Begins when first meet client

Physical appearance
Mental Status
Mobility
Behavior
Attention to detail - clues to problems
for further assessment
 General appearance: healthy, obvious
conditions
 Age: close to stated age
 Skin: color (variations), lesions
 Hygiene: cleanliness, grooming, odors
 Stature: height appropriate for age
 Nutritional status: well nourished,
cachectic, obese
 Symmetry: R/L sides similar
While client is responding to
questions and giving information
about history
Affect and mood
Level of anxiety
Orientation to person, place & time
Speech
Body movement
Gait
Posture
Range of Motion
Dress and Grooming
Body odors
Facial expression
Mood and affect
Ability to make eye contact
Level of anxiety
Ask client first before getting
measurements
Helps establish baseline data and
helps determine health status
Medication dosage calculation
Adult height attained between 18 and
20 years
Baseline indicators of a client’s health status
A change can indicate a change in
physiological function
Vital Signs:
T = Temperature
P = Pulse
R = Respiratory Rate
BP = Blood Pressure
O2 sat = Oxygen Saturation
Pain
Nurse’s responsibility/delegation
Knowledge of equipment
Knowledge of client’s range
Knowledge of client’s history and current status
Environmental factors
Systematic approach
Approach with the client
Frequency of assessment
Assessment for medications
Analysis and verification of results
Communication of results
Regulated by hypothalamus: heat gain vs.
heat loss
96.4° to 99.1° F (36.8° to 37.3° C)
98.6° F (37° C) core temp
Cellular metabolism most efficient
Stays relatively constant despite
environmental changes and physical
activity
Age
Diurnal variations:
Lowest in early morning (0100-0400),
higher in late afternoon/evening
(max @ 1800)
Menstrual cycle: temp  and persists until
ovulation (due to progesterone )
Exercise also increases temp (
metabolism)
Stress  temperature
Oral: glass, paper, or electronic thermometer
(normal 98.6F/37C)
Axillary: glass or electronic thermometer
(normal 97.6F/36.3C)
Rectal or "core“: glass or electronic
thermometer (normal 99.6F/37.7C)
Tympanic: electronic thermometer
(normal 99.6F/37.7C)

Of these, axillary is the least and rectal is the

most accurate.
Normal 97 – 99.9F
Delay 10 minutes if ingested hot/cold liquids
Electronic thermometer (sheathed): under
tongue, place in either right or left posterior
sublingual pocket (15-30 seconds)
Safe for children/confused adults
Don’t take oral temp if had oral surgery or
lesions
Normal 99.6F/37.7C
Probe covered, placed in external ear
canal; in contact with all sides of canal (2-
3 seconds)
Questionable reliability in children
(direction of beam)
Less than 3 years: pull down
Over 3 years: pull up
Adults: pull up and back
Normal 97.6F/36.3C
Common site for infants and children
Not close to major blood vessels
Low sensitivity to detect fever (febrile patients)
Electronic: middle of axilla with arms folded
Alternative site for those with oral inflammation,
wired jaws, oral surgery, mouth breathers
(nasal surgery)
Normal 99.6F/37.7C (.7 to .8o higher)
Used less frequently with newer methods
Used more common in comatose or seizing clients
Do not use if client had rectal surgery, hemorrhoids
or lower GI disorders
Adults: less comfortable, more time, increased risk
of infection
Sims’ position
1.5 inches into rectum (electronic)
Children: last resort
1 inch
Newborns, Infants:  risk of rectal perforation
½ inch
Shake down, verify
Insert cover, position properly
Wait 2-3 minutes
Read correctly
2 opportunities
Pat the axilla dry if moist
Bulb is placed in the middle of the
axilla
Wait 6-9 minutes
Compare reading to oral (one degree
less than oral)
Wear gloves, water soluble lubricant
Position in Sims or lateral
Insert ½ to 1 ½ inches depending on
age
(½ infant; 1 child; 1-1 ½ adult)
Wait 2-3 minutes
Compare reading to oral (one degree
higher than oral)
Know how to document on flow sheet
Terminology:
Hyperthermia: very high fever
Febrile: fever
Hypothermia: low fever
Afebrile: no fever
Factors Affecting Temperature:
Diurnal variation
Menstrual cycle
Exercises
Stress
Valuable information about cardiovascular
system
Information regarding strength of the
pulse and perfusion of blood to various
parts of the body
Indirect reflection of heart contraction
Measure:
Rate: beats per minute
Rhythm: regularity (time between
beats)
Strength: volume of blood ejected with
each beat
Equality: comparison of same pulse in
opposite extremities by taking
simultaneously
Rhythm:
Regular rhythm
 Evenly spaced beats; 30” x 2; 15” x 4
Irregular rhythm
 Full minute
 Regularly irregular: regular pattern overall with
“skipped” beats
 Irregularly irregular: chaotic, no real pattern, very
difficult to measure rate accurately
Strength:
Bounding, strong, weak or thready
Pulse assessment sites:
Temporal
Carotid
Apical
Brachial
Radial
Femoral
Popliteal
Posterior tibial
Pedal
WHAT IS A NORMAL PULSE?
Adult: 60 to 100
Newborn: 120-170
1 year: 80-160
3 years: 80-120
6 years: 75-115
10 years: 70-110
 Average Pulse and Blood Pressure
in Normal Children

