Vital Signs/Health Assessment Outline
Lecture by:
Maggie Keil MNe, RN
Objective Four: Vital Signs/Basic Physical
Exam

Taylor: Pages 418-452 and 456-503
Vital Signs
Baseline Values
Frequency
 Recording
 Assessing Body Temperature
 Assessing Respirations
 Assessing Pulse And Blood Pressure


Vital Signs

Baseline Values

Frequency

Recording
Assessing Body Temperature

Definitions

Methods Of Heat Loss

Factors Affecting Body Temperature

Factors That Affect Body Temperature Measurement

Body Temperature Variations

Nursing Diagnosis For Altered Body Temperature
Methods Of Heat Loss
Factors Affecting Body Temperature

Circadian Rhythms

Age

Gender

Stress

Environmental Temperature

Exercise
Factors That Affect Body Temperature
Measurement

Oral Temp Assessment

Rectal Assessment

Tympanic (ear) Assessment

Axillary Assessment

Farenheit=(9/5xC) +32 degrees

Celsius=(F-32 degrees) x 5/9
Body Temperature Variations

Normal Body Temperature

Increased Body Temperature
Body Temperature Variations

Decreased Body Temperature
Nursing Diagnosis For Altered Body
Temperature

Risk For Altered Body Temperature

Hyperthermia

Hypothermia

Ineffective Thermoregulation
Assessing Respirations
Definitions
Regulation of Respirations
 Factors Affecting Respirations
 Nursing Diagnoses for Altered Respirations


Definitions

Pulmonary Ventilation

Inspiration

Expiration

External Respiration

Internal Respiration

Circulation

Diffusion

Transport
Regulation Of Respirations

Body demands
Factors Affecting Respirations

Age

Lifestyle

Meds

Pain

Postural Changes

Gender
Factors Affecting Respirations

Respiratory Rate:

Eupnea

Tachypnea

Bradypnea

Respiratory Rhythm/Depth:

Hypoventilation

Hyperventilation
Patterns Of Respiration
Respiratory Rhythms/Depth

Costal Breathing

Diaphragmatic (abd) Breathing

Apnea

Dyspnea

Orthopnea

Cyanosis
Nursing Diagnosis For Altered Respirations

Impaired Gas Exchange

Ineffective Airway Clearance

Ineffective Breathing Pattern

Inability to Sustain Spontaneous Ventilation
Assessing Pulse And Blood Pressure

Cardiovascular Status

Stroke Volume

Cardiac Output

Compensatory Mechanisms
Assessing Pulse
Definition
Regulation of Pulse
 Factors Affecting Pulse Rate


Definition

P u ls e
Regulation Of Pulse

Autonomic Nervous System
Factors Affecting Pulse Rate

Tachycardia

Bradycardia

Pulse Rhythm
Factors Affecting Pulse Rate
Assessing Blood Pressure
Definitions
 Regulation of Blood Pressure
 Variations in Blood Pressure

Definitions

Blood Pressure

Systolic Pressure

Diastolic Pressure

Pulse Pressure

Pulse Deficits
Regulation Of Blood Pressure

Peripheral Resistance

Pumping Action of Heart

ANS

Cummulative-inc. BP factors

Blood Volume

Viscosity of Blood

Elasticity of Vessel Walls

Korotkoff Sounds-Pressure Dynamics
Korotkoff Sounds-Pressure Dynamics
Variations in Blood Pressure

Age

Normal Fluctuation

Gender

Lifestyle

Eating

Size

Pain

Emotions

Position/Race/Meds
Variations In Blood Pressure (Sites)
Variations in Blood Pressure-Hypertension
Variations In Blood Pressure
Nursing Considerations
Variations In Blood Pressure-Nsg
Considerations
Variations In Blood Pressure

Hypotension

Orthostatic Hypotension
Nursing Diagnoses For Pulse And Blood
Pressure

Altered Tissue Perfusion

Risk for Fluid Volume Imbalance

Fluid Volume Excess

Fluid Volume Deficit

Decreased Cardiac Output
Website

American Heart Association
www.americanheart.org
Physical Assessment

Health History

Guidelines for Physical Assessment
Health History

Chapters 15 and 21
Websites:


American Cancer Society:
www.cancer.org

Breast Cancer Network

www.breastcancer.net
Guidelines for Physical Assessment

Where Performed

When

Purpose

Types Of Assessments

Instruments
 P o s itio n in g
Guidelines For Physical Assessment
(Continued)

Draping

Preparing Environment

Techniques:

Inspection

Palpation

Percussion

Auscultation
Guidelines For Physical Assessment
Guidelines For Physical Assessment

Sexual History

Older Adults

Cultural Values and Assessment

Disabled Clients

Abused Client’s

Data Documentation
Have A Nice Day
Mrs. Keil!