Health Skills I
Unit 102
Vital Signs
Objectives
• Identify observational techniques for
determining the health status of a patient.
Unit 102.1
Observational Techniques
• Observation of Patient
– observe physical signs and alertness
– listen to patient and ask questions
Objective Data
• can be observed or tested by healthcare
provider
• overt, not concealed
• Examples:
– observe that a patient refused to eat
– measure an increased temperature
– observe drainage from a wound
– skin is warm to the touch
– vomited 300 cc
Subjective Data
• information perceived only by the affected
person
• Examples:
– feels nervous
– pain in the abdomen
– nauseated
– feels chilled
Senses to Collect Data
• Look
– observe visible signs that indicate a problem
• Listen
– patient’s complaints, description of the
problem in their words
• Feel
– degree’s in body temperature, pulse quality
• Smell
– unusual odors
Collecting Data
Inspection
• visual examination
– signs of movement and posture
– skin color signs of distress
– ability to maintain health practices (hygiene,
dress)
– gait
Collecting Data
Auscultation
• listening with use of a stethoscope
–
–
–
–
–
blood pressure
heart sounds and/or rate
lung sounds
bowel sounds
detecting bruits
Collecting Data
Palpation
• examination of body parts through feeling
with fingertips and hands to
– assess skin temperature
– determine pulse rate, quality,rhythm, absence or
presence
– lumps/masses
– abdominal tenderness/distention
Collecting Data
Percussion
• tapping body parts with your fingers and
listening to sounds produced to
– detect presence of air
– evaluate amount of fluid in a body cavity
– determine size, borders and consistency of body
organs or masses
Purpose of Systematic Physical
Assessment
• to determine physical and emotional
changes through step by step observation
• NOTE:
– apparent state of health, does patient seem
acutely ill?
Signs of Distress
•
•
•
•
•
•
•
NOTE:
dyspnea (difficulty breathing)
vomiting
pallor
pain
crying
evidence of nervousness
Skin Color
• NOTE:
– pink
• indicates adequate oxygen levels
– pallor (pale)
• major organs being challenged with fluid or blood loss,
peripheral blood is being shunted to the core of the
body to self protect them
– ashen (gray)
• body systems begin to suffer due to decreasing oxygen
level in blood
Skin Color
• NOTE:
– cyanotic (blue)
• indicates that body systems are in critical state due to
an excessive amount of blood not carrying oxygen
– flushed (pink/red)
• harmful levels of carbon monoxide or increased carbon
dioxide levels are present
• Ketoacidosis (high blood glucose levels) will cause
flushing, as will hypertension (high blood pressure)
Stature & Build
• NOTE:
– large/small body frame
– obesity
– congenital anomalies (changes from normal at
birth)
Posture, Motor Activity
and Gait
• NOTE:
– deformities
– spine curvature
– gait
• shuffling
• stable
Dress, Grooming
and Hygiene
• NOTE:
– if appropriate
– clean
– neat
Odors
Body and Breath
• NOTE:
– breath for acetone odor (may be diabetic)
– alcohol odor (may be cause of problem)
– urine odor (incontinence)
– poor hygiene (emotional disturbances or social
issues)
Relationships,
Manner and Mood
• NOTE are they:
–
–
–
–
–
–
pleasant
smiling
making eye contact
initiating conversation
crying
appropriate
conversation
– following directions
–
–
–
–
–
depressed
anxious
agitated
elated
flat
Speech
• NOTE:
– clarity
– slurring
State of Awareness
and Consciousness
• NOTE, are they:
– alert
– oriented to:
• person
• place
• time and significant others
– drowsy
– is response time appropriate
Support or Monitoring
Devices
• NOTE, does the patient use a:
– walker
– wheelchair
– prosthesis
– hearing aid
– glasses
– dentures
– are these supports and devices working
properly and is the patient knowledgeable in
using them?
Facial Expressions
• NOTE:
– tension
– grimacing
– affect
• happy
• sad
• flat
Reporting Observed Data
– reporting should be done promptly,
accurately, and objectively
– identify need for emergency care
– may play role in treatment plan by others
– may indicate a need for medication changes
– to know if patient is improving or not
– documentation important for 3rd party
payment (Insurance)
Knowledge Assessment
• Compare and contrast objective and
subjective data and give examples of each.
• Define and give examples of when inspection,
auscultation, palpitation, and percussion are
used.
• Describe items of a physical assessment.
(Example skin color, stature and build)