into the next, continually changing based on the client's health status.
• Involves Skill in Decision-making: Nurses choose the best actions to meet goals or solve problems.
• Uses Critical Thinking skills: Nurses use critical thinking to address new ideas or unusual situations.

Purpose of Nursing Process

The purpose of the nursing process is:

• Identify a client's health status and actual or potential health care problems or needs.
• Establish plans to meet the identified needs.
• Deliver specific nursing interventions to meet those identified needs.

Phases of Nursing Process

The nursing process is a systematic guide to client-centered care with sequential steps - assessment, nursing diagnosis, outcome identification, planning, implementation, and evaluation. These steps are elaborated below:

• I. Assessment
  • Assessment, the first step, uses critical thinking and involves data collection (subjective and objective).
  • Subjective data involves verbal statements from the patient or caregiver.
  • Objective data is measurable, tangible data such as vital signs, intake and output, height, and weight.
  • Data may come directly from the patient or from primary caregivers.
  • The purpose of assessment is to establish a database.
  • Activities in Assessment:
    • Collecting - gather information (physical, psychological, emotional, socio-cultural, and spiritual factors).
    • Validating – ensuring accurate information.
    • Organizing - cluster facts into groups of information.
• II. Nursing Diagnosis
  • The North American Nursing Diagnosis Association (NANDA) provides nurses with an up-to-date nursing diagnosis list.
  • A nursing diagnosis is a clinical judgment about responses to actual or potential health problems on the part of the patient, family, or community.
  • Components of a NANDA Nursing Diagnosis:
    1. Problem
    2. Etiology
    3. Signs and symptoms
  • Formulating Diagnostic Statements:
    1. Basic Two-Part Statements:
       • Problem (P): Statement of the client’s response (NANDA label).
       • Etiology (E): Factors contributing to or probable causes of the responses.
       • The two parts are joined by the words "related to". Example: Constipation related to low fiber intake.
    2. Basic Three-Part Nursing Diagnosis Statements (PES Format):
       • Problem (P): Statement of the client’s response (NANDA label).
       • Etiology (E): Factors contributing to or probable causes of the response.
       • Signs and symptoms (S): Defining characteristics manifested by the client.
       • The PES format is recommended for beginning diagnosticians
  • Types of Nursing Diagnoses:
    • Actual Nursing Diagnosis:
      • Health problem that is present at the time of nursing assessment.
      • Based on the presence of signs and symptoms.
      • Example: Altered comfort: Pain. Pain: Severe headache related to fear of addiction to narcotics.
    • Risk Nursing Diagnosis:
      • A clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop
      • Example: Risk for infection. Risk for constipation
    • Possible Nursing Diagnosis:
      • Evidence about a health problem is unclear or the causative factors are unknown.
      • Requires more data either to support or to refute it.
      • Example: Possible social isolation related to unknown etiology
• III. Outcome Identification
  • Refers to formulating and documenting measurable, realistic, client-focused goals. Provides the basis for evaluating nursing diagnosis and interventions.
  • Activities in Outcome Identification include:
    1. Establish priorities
       • Life-threatening should be given the highest priority.
       • ABC’s (airway, breathing, circulation).
       • Maslow’s hierarchy of needs (physiologic needs over psychosocial)
       • Unstable clients vs. clients with stable conditions.
       • Actual problems vs. potential concerns
    2. Establish goals and outcome criteria:
       • Goals: broad statements.
       • Short-term goal.
       • Long-term goal.
       • Outcome criteria: should be SMART in the attainment of the goal.
         • S – specific
         • M – measurable
         • A – attainable
         • R – realistic
         • T - time-framed
  • Purpose of Desired Goals/Outcomes Identification
    1. Provide direction for planning nursing interventions.
    2. Serve as criteria for evaluating client progress.
    3. Enable the client and nurse to determine when the problem has been resolved.
    4. Help motivate the client and nurse by providing a sense of achievement.
• IV. Planning
  • Involves determining beforehand the strategies or course of actions to be taken before implementation of nursing care. Planning is the nurse’s responsibility.
  • Input from the client and support persons is essential if a plan is to be effective.
  • Types of Planning:
    1. Initial Planning
       • The nurse who performs the admission assessment usually develops the initial comprehensive plan of care.
       • Planning should be initiated as soon as possible after the initial assessment.
    2. Ongoing Planning:
       • It is done by all nurses who work with the client
       • It also occurs at the beginning of a shift as the nurse plans the care to be given that day.
       • Using ongoing assessment data, the nurse carries out daily planning for the following purposes:
         • To determine whether the client’s health status has changed
         • To set priorities for the client’s care during the shift
         • To decide which problems to focus on during the shift
         • Coordinate the nurse’s activities so that more than one problem can be addressed at each client contact.
    3. Discharge Planning
       • Anticipating and planning for needs after discharge is a crucial part of comprehensive health care and should be addressed in each client’s care plan.
       • Effective discharge planning begins at first client contact and involves comprehensive and ongoing assessment to obtain information about the client’s ongoing needs.
• V. Implementation
  • Putting the nursing care plan into action. The nurse performs or delegates the nursing activities for the interventions developed in the planning step and then concludes the implementing step by recording nursing activities and the resulting client responses.
  • Purpose of Intervention
    • To carry out planned nursing interventions to help the client attain goals and achieve an optimal level of health
  • Activities in Intervention
    • Set priorities.
    • Perform nursing interventions
    • Record actions. SOMETHING THAT IS NOT WRITTEN IS CONSIDERED NOT DONE!!!
  • Types of Nursing Intervention
    • Direct care is an intervention performed by the nurse through interaction with the client
    • Indirect care is an intervention delegated by the nurse to another provider or performed away from but on behalf of the client, such as interdisciplinary collaboration or the care environment's management.
    • Independent interventions are those activities that nurses are licensed to initiate based on their knowledge and skills.
    • Dependent interventions are activities carried out under the orders or supervision of a licensed physician or other health care provider authorized to write orders to nurses.
    • Collaborative interventions are actions the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dietitians, and primary care providers.
• VI. Evaluation
  • Evaluate the outcome. As with all nursing care, in evaluating, the nurse determines the effectiveness of the plan and whether the initial purpose was achieved.
  • Evaluation is assessing the client’s response to nursing intervention and then comparing the response to predetermined standards or outcome criteria.
  • The evaluation phase has five components:
    1. Collecting data related to the desired outcomes
    2. Comparing the data with desired outcomes
    3. Relating nursing activities to outcomes
    4. Drawing conclusions about problem status
    5. Continuing, modifying, or terminating the nursing care plan

