Chapter 27 Vital Signs and Physical Assessment Fundamentals of Nursing: Standards & Practices, 2E.

Chapter 27

Vital Signs and Physical Assessment

Fundamentals of Nursing: Standards & Practices, 2E

Copyright 2002 by Delmar, a division of Thomson Learning 27-2

Vital Signs

The taking of vital signs refers to measurement of the client’s body temperature (T), pulse (P), respiratory (R) rates, and blood pressure (BP).

A baseline value establishes the norm against which subsequent measurements can be compared.


Variations from normal findings may indicate potential problems with the client’s health status.

Nurses should confirm “normal” measurements with clients because the perception of what is normal may vary among clients.


The sequence for recording vital signs measurements in the nurses’ notes is T-P-R and BP.

Most agencies have graphic forms for documentation of vital signs. These forms facilitate data comparison at a glance.


Physiological FunctionThermoregulation is the body’s

function of heat regulation in order to maintain a constant internal body temperature.• Heat production• Heat loss• Behavioral control of body temperature


Respiration is the act of breathing.• External respiration• Internal respiration• Inspiration• Expiration• Vital capacity


Hemodynamic regulation is the function of blood circulating in order to maintain an appropriate environment in tissue fluids.• Blood flow

Systole Diastole


Stroke volume Cardiac output Pulse pressure

• Pulse• Blood pressure


Factors Influencing Vital Signs

AgeGenderHeredityRaceLifestyleEnvironment


MedicationsPainOthers factors

• Exercise• Anxiety and stress• Postural changes• Diurnal (daily) variations


Measuring Vital Signs

Equipment • Thermometer - glass, electronic,

disposable, tympanic• Stethoscope• Ultrasound (Doppler)• Sphygmomanometer• Scale


Height and weight• Height is expressed in inches (in), feet

(ft), centimeters (cm), or meters (m).• A scale for measuring height is usually

attached to a standing weight scale.• Measure an infant’s length from vertex

of head to soles of feet while infant is lying with knees extended.


• Measurement of weight is expressed in ounces (oz), pounds (lb), grams (g), or kilograms (kg).

• Daily weights should be obtained at the same time of the day, on the same scale, and with the client wearing the same type of clothing.


• Types of scales include standing, chair, stretcher, bed, and platform scales.

• Measure an infant on a platform scale, keeping one hand over the top of infant to prevent accidental injury.

• Accurate recordings of weight are imperative because they are used in drug dosage calculations and to evaluate the effectiveness of many treatments.


Body temperature• Use either the Centigrade or Fahrenheit

scale to measure temperature.• Internal core temperature sites are oral,

rectal, and axillary.• Advanced techniques include use of

thermistors for pulmonary artery temperature and infrared thermometers for ear canals.


• Oral and rectal temperatures are higher than axillary; rectal measurements are higher than oral.

• The axilla is commonly used for infants and children with disabilities because it is the safest method.

• Review Procedure 27-1 on measuring body temperature.


• Alterations in thermoregulation Pyrexia Heat exhaustion Heat stroke Hypothermia Frostbite


Pulse• Pulse is the measurement of a

pressure pulsation created when the heart contracts and ejects blood into the aorta.

• Pulse points include temporal, carotid, apical, brachial, radial, ulnar, femoral, popliteal, posterior tibial, and dorsalis pedis.


• A Doppler ultrasound stethoscope is used on superficial pulse points.

• A stethoscope is used to auscultate the apical pulse.

• Review Procedure 27-2 on assessing pulse rate.


• A pulse deficit occurs when the apical pulse rate is greater than the radial pulse rate.

• Pulse characteristics Pulse quality Pulse rate - bradycardia, tachycardia Pulse rhythm Pulse volume


Respirations• Respiratory assessment is the

measurement of the breathing pattern.• Assessment of respirations provides

clinical data regarding the pH of arterial blood.


• The nurse ascertains the rate, depth, and rhythm of respirations.

• Review Procedure 27-3 on assessing respirations.


• Characteristics of breath sounds Eupnea, bradypnea, tachypnea Hypoventilation Hyperventilation Costal breathing Diaphragmatic breathing Dyspnea


• Respiratory alterations may cause changes in skin color as observed by a bluish appearance in the nail beds, lips, and skin.

• The bluish color (cyanosis) results from reduced oxygen levels in the arterial blood.


Blood pressure• The most common site for indirect

measurement is the client’s arm over the brachial artery.

• The radial, popliteal, posterior tibial, or dorsalis pedis arteries can also be used to measure blood pressure if the brachial artery is inaccessible.


