Chapter 12: Potter and Perry
Physical Assessment
Chapter 13:
Potter and Perry
Linnetta Neal, RN, MSN
Vital
Signs
˜
The
most frequent measurements taken by health care professionals
˜
Includes:
Ø
Level
Of Consciousness
Ø
Temperature
(Temp)
Ø
Radial
Pulse (P)
Ø
Respirations
(R)
Ø
Blood
Pressure (BP)
Ø
Pain
Ø
Pulse
Oximetry (Pulse Ox)
Ø
Cardiac
& Vascular Assessment
Vital
Signs
˜
When to measure Vital Signs – Box 12- 1, pg 226
˜
Assessed whenever a patient enters any health care
agency
˜
Obtained with a physical assessment or independent of
the physical assessment
Vital
Signs
˜
Guidelines for measuring Vital Signs
˜
Must be measured accurately
˜
Equipment based on client condition, size, etc.
˜
Client’s usual range of vital signs
˜
Client’s medical history, therapies and medications
˜
Must be interpreted and communicated in order for
interventions to be initiated
˜
Evaluate verbal responses
˜
Ask questions to determine orientation to Person, Place and Time:
Ø “What is
your name?” (Person)
Ø “Tell me
where you are. ” (Place)
Ø “What is
time? Date? Year? (Time)
Assess
Motor Function
Ø Upper and
lower extremities
Assess
superficial sensations
Ø Pain, touch,
temperature
Pupil
Assessment
˜
Size
˜
Shape
˜
Equality
˜
Reaction to light
˜
Accommodation
Body
Temperature
˜
Heat produced – Heat loss = Body temperature
˜
Ranges
Ø 36° to 38° C
Ø 96.8° to
100.4° F
˜
Body tissues and cells function best within this
normal range.
Body
Temperature Regulation
˜
Neural and vascular control
˜
Heat production
˜
Heat loss
˜
Behavioral control
Temperature
alterations
Ø
Fever/pyrexia
Ø Febrile vs.
Afebrile
Ø
Hypothermia
Ø
Hyperthermia
Thermoregulation
and Assessment
˜
Sites
Ø Core
Ø Surface – Oral, Rectal, Axillary, Tympanic
˜
Thermometers
Ø Electronic
Ø Chemical dot
Ø Disposable
Ø Glass
Factors
which Influence Body Temperature
˜
Response to physical stress
˜
Response to psychological stress
˜
Response to medical and nursing therapy
Why does the nurse document both the temperature and the site
of the client’s temperature?
•
Different reading will be obtained from each site
•
Rectal temperatures will be lower than oral
temperatures
•
Infections can influence the temperature at each site
•
Physicians insist on accurate documentation
Pulse
˜
Palpable bounding of the blood flow in a peripheral
artery
˜
Location
Ø Apical, carotid,
femoral, peripheral, radial
Using
A Stethoscope
˜
Stethoscope
Ø Used to assess apical pulse
Ø
Bell used to hear
low-pitched sounds
Ø
Diaphragm used to
hear high-pitched sounds
Assessment
of Pulse
˜
Definition: palpable bounding of blood flow in the
peripheral artery
˜
Rate (Bradycardia vs. tachycardia)
Ø Need a
baseline, may have variations
Ø Apical S1 and S2
˜
Rhythm
Ø Regular,
irregular
Assessment
of Pulse
˜
Strength and equality
Ø Reflects the
volume and pressure of blood ejected against the arterial wall with each beat
Factors
influencing Pulse Rates
Ø
Exercise
Ø
Temperature
Ø
Emotions
Ø
Drugs
Ø
Hemorrhage
Ø
Postural changes
Ø
Pulmonary conditions
Respiration
˜
The mechanism the body uses to exchange gases between
the atmosphere, blood, and cells
˜
Ventilation
˜
Diffusion
˜
Perfusion
Assessment
of Respiration
˜
Definition: mechanism the body uses
to exchange gases between the atmosphere, blood, and cells
Ø Ventilation
Ø Diffusion
Ø Perfusion
˜
Normal: 12 to 16 breaths per minute
in a smooth, uninterrupted pattern
˜
Eupnea
˜
Bradypnea
˜
Tachypnea
˜
Apnea
Measurement
of Respirations
˜
Accurate measurement requires observation and
palpation of chest wall movement
Ø Respiratory
rate
Ø Ventilatory
depth
Ø Ventilatory
rhythm
˜
Measurement of arterial oxygen saturation
Ø Pulse
oximetry
Measurement of O2 Saturation
˜
Pulse Oximetry – indirect and non-invasive measurement
of oxygen saturation; measured with a
probe and photosensor connected to an oximeter
˜
Text says normal values >90-100%; most hospitals
consider any value less than 93% to be low
Blood
Pressure
˜
Force exerted on the walls of the artery
˜
Systolic
Ø Peak of
maximum ejection
˜
Diastolic
Ø Relaxation,
lowest pressure exerted
˜
Pulse pressure
Ø Difference
between systolic and diastolic
Physiology
of Arterial
Blood Pressure
˜
Reflects the interrelationships of CO, PVR, blood
volume and viscosity, and artery elasticity
˜
Blood pressure variations
Ø Hypertension
Ø Hypotension
Ø Orthostatic
hypotension
Assessment
of Blood Pressure
˜
Directly or indirectly
˜
Equipment
Ø Sphygmomanometer
(manual or electronic)
˜
Auscultation of Korotkoff phases
Ø Lying,
sitting, or standing
˜
Palpation
Indirect measurement
˜
Automatic Blood Pressure Measurement
Cardiac Assessment
˜
Involves auscultation or listening to
heart sounds
Ø Use stethoscope to assess (“lub”-dub” is ONE HEARTBEAT)
˜
Aortic area (S2 louder)
˜
Pulmonic area
˜
Erb’s Point (second Pulmonic area)
˜
Tricuspid area
˜
Mitral area (S1 louder)
Ø PMI (Point of Maximal Impulse) pp. 244 & 305
Vascular
Assessment
˜
Carotid
˜
Brachial
˜
Radial
˜
Femoral
˜
Dorsalis pedis
˜
Posterior tibial
˜
Describe Rhythm
˜
Strength
Ø 0 - absent
Ø 1+ diminished
Ø 2+ normal
Ø 3+ full; increased
Ø 4+ bounding
˜
Describe Symmetry
Pain
Assessment
(Discussed in-depth in Promoting Comfort)
˜
Identification of pain is valuable and necessary to
Ø Manage pain
effectively
Ø To manage
medical diagnosis
˜
Level of Pain
Ø Determine on
scale of 0 (no pain) to 10 (excruciating)
Documentation
of Vital Signs
˜
Practice in NAL on
Graphic Flow sheets