Guidelines for Writing Nursing Care Plans

1. Date and sign the plan.
2. Use category headings.
3. Use standardized/approved symbols and key words.
4. Be specific about timing of interventions.
5. Tailor the plan to the client's unique characteristics.
6. Incorporate preventive and health maintenance aspects.
7. Ensure ongoing assessment of the client.
8. Include collaborative and coordination activities.
9. Include plans for the client's discharge and home care needs.

Health Assessment in Nursing Practice

Nurses make four assessments: initial, focused, time-lapsed, and emergency.

Types of Assessment

1. Initial Assessment:
   • Performed when the client enters health care from a health care agency.
   • Purposes: Evaluate client’s health status, identify functional health patterns that are problematic and provide an in-depth, comprehensive database.
2. Time-Lapsed or Ongoing Assessment:
   • Takes place after the initial assessment to evaluate any changes in the client's functional health.
   • Nurses perform time-lapsed assessment when substantial periods have elapsed between assessments (e.g., out-patient clinic visits, home health visits, and health and development screenings).
3. Focused or Problem-oriented Assessment:
   • Collects data about a problem that has already been identified.
   • Has a narrower scope and a shorter time frame than the initial assessment.
   • Nurses determine whether the problems still exist and whether the problem's status has changed (i.e., improved, worsened, or resolved).
4. Emergency Assessments:
   • Takes place in life-threatening situations in which the preservation of life is the top priority.
   • Rapid identification of and intervention for the client's health problems. During emergency procedures, a nurse focuses on rapidly identifying the root causes of concern for the patient and assessing the patient's airway, breathing, and circulation (ABCs).
   • Emergency assessments must also include an assessment for scene safety

Summary of Types of Assessment

Nurses’ Role in Health Assessment

1. Caregiver
2. Communicator
3. Teacher
4. Client Advocate
5. Counselor
6. Case Manager
7. Change Agent
8. Leader
9. Manager
10. Research Consumer
11. Expanded Career Roles

Unit 2: Steps of Health Assessment

Overview

This unit covers data collection, physical examination techniques, and diagnostic tests/procedures.

