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ASSESSING GENERAL STATUS AND VITAL Hyperthermia – higher than 38.0 C or 100 F (seen in
SIGNS viral or bacterial infxn, malignancies, trauma, and
various blood, endocrine, and immune disorders.
- The client’s vital signs are the body’s
indicators for health. Older adult temperature: range from 95.0°F to 97.5°F.
- Usually when a vital sign (or signs) is Therefore, the older client may not have an obviously
abnormal, something is wrong in at least one elevated temperature with an infection or be
of the body systems. considered hypothermic below 96°F.
- Provides data that reflects the status of the
Conversion of Temperature
several body systems.
• Fahrenheit to Celcius
Vital Signs:
• F = 9/5 ( C ) + 32
- Pulse
- Respirations • Celcius to Fahrenheit
- Blood pressure
- Temperature • C = 5/9 ( F – 32 )
- Pain – fifth vital sign PULSE
Note: Measure the temperature first, followed by pulse, • A shock wave is produced when the heart
respirations, and blood pressure. contracts and forcefully pumps blood out of
TEMPERATURE the ventricles into the aorta.
• The shock waves travels along the fibers of the
- For the body to function on a cellular level, a arteries and is commonly called the arterial
core body temperature between 36.5 C to 37.7 peripheral pulse.
C (96 F to 99.9 F) must be maintained. • Types of Pulses:
- It can be taken in different anatomic sites and • Carotid
none are completely accurate. • Brachial
- Factors causing normal variations in body • Apical/ Central Pulse
temperature: • Radial Pulse
o Exercise • Femoral
o Stress • Popliteal
o Ovulation • Posterior Tibial
o Body temp is lowest early in the • Pedal pulse (dorsalis pedis)
morning (4:00 to 6:00 am) and highest
at night (8:00 pm to midnight) PULSE ASSESSMENT
• sitting or supine position
Hypothermia – body temp lower than 36.5 C or 96 F
Assessment:
(seen in prolonged exposure to cold, hypoglycemia,
1. Rate
hypothyroidism, or starvation).
-number of beats/minute
Dianna Rose O. Belen, RN, LPT NCM 101 HEALTH ASSESSMENT 2018
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• 60 -100-normal • taken by two nurse or 1 nurse only

• Pregnant -90 but not greater than 100 • -normal pulse deficit = 0
• Less than 60 -bradycardia (near death, late sign • - if w/ deficit -bleeding or obstruction
of shock, elderly)
• Tachycardia BLOOD PRESSURE
• Greater than 100 -force or pressure exerted on arterial wall every
• 1st Manifestation - exercise, bleeding, contraction of the heart
anxiety, constipation/diarrhea, anger

2. Rhythm
• pattern of beats/ regularity of beats
• Regular or Irregular/ Arrythmia / Dysrhytmia
(skip beats, smoking)
• Note: for cardiac patient & initial Assessment:
• take PR for 1 full minute; for normal client
& successive taking of PR -15 seconds x 4
• 3. Amplitude/ Volume/Depth -Strength of
heart contraction ; force of blood with each
beat; For peripheral pulse only

Grading of Pulse Strength

• 0 - absent; dead
• 1 - weak; thready; feeble (EASY TO
OBLITERATE)
• 2 - normal pulse; pulse can be easily taken
(OBLITERATE WITH MODERATE
PRESSURE)
• 3 - full, increased pulse
• 4 - bounding, strong/ bounding ((UNABLE
TO OBLITERATE
OR REQUIRES FlRM PRESSURE)
FACTORS AFFECTING BP
4. Equality- both pulses/ present on both sides of the
• Age
body
• Stress
5. Elasticity-reflects expansibility or its deformities
• Exercise
- Normal-smooth, straight, soft, and pliable. • Race
• Obesity
PULSE DEFICIT - difference between apical and • Gender = Females – lower after puberty but
radial pulse taken simultaneously higher after menopause
Dianna Rose O. Belen, RN, LPT NCM 101 HEALTH ASSESSMENT 2018
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• Medications
• Diurnal variations – lower in am and higher in
afternoon
• Disease process

