HEALTH ASSESSMENT

vital signs - Important/essentials

- Signs that reflect the patient's health status

4 Vital signs
 Body Temp
 Pulse
 Respiration
 Blood Pressure
 (+) Pain - Joint Commission

Is Vs taking an automatic/routine procedure?

NO
 it should be a scientific and thoughtful assessment

When and how ofteh should VS be monitored? According to Doctor's Orders?

NO
 it should be within the nurses professional judgement
 based on the health status

Moments for vs taking:

 admission - to establish baseline data
 interventions - before, during and after
 Medication - to assess drug effects
 surgery/invasive procedure
 status changes

Nursing Abbre
qd - every day
qod - every other day
bid - twice a day
tid - thrice a day
qid - 4x a day
qh - Every Hour
stat - At once
hs - hours of sleep/ at bed time
ac - before meal
pc - after meal
prn - as needed
L - Left
R - Right
B - Both
S - w/o
c- with
ss- one half
dc - discontinue
gtt - drops
ugtt - micro
noct - at night
npo - non per orem
sob - shortness of breath
tpr - temp, pulse and respi
ad lib - as much as needed
Rx - Prescription
Sx - Surgery
Dx - Diagnosis
CA - Cellular Aberration
ROM - range of motion
ROME - Range of motion exercises
PROME - Passive range of motion exercises
AROME- Active range of motion exercises

BODY TEMPERATURE
 balance between heat loss and heat production in the body
TYPES OF TEMP
Core Temperature
 true temperature
 internal temperature - it reflects the temp of internal organ
Surface Temperature
 pseudo temperature
 external temperature : reflects the temp of skin and muscles

FACTORS AFFECTING TEMP

B Basal metabolic rate (BMR) : Energy consumption : HEAT
E Exercise : Muscle Activity
S Sex - Female - Hormones
T - Thyroxine - (T3/T4) : Hyperthyroidism

F - Fever : Protective response

R - Reactions (extreme)
E - Environment
A - Age : new born - immature hypothalamus
Elderly
N - Nutrition
D - Diurnal Variation/Circadian Rhythm
S - Stress

HEAT TRANSFER
Radiation - transfer of heat from one surface to another : transfer through infrared race
(-) contact
Evaporation - Water Loss (TSB)
Conduction - molecular heat transfer
(+) Contact
Convection - AIR drafts/current

ASSESSMENT SITES
Mercury thermometer
 toxic substance

Pyrexia / Hyperthermia
Fever : elevation of temp
Hypeepyrexia - High Fever 40 degree
Febrile - (+) fever
Afebrile - (-)

Types of Fever

Intermittent - N - AB - N within 24hrs

Relapsing - N - AB - N DAYS
Remittent - Wide Fluctuations
more than 2 degrees
Constant - Small fluctuations
less than 2 degrees

HYPOTHERMIA - below normal range

Causes :
 Excessive heat loss
 Inadequate heat production
 Impaired regulation
FROSTBITE - Lack of Circulation
 periphery/protrude
1. Fingers
2. Nose
3. Ears
4. Feet
MILD - Less than 4hrs : Nx: Blanket + Warm fluids
SEVERE - more than 4hrs : Nx: Hypothermia blanket + Warm IV
Classification of Frostbite
Grade 1 : Redness
Grade 2 : Blisters Formation
Grade 3 : Ulcer Formation
Grade 4 : Necrosis

PULSE
 Reflection of heart beat
 movement of blood / heart beat
PULSE
 Stroke volume - amount of blood per contraction
 Heart rate - number of contraction per minute
 Cardiac output (CO) - SV x HR : the amount of blood per minute : 4-6L/min
 Compliability - distensibility - ability of blood vessels to expand

Types of Pulse
 Peripheral Pulse - Pseudo pulse
 Temporal
 Maxillary
 Carotid
 Brachial
 Radial
 Femoral
 Popliteal
 Posterior Tibials
 Dorsalis Pedis

 Central Pulse - True pulse

 Apical pulse
 Left 4th-5th intercostal space
 mid clavicular line
 under the nipple ( anatomic position)

ASSESING PULSE
 Either through palpation or auscultation
 If Auscultating the Heart - Diaphragm
 If auscultating Peripherally - Bell
 If palpating - 2-3 fingers (index , middle ring) - bistal ends (P vibrations)

Apical Pulse