Learning Objectives

• Collect subjective and objective data of clients.
• Perform techniques in the physical examination.
• Know the different diagnostic tests and procedures.

Subjective Data and Objective Data

• Symptoms are subjective concerns or what the patient tells you.
• Signs are considered one type of objective information, or what you observe.

Collection of Subjective Data Through Interview and Health History

The health history format provides a framework for organizing the patient’s story, facilitates clinical reasoning, and clarifies patient concerns, diagnoses, and plans to other health care providers.

• Necessary information in health history:
  1. Biographic data:
     • Client’s name, address, age, sex, marital status, occupation, religious preference, and health care financing
  2. Chief complaint or Reasons for seeking health care:
     • The answer was given to the question “What is troubling you?” or “Describe the reason you came to the hospital or clinic today.”
     • The chief complaint should be recorded in the client’s own words. For example, “My stomach hurts, and I feel awful.”
  3. Present illness:
     • A complete, clear, and chronologic description of the problems prompting the patient’s visit, including the onset of the problem, the setting in which it developed, its manifestations, and any treatments to date.
     • Each principal symptom should be well characterized and should include the seven attributes of a symptom: (1) location; (2) quality; (3) quantity or severity; (4) timing, including onset, duration, and frequency; (5) the setting in which it occurs; (6) factors that have aggravated or relieved the symptom; and (7) associated manifestations.
     • Patients often have more than one symptom or concern. Each symptom merits its paragraph and a full description.
     • Medications should be noted, including name, dose, route, and frequency of use.
     • Allergies, including specific reactions to each medication, such as rash or nausea, must be recorded, as well as allergies to foods, insects, or environmental factors.
     • Note tobacco use, including the type. Cigarettes are often reported in packyears.
     • Alcohol and drug use should always be investigated and is often pertinent to the Presenting Illness.
  4. Past health history:
     • Childhood and Adult Illnesses
     • Medical and Surgical
     • Obstetric/Gynecologic
     • Psychiatric
     • Health Maintenance: Cover selected aspects of Health Maintenance, especially immunizations and screening tests.
  5. Family health history:
     • Outline or diagram the age and health, or age and cause of death, of each immediate relative, including parents, grandparents, siblings, children, and grandchildren.
     • Review each of the following conditions and record whether they are present or absent in the family: hypertension, coronary artery disease, elevated cholesterol levels, stroke, diabetes, thyroid or renal disease, arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness.
  6. Personal and Social History:
     • Captures the patient’s personality and interests, sources of support, coping style, strengths, and concerns.
     • It should include occupation and the last year of schooling; home situation and significant others; sources of stress, both recent and long-term; important life experiences such as military service, job history, financial situation, and retirement; leisure activities; religious affiliation and spiritual beliefs; and activities of daily living (ADLs).

Collection of Objective Data

• A complete health assessment may be conducted starting at the head and proceeding systematically downward (head-to-toe assessment).
• The health assessment is therefore conducted in a systematic and efficient manner that results in the fewest position changes for the client considering energy, time, age, severity of illness and preferences of the nurse and healthcare agency priorities.
• Frequently, nurses assess a specific body area instead of the entire body. These specific assessments are made with observations of problems, the client’s presenting problem, interventions, and medical therapies.

Order of Head-to-Toe Assessment

1. General survey
2. Vital signs
3. Head (Hair, scalp, face -Eyes and vision, Ears and hearing, Nose, Mouth and oropharynx, Cranial nerves)
4. Neck (Muscles, Lymph nodes, Trachea, Thyroid gland, Carotid arteries, Neck veins)
5. Upper extremities (Skin and nails, Muscle strength and tone, Joint range of motion, Brachial and radial pulses, Sensation)
6. Chest and back (Skin, Chest shape and size, Lungs, Heart, Spinal column, Breasts and axillae)
7. Abdomen (Skin, Abdominal sounds, Femoral pulses)
8. External genitals
9. Anus
10. Lower extremities (Skin and toenails, Gait and balance, Joint range of motion, Popliteal, posterior tibial, and pedal pulses)