2 COMPONENTS OF BP

• Systole - heart contraction

• Diastole - heart relaxation
• Normotensive - systole of less than 120 mm
Hg and diastole of less than 80 mm Hg.
Errors in BP Taking
• Hypotensive – Systole less than 90 mmHg;
• Arm unsupported
diastole less than 60 mmHg
• Insufficient rest before assessment
• Hypertensive – Systole greater than 140
• Assessing immediately after smoking, in pain
mmHg; diastole less than 60 mmHg
or meal
• Failure to use the same arm consistently-
Pulse Pressure
inconsistent measurements
• PULSE PRESSURE
• Failure to identify auscultatory gap-low
• - difference between systolic and
systolic and low diastolic
diastolic pressure
• Repeating Assessment too quickly- low
Normal PP: 30-40 mm HG
diastolic and high systolic

Assessing Orthostatic Hypotension

Identifying Korotkoff’s Sounds
- P1- sharp tapping sound—SYSTOLE
- P2-muffled, swooshing, or swishing
- P3- thumping but softer than P1
- P4-muffled, soft blowing
- P5- last sound to be heard followed by silence-
DIASTOLE
Pointers in Taking BP
RESPIRATION
• results from peripheral vasodilation causing
blood to leave central/organs such as brain,
heart towards the periphery
• Place client in supine position for 2-3 mins
• Take BP & RR
• Assist client to sit or stand
• After 1 min, take BP or PR
• PR increase of 40 beats/min & drop of 30 mm
Hg in BP results to abnormal orthostatic vital
signs

• --the act of breathing (automatic/effortless)

• --controlled by:
Dianna Rose O. Belen, RN, LPT NCM 101 HEALTH ASSESSMENT 2018

(a) respiratory centers in the
medulla oblongata and pons
(b) chemoreceptors located centrally
in medulla and peripherally in the carotid and aortic
bodies
TYPES OF BREATHING
• Costal/thoracic-uses external intercostals
muscles and other accessory muscles such as
sternocleidomastoid muscles; can be observed
by upward and outward movement of the chest
• Diaphragmatic/abdominal- involves the
contraction and relaxation of the diaphragm
observed by movement of the abdomen
• Pursed Lip Breathing-inhale and exhale in
pursed lip; prolongs EXPIRATION to expel
excess CO2 in the lungs; for patient with
COPD
ASSESSMENT OF RESPIRATION
1. Rate- number of respiration per minute
Terminologies
• EUPNEA-normal breathing
• TACHYPNEA- quick, swallow breaths
• BRADYPNEA-slow breathing
• APNEA-absence of breathing
• Note: for bradypnea—never give narcotic
analgesics- cause CNS and respiratory
depression
2. Rhythm- regularity or pattern of Respiration
Dianna Rose O. Belen, RN, LPT NCM 101 HEALTH ASSESSMENT
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• -HYPERVENTILATION - overexpansion of
the lungs characterized by rapid and deep
breaths (air hunger)
• -HYPOVENTILATION- under expansion of
the lungs characterized by shallow, slow
respirations.
• -Kussmaul respiration - rapid breathing, a type
of hyperventilation
• -Cheyne Stokes Respiration- rhythmic waxing
& waning of respiration from very deep to
very swallow and temporary apnea
• -Biot’s Respiration- period of Normal
breathing (3-4 breaths) followed by a varying
period of apnea (10 sec-1minute)
• -Apneustic Respiration-prolonged inhalation
followed by short exhalation
-CNS problem, asthma
3. Character/ Quality-aspects of breathing that are
different from normal, effortless breathing
-DYSPNEA-difficulty breathing
Mngt: Semi fowler’s or High Fowler’s
-Orthopnea- DOB when lying; common in patients
with asthma and emphysema;
Mngt: Orthopneic Position
• 4. Breath Sounds
• Stridor- shrill harsh sound heard during Inspiration
caused by laryngeal spasm, edema or obstruction
• Wheeze- musical, squeaky, whistling sound caused
by narrowing of bronchioles during EXPIRATION
initially
• Stertor- snoring or sonorous respiration usually due
to a partial obstruction of the upper
airway/common in obese and back rolling of the
tongue
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Mngt: lateral position to facilitate drainage

of secretions
• Postop patients-supine with head turn to sides or
hyperextended
• Bubbling-gurgling sounds heard as air passes
through Moist secretions in the respiratory tract
• Rales/crackles-soft high pitch sound, discontinuous
popping sounds that occur during inspiration
• Rhonchi- sound produced resulting from
excessive mucus; pneumonia
• Pleural Friction Rub-harsh crackling sound like
two pieces of leather being rubbed together

Dianna Rose O. Belen, RN, LPT NCM 101 HEALTH ASSESSMENT 2018