Age Birth 6mo 1yr 2yr 6yr 8yr 10yr

Pulse 140 130 115 110 103 100 95

Systolic BP 70 90 90 92 95 100 105

Most frequently measured
Arm is supported on a bed, chair or nurse’s arm
Wrist is extended (not bent)
Lightly compress tips of first 2 fingers against
radius, obliterate pulse initially, and then relax
pressure so pulse becomes easily palpable
For a regular pulse count for 30 seconds and
multiply by 2
Irregular pulse: count for a full 60 seconds
Apical pulse:
Auscultate for 1 minute
5th intercostal space midclavicular
line
Use stethoscope when assessing
Measure rate and rhythm
Brachial: located in groove
between the triceps and biceps
muscle medial to the biceps
tendon in the antecubital fossa
Carotid: located along the
medial edge of the
sternocleidomastoid muscle in
the lower third of the neck
Radial: Accurate count
Apical: 60 seconds
Apical/Radial: 60 seconds
2 opportunities for each
Know how to document on flow sheet
Factors affecting pulse:
 with exercise, fever, stress
 with males, age, athletes
Terminology:
Pulse sites
Rate: beats per minute
Rhythm: regularity (time between beats)
Pulse deficit: difference between radial and
apical
Bradycardia: < 60 bpm
Tachycardia: > 100 bpm
Exchange of O2 and CO2: oxygen reaches body
cells and carbon dioxide is removed from the
cells
Respiration involves:
Ventilation: the movement of gases in and out of
the lungs
Diffusion: the movement of oxygen and carbon
dioxide between the alveoli and the red blood cells
Perfusion: distribution of red blood cells to and from
the pulmonary capillaries
 Best done immediately after taking the
patient's pulse. Do not announce that
you are measuring respirations.
 Without letting go of the patients wrist
begin to observe the patient's breathing.
Is it normal or labored?
 Count breaths for 30 seconds and
multiply this number by 2 to yield the
breaths per minute.
 In adults, normal resting respiratory rate
is between 14-20 breaths/minute.
Note the rate, rhythm, depth and effort of
breathing
Rate = number of ventilatory cycles
(inhalation and exhalation) per minute
Males: diaphragmatic (abdominal)
Females: thoracic
Rhythm = regularity of breathing (equal
space between breaths)
Regular or irregular
Depth = observation of excursion
(movement) of chest wall
Deep (large amount of air)
Normal
Shallow (small amount of air)
Effort: even, quiet, effortless
Accurate count (best for 30 sec.)
2 opportunities
Document on flow sheet
Factors affecting respiration:
 with exercise, fever, stress,
altitude
Varies with age
Terminology:
Rate: number of ventilatory cycles (inh + exh)
Rhythm: regularity of breathing (reg or irreg)
Depth: observation of excursion (movement of
chest wall) deep or shallow
Effort: even, quiet effortless
Tachypnea: fast
Bradypnea: slow
Apnea: no breathing
Dyspnea: difficulty breathing
Orthopnea: diff lying
Retractions: intercostals or substernal
Force of blood against arterial wall
Relationship between cardiac output and
peripheral resistance
BP dependent on blood volume, velocity,
vessel elasticity
Measured in mm Hg: height of mercury column
from blood pressure
Systolic: maximum pressure on arteries
during ventricular contraction (ejection)
Diastolic: minimum pressure on arteries
during ventricular relaxation
BP = CO x R
BP= blood pressure
CO=cardiac output (heart rate x stroke vol)
R = Peripheral vascular resistance
Resistance refers to the resistance to blood
flow determined by the tone of vascular
musculature and diameter of blood vessels
As resistance rises, arterial BP rises
As vessels dilate and resistance falls, BP
decreases
Recorded = systolic/diastolic (not a
fraction)
Pulse pressure: difference between
systolic and diastolic pressure 120/80=40
(usually 30- 40 mm Hg)
Direct: arterial catheterization
Indirect measurement
Sphygmomanometer and stethoscope
(auscultation)
NIBPM: electronic sensing of vibrations,
not Korotkoff sounds
Factors that affect BP measurements:
Age: gradual rise
Gender: females  males after puberty;
females  males after menopause;
Race: HTN 2x higher in African Amer
Diurnal variations: in early am; highest in late
afternoon or early evening
Emotions: anxiety, stress or anger can 
Pain: acute pain can 
Personal habits: caffeine and smoking within
30 minutes before taking may 
Weight: obese have 