Purposes of Physical Examination

• To obtain baseline data about the client’s functional abilities
• To supplement data obtained in the nursing history
• To obtain data that will help establish nursing diagnoses and plans of care
• To evaluate the physiological outcomes of health care and thus the progress of a client’s health problem
• To make clinical judgments about a client’s health status
• To identify areas for health promotion and disease prevention

Preparation for Physical Examination

1. Reflect on your approach to the patient
2. Adjust the lighting and the environment
3. Check your equipment (ophthalmoscope, stethoscope, etc.)
4. Make the patient comfortable (close doors, provide privacy) Draping the patient to visualize one area of the body at a time.
5. Observe standard and universal precautions

Client Positions

Several positions are frequently required during the physical assessment. It is important to consider the client’s ability to assume a position.

Techniques of Examination

1. Inspection: Close observation of appearance, behavior, and movement.
2. Palpation: Tactile pressure to assess skin elevation, warmth, tendons, or masses. Use light and deep palpation.
3. Percussion: Use of striking finger to deliver a rapid tap against the distal pleximeter finger. Percussion elicits five types of sound: Flatness, Dullness, Resonance, Hyperresonance, Tympany.
4. Auscultation: Use stethoscope to detect characteristics of heart, lung, and bowel sounds.

Diagnostic Tests and Procedures

These are tools that provide information about the client. Nurses require knowledge of the most common laboratory and diagnostic tests. Nurses must also know the pretest (client preparation), intratest (specimen collection), and post-test (nursing care) implications of the test results.

Preparing for Diagnostic Testing

a) Instruct the client and family about the procedure for the diagnostic testing ordered (e.g. whether food is allowed prior to or after testing, and the length of time of the testing).
b) Explain the purpose of the test.
c) Instruct the client and family about activity restrictions related to testing (e.g. remain supine for 1 hour after testing is completed).
d) Instruct the client and family on the reaction the diagnostic test may produce (e.g. flushing when the dye is injected).
e) Provide the client with detailed information about the diagnostic testing equipment.
f) Inform the client and family of the time frame for when the results will be available
g) Instruct the client and family to ask any questions so that the health care provider can clarify information and allay any fears.

Blood tests

Blood tests are commonly used diagnostic tests that can provide valuable information about the hematologic system and many other body systems. Venipuncture: puncture of a vein for collection of a blood specimen

Complete blood count

For a complete blood count (CBC), which includes hemoglobin and hematocrit measurements, erythrocyte (red blood cells) count, leukocyte (white blood cell) count, red blood cell indices, and a differential white cell count.

Serum Electrolytes

Serum electrolytes are often routinely ordered for any client admitted to a hospital as a screening test for electrolyte and acid–base imbalances. The most commonly ordered serum tests are for sodium, potassium, chloride, and bicarbonate ions.

Blood Urea Nitrogen (BUN)

Blood levels of two metabolically produced substances, urea and creatinine, are routinely used to evaluate renal function. Urea, the end product of protein metabolism, is measured as blood urea nitrogen (BUN).

Arterial Blood Gases

Measurement of arterial blood gases is another important diagnostic procedure. Specialty nurses, medical technicians, and respiratory therapists normally take specimens of arterial blood from the radial, brachial, or femoral arteries.

Blood Chemistry

In addition to serum electrolytes, common chemistry examinations include determining certain enzymes, serum glucose, hormones, and other substances such as cholesterol and triglycerides. A common laboratory test is the glycosylated hemoglobin or hemoglobin A1C (HbA1C), which is a measurement of blood glucose that is bound to hemoglobin. The first specific blood test to detect and guide treatment for heart failure is the brain natriuretic peptide or B-type natriuretic peptide (BNP) test.

Metabolic Screening

Newborns are routinely screened for congenital metabolic conditions. Tests for phenylketonuria (PKU) and congenital hypothyroidism are required in all states in the United States. Screening involves collecting peripheral venous blood on prepared blotting paper.

Capillary Blood Glucose

A capillary blood specimen is often taken to measure blood glucose when frequent tests are required or when a venipuncture cannot be performed. If a client has a physical impairment, an available meter can rest on the arm and perform the lancing and testing automatically.