• A sphygmomanometer is a device used to measure indirect blood pressure - mercury or aneroid types.

• An accurate measurement requires the correct width blood pressure cuff as determined by the circumference of the client’s extremity.


• Techniques of measurement Auscultation - Korotkoff sounds Palpation Review Procedure 27-4 on assessing

blood pressure


• Hypotension refers to a systolic blood pressure less than 90 mm Hg or 20 to 30 mm Hg below the client’s normal systolic pressure.

• Hypertension refers to a persistent systolic pressure greater than 135 to 140 mm Hg and a diastolic pressure greater than 90 mm Hg.


Physical Examination

Purposes of physical examination• It ascertains client’s level of health and

physiological function.• It identifies factors placing the client at

risk and determines areas of preventive nursing.


• It confirms alterations, disease, or inability to perform the activities of daily living.

• It identifies the need for additional testing or examination.

• It evaluates the outcomes of treatment and therapy.


Preparation for the physical examination• The nurse should keep the client informed

while performing the examination.• The nurse should appear calm, organized,

and competent at the bedside.• The nurse should review the agency’s

assessment forms prior to meeting with the client.


Environment• Accommodate any special needs of the client.• Allow for placement of the equipment on a

surface that is clean and free from movement at the bedside.

• The room needs to be quiet, warm, and well lit.

• Make necessary adjustments to ensure privacy.


Equipment• Wash hands and gather necessary

equipment.• Secure the forms required for

documenting the assessment findings.• Gather enough clean gloves to change

as needed for the examination.


Positioning and draping• Position the client to ensure accessibility

to the body part being assessed.• Drape the client to prevent unnecessary

exposure during the examination.• A bath blanket, sheet, towels and/or the

client’s gown can be used as drapes.


General survey• Observe for signs of distress.• Observe the client’s state of health,

stature, and sexual development.• Weight, height, and vital signs are

measured.• Note posture, motor activity, gait, dress,

grooming, and personal hygiene.


• Observe facial expressions and behaviors.

• Listen to quality of speech and note the level of consciousness.

• Special considerations Elderly clients Disabled clients Abused clients


Sexual History• Illness and medical interventions can

interfere with sexual functioning.• Sexual responsiveness can be altered by

taking narcotics, sedatives, antidepressants and antispasmodics.

• Prolonged therapies may cause physiologic changes that affect sexual desire.


Techniques• Inspection• Palpation• Percussion• Auscultation


Integument• Skin• Hair• Nails• Review Tables 27-9, 27-10, and 27-11

for assessment of the integumentary system.


Head and neck• Skull and face• Eyes• Ears• Nose and sinuses


• Mouth and pharynx• Neck• Review table 27-13 for assessment of

the head and neck.


Thorax and lungs• Normal breath sounds

Vesicular Bronchovesicular Bronchial


• Adventitious breath sounds Crackles Rhonchi Wheezes Pleural friction rub Stridor

• Review Table 27-14 for assessment of the thorax and lungs.


Heart and vascular system• Heart• Vascular system• Review Table 27-15 for assessment of

the heart and vascular system.


Breasts and Axilla• Review Table 27-16 for assessment of

the breasts and axilla.Abdomen

• Review Table 27-17 for assessment of the abdomen.


Female genitalia and anus• Review Table 27-18 for assessment of

the female genitalia and anus.Male genitalia and anus

• Review Table 27-19 for assessment of the male genitalia and anus.


Musculoskeletal system• Review Table 27-20 for assessment of

the musculoskeletal system.Neurologic system

• Mental status• Cognitive abilities and mentation• Sensory assessment


• Cranial nerves assessment• Motor assessment• Cerebellar assessment• Reflex assessment

Review Table 27-22 for assessment of common deep tendon reflexes.

• Review Table 27-21 for assessment of the neurologic system.


Care of the client after the examination• Home or outpatient setting• Acute or extended care setting


Data documentation• Health care agencies have specific

forms for recording the assessment findings.

• Record findings on the appropriate form as the data are gathered.

• Reporting information is a critical part of documentation.


• Documentation should reflect the objective data obtained from the examination regarding the client’s current condition.

• Abnormal findings should be addressed when planning the nursing care and client outcomes.

Chapter 27 Vital Signs and Physical Assessment Fundamentals of Nursing: Standards & Practices, 2E.

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Transcript of Chapter 27 Vital Signs and Physical Assessment Fundamentals of Nursing: Standards & Practices, 2E.