Medications
Upper arm most common site; thigh alternate site
(10-40 mm higher)
Blood flow occluded by inflated cuff
Cuff deflated until sounds of pulsing blood return
(1st Korotkoff sound); systolic pressure
 Clear, rhythmic, thumping sound, increasing
intensity
2nd, 3rd, 4th Korotkoff sounds –
swishing/thump/muffled-low pitch sound
Pressure at which no sound heard indicates artery
completely open (5th Korotkoff sound); diastolic
pressure
Phase 1: sharp thuds, start at systolic blood
pressure
Phase 2: blowing sound; may disappear
entirely (the auscultatory gap )
Phase 3: crisp thud, a bit quieter than phase 1
Phase 4: sounds become muffled
Phase 5: end of sounds -- ends at diastolic
blood pressure
Common errors in BP measurement
Accuracy affected by technique
Research finds that providers incorrect
technique results from lack of
knowledge
False high/low measurements
Many errors due to wrong cuff size
False-high BP measurement:
Arm above level of heart
Cuff too narrow
Cuff too loose
Deflating cuff too slowly
Reinflating cuff without completely
deflating
Not waiting 1-2 minutes before repeat
measure
False-low BP measurement:
Arm below level of heart
Manometer higher than heart
Cuff too wide
Not inflating cuff enough
Deflating too rapidly
Pressing diaphragm too firmly on
brachial artery
Normal: <120/<80
Prehypertensive: 120-139/80-89
Stage 1 hypertension: 140-159/90-99
Stage 2 hypertension: >160/>100
 Position the patient's arm so the antecubital
fold is level with the heart. Support the
patient's arm with your arm or a bedside table.
 Center the bladder of the cuff over the
brachial artery approximately 2 cm above the
antecubital fold. Proper cuff size is essential
to obtain an accurate reading. Be sure the
index line falls between the size marks when
you apply the cuff. Position the patient's arm
so it is slightly flexed at the elbow.
 Palpate the brachial or radial pulse and inflate
the cuff until the pulse disappears. Inflate an
additional 20 mmHg higher and release cuff
until you can again feel the pulse. This is a
rough estimate of the systolic pressure.
 Place the stethoscope over the brachial artery.
 Inflate the cuff to 30 mmHg above the
estimated systolic pressure.
 Release the pressure slowly, no greater than
5 mmHg per second.
 The level at which you consistently hear beats
is the systolic pressure.
 Continue to lower the pressure until the
sounds muffle and disappear. This is the
diastolic pressure.
 Record the blood pressure as systolic over
diastolic ("120/70" for example).
With fingers palpating radial or brachial artery, inflate
cuff rapidly until you can't feel the pulse, then 20 mm
higher
Release cuff at 2 to 3 mm Hg per second until you
again feel the pulse; this is the palpable systolic
pressure
Wait 30 seconds before measuring blood pressure
Measuring palpable pressure first avoids risk of
seriously underestimating blood pressure
Wash hands, clean stethoscope
Position patient
Obtain correct size BP cuff (40% width or 2/3 (80%)
length)
Palpate brachial artery
Center bladder over artery
Wrap cuff securely, 1 inch above AC
Inflate cuff 30 above last heard or palpated
systolic
Release valve slowly
Correct interpret readings (2 chances) within
4mmHg
Document on flow sheet
 Factors affecting BP:
  with age, after menopause, African Amer, in the
PM, emotions, pain, caffeine, smoking, weight
  after puberty and in the AM
 Cuff size, medications, choice of arm
 Terminology:
 Systolic: top # (ventricle contracting)
 Diastolic: bottom # (ventricle filling)
 Pulse pressure: difference between systolic and
diastolic
 Orthostatic hypotension: drop in BP as you stand
 When and why to avoid a certain arm:
Mastectomy
IV fluids or blood infusing
Burns
AV Grafts
 Signs and symptoms of hypertension:
HA
Flushing
Ringing in the ears
Nose bleed
 Signs and symptoms of hypotension:
Increased heart rate
Dizziness
Cool
Clammy
Included with vital signs
Pulse oximetry: oxygen saturation of
hemoglobin
Probe on fingertip (other sites)
Digital readout
Saturation levels less than 90%
necessitate further evaluation
Caregiver’s knowledge deficiency in
measurement and interpretation reported
COLDSPAT
Character
Onset
Location
Duration (constant or intermittent)
Severity (On 0-10 scale)
Precipitating Factors
Alleviating Factors
Treatment