Specimen Collection and Testing

The nurse contributes to the assessment of a client’s health status by collecting specimens of body fluids. Depending on the type of specimen and skill required, the nurse may be able to delegate this task to unlicensed assistive personnel (UAP) under the supervision of the nurse. Nursing responsibilities associated with specimen collection include the following:

1. Provide client comfort, privacy, and safety.
2. Explain the purpose of the specimen collection and the procedure for obtaining the specimen.
3. Use the correct procedure for obtaining a specimen or ensure that the client or staff follows the correct procedure.
4. Note relevant information on the laboratory requisition slip, for example, medications the client is taking that may affect the results.
5. Transport the specimen to the laboratory promptly.
6. Report abnormal laboratory findings to the health care provider in a timely manner consistent with the severity of the abnormal results.

Stool Specimens

Analysis of stool specimens can provide information about a client’s health condition. Only a small amount of feces is required because the specimen will be cultured. Collection containers or tubes must be sterile and aseptic technique used during collection.

Fecal Occult Blood Testing

Fecal occult blood testing (FOBT) is the most frequently performed fecal analysis. There are two types of FOBT: (1) the traditional guaiac smear (Hemoccult) and (2) flushable reagent pads (EZ Detect or Colocare). Certain foods, medications, and vitamin C can produce inaccurate test results.

Urine Specimens

The nurse is responsible for collecting urine specimens for a number of tests: clean voided urine specimens for routine urinalysis, clean-catch or midstream urine specimens for urine culture, and timed urine specimens for a variety of tests that depend on the client’s specific health problem. Urine specimen collection may require collection via straight catheter insertion.

Sputum Specimens

Sputum is the mucous secretion from the lungs, bronchi, and trachea. Sputum specimens are usually collected in the morning/ serial collection of three early-morning specimens.

Throat Culture

A throat culture sample is collected from the mucosa of the oropharynx and tonsillar regions using a culture swab. The sample is then cultured and examined for the presence of disease-producing microorganisms.

Visualization Procedures

Visualization procedures include indirect visualization (noninvasive) and direct visualization (invasive) techniques for visualizing body organ and system functions.

• Diagnostic Aid: X-rays
  • Enhancement of the tract is achieved by the introduction of a radiopaque substance such as barium.
  • Renal ultrasonography is a noninvasive test that uses reflected sound waves to visualize the kidneys.
  • During a cystoscopy, the bladder, ureteral orifices, and urethra can be directly visualized using a cystoscope, a lighted instrument inserted through the urethra.
• Electrocardiography: Provides a graphic recording of the heart’s electrical activity.
• Echocardiogram: Noninvasive test that uses ultrasound to visualize structures of the heart and evaluate left ventricular function.
• Lung scan, also known as a V/Q (ventilation/perfusion) scan: Records the emissions from radioisotopes that indicate how well gas and blood are traveling through the lungs.
• Computed Tomography: Produces a three-dimensional image of the organ or structure.
• Magnetic Resonance Imaging: A noninvasive diagnostic scanning technique in which the client is placed in a magnetic field.
• Nuclear Imaging Studies: Involve the therapeutic use of radioactive isotopes for diagnostic purposes

Aspiration/Biopsy

Aspiration is the withdrawal of fluid, a biopsy is the removal and examination of tissue. Both aspiration and biopsy are invasive procedures.

• Lumbar Puncture: Cerebrospinal fluid (CSF) is withdrawn through a needle inserted into the subarachnoid space of the spinal canal.
• Abdominal Paracentesis: Carried out to obtain a fluid specimen for laboratory study and to relieve pressure on the abdominal organs due to the presence of excess fluid.
• Thoracentesis: Performed to remove the excess fluid or air to ease breathing.
• Bone Marrow Biopsy: The removal of a specimen of bone marrow for laboratory study. The biopsy is used to detect specific diseases of the blood
• Liver Biopsy: A short procedure, generally performed at the client’s bedside, in which a sample of liver tissue is aspirated.

Unit 3. Holistic Nursing Assessment

Overview

A holistic nursing assessment focuses not only on physical health of an individual. It also addresses emotional, mental, social and spiritual health. The whole condition of the patient is taken into consideration for ongoing wellness across the lifespan.

Learning Objectives

Upon completion of this unit, I am able to do the following:

1. Assess the general status and vital signs;
2. Discuss the mental status of children, adolescent, and adults;
3. Define the psychosocial, cognitive and moral development;
4. Know how to assess pain and violence;
5. recognize the importance of culture, ethnicity, spirituality and religious practices of a client; and
6. explain how to assess nutritional status of a client.

General Survey

As you talk with and examine the patient, heighten your focus on the patient’s mood, build, and behavior. These details enrich and deepen your emerging clinical impression.

Assessment of General Appearance

The general appearance and behavior of an individual must be assessed in relationship to culture, educational level, socioeconomic status, and current circumstances.

Throughout the encounter with the client, observe the following:

• Apparent State of Health
• Level of Consciousness (alert, lethargy, obtundation, stupor, coma)

Signs of Distress

Does the patient show evidence of the problems listed below?

• cardiac or respiratory distress
• pain
• anxiety or depression

Skin Color and Obvious Lesions

• Assess any changes in skin color, scars, plaques, or nevi.
• Abnormal skin colors include pallor = pale, cyanosis = bluish, jaundice or icterus = yellowish, hyperpigmentation = brown

Dress, Grooming, and Personal Hygiene

• How is the patient dressed? Is the clothing appropriate for the temperature and weather? Is it clean and appropriate to the setting?
• Glance at the patient’s shoes, hair, jewelry, and fingernails
• Do personal hygiene and grooming seem appropriate to the patient’s age, lifestyle, occupation, and stage of life?

Facial Expression

• Observe the facial expression at rest, during conversation about specific topics, during the physical examination, and in interaction with others.
• Watch for eye contact. Is it natural? Sustained and unblinking? Averted quickly? Absent?

Odors of the Body and Breath

Watch for the stare of hyperthyroidism; the immobile face of Parkinsonism; the flat or sad affect of depression. Decreased eye contact may be cultural or may suggest anxiety, fear, or sadness.

Posture, Gait, and Motor Activity

• What is the patient’s preferred posture?
• Is the patient restless or quiet? How often does the patient change position?
• Is there any involuntary motor activity? Are some body parts immobile? Which ones?
• Does the patient walk smoothly, with comfort, self-confidence, and balance, or is there a limp or discomfort, fear of falling, loss of balance, or any movement disorder?

Height and Weight

In adults, the ratio of weight to height provides a general measure of health.
Record the baseline values of their height, weight, BMI and their risk for obesity status. It is a must to conduct it as a part of clinic visit.

• Height is measured with a measuring stick attached to weight scales or to a wall
• Weight is usually measured when a client is admitted to a health agency
• Calculating the BMI:
  • BMI is a person’s weight in kilograms or pounds divided by the square of height in meters.
    $BMI = \frac{weight (kg)}{[height (m)]^2}$
  • Classification of Overweight and Obesity by BMI:
    • Underweight - less than 18.5
    • Normal - 18.5-24.9
    • Overweight - 25.0-29.9
    • Obesity I - 30.0-34.9
    • Obesity II - 35.0-39.9
    • Extreme Obesity III - greater than 40
• Waist circumference
  • If the BMI is 35 or greater, measure the patient’s waist circumference just above the hips.
  • Risk for diabetes, hypertension, and cardiovascular disease increases significantly if the waist circumference is 35 inches or more in women and 40 inches or more in men.

Vital Signs

Vital signs are clinical measurements, specifically blood pressure, pulse rate, temperature and respiration rate, that indicate the state of an individual’s essential body functions. Many agencies have designated pain as a fifth vital sign. Oxygen saturation is also commonly measured at the same time as the traditional vital signs (Berman & Snyder, Kozier & Erb’s Fundamentals of Nursing, 2012).

When to Assess Vital Signs

• On admission to a health care agency to obtain baseline data.
• When a client has a change in health status or reports symptoms such as chest pain or feeling hot or faint.
• Before and after surgery or an invasive procedure.
• Before and/or after the administration of a medication that could affect the respiratory or cardiovascular systems.
• Before and after any nursing intervention that could affect the vital signs (e.g., ambulating a client who has been on bed rest).

Temperature

Body temperature reflects the balance between the heat produced and the heat lost from the body, and is measured in heat units called degrees.

• Kinds of Body Temperature
  • Core temperature
  • Surface temperature
• Factors Affect the Body’s Heat Production
  • Basal metabolic rate (BMR).
  • Muscle activity.
  • Thyroxine output.
  • E