Islamic University of Gaza Faculty of Nursing

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Islamic University of GazaFaculty of Nursing

• Chapter 6General Assessment Including Vital
  Signs

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Procedure

• Observe
• Behavior (cooperative or uncooperative).
• Mood steady or anxious.
• Appearance well dressed or dress bizarre or
  inappropriate.
• Body movements if there is coordinated, or
  uncoordinated, shaky and unsteady

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Vital signs

• Assessment of Temp., pulse, respiration and blood
  pressure are known as life signs.
• Indicators of the bodys physiologic status and
  response to physical, environmental and
  physiologic stressors.
• Temperature
• Rectal temp is the most accurate.
• Unless contraindicated as in a client with a
  severe cardiac arrhythmia, a rectal temp is often
  preferred.

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Vital signs cont.

• Pulse "60-80 b/m" regular
• Palpate the radial pulse count for at least "30"
  second.
• If the pulse is irregular, count for full minute.
• Note if the pulse is strong or weak, bounding or
  thready .

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Vital signs cont.

• Respiration "16-20/minute (for healthy adult
  person
• Count the number of respiration in full minute.
• Note rhythm and depth of breathing.
• Blood pressure
• Measure Blood Pressure in both arms.
• Palpate the systolic pressure before using the
  stethoscope
• Apply cuff firmly, if too loose it will give
  falsely high reading.
• Use cuff in appropriate size.
• Note position of client When measuring blood
  pressure.
• Monitor blood pressure after client is seated or
  supine quietly for "10" minute.

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Muscle assessment

• Assess muscle strength tone when doing Range of
  motion.
• Tone Muscular resistance felt by examiner as
  the relaxed extremity is passively moved through
  its range of motion.
• Ask client to relax or hang limb, support
  move it through Range of motion.
• Assess for increase tone hyper-tonicity or
  decrease tone hypo-tonicity.
• Strength of dominant side is more than non
  dominant, and it is normally for specific ratio.

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Assessment of general Appearance

• Body builds, posture and gait. Note proportion of
  height weight "Weight height 100 ---- /-
  10kg".
• Hygiene, grooming (Note cleanliness, body odors,
  appropriate dress for age and environment).
• Signs of illness. (Note posture, skin color,
  respirations, and nonverbal communications of
  pain or distress).
• Affect, Attitude, Mood. (Note speech, facial
  expressions, ability to relax, eye contact,
  behavior).
• Cognitive process. (Note speech content and
  patterns, orientation, appropriate verbal
  responses).
• Height and weight Weigh client without shoes,
  and without extra clothing.

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Assessment of skin, Hair, and nails

• Skin infection, rashes, lesions, itching.
• ( Precipitating factors stress, weather, drugs,
  exposure to allergens).
• Changes in skin color, lesions, and bruising.
• Amount of sun exposure (type of lotions used).
• Scalp lesions, itching, and infections.
• Changes in texture and amount of hair.
• Changes in nails and Nail breaking, and
  inflammation.
• The examination of skin includes, inspections
  of skin color, moisture, temperature, thickness,
  and turgor.
• Vascular changes, edema, and any lesions are
  noted.
• Skin odors are usually noted in the skin fold.

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Color of skin

• Varies from body part to body part and from
  person to person.
• Normal changes in skin color my occur with
  aging.
• Assessment first involves area of skin not
  exposed to the sun e.g. palms of the hands.
• Pallor easily perceived in the buccal mouth
  mucosa particularly in individuals with dark
  skin.
• Cyanosis seen in areas, e.g. lips, nail beds
  conjunctiva, and palm.
• Jaundice seen in clients sclera.
• Erythema may indicate circulatory changes

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Moisture of skin

• Moisture in the skin related to the degree of
  clients hydration and the condition of the outer
  lipid layer of the skin surface.
• Skin is normally smooth and dry.
• Skin folds e.g. axillae are normally moist.
• Assessment of skin done by palpation.
• In presence of skin lesions nurse must wear
  gloves to prevent exposure to infections.
• Temperature Temp of skin depends on the amount
  of blood circulating through dermis.
• Palpation of skin with dorsum of the hand.
• Assessment of skin is critical point in some
  conditions e.g. after cast application, or tight
  bandage, or after vascular surgery.

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• Texture Character of skin surface and the feel
  of deeper portion are its texture.
• Texture of skin normally smooth, soft and
  flexible. If any abnormalities in texture, ask
  the client if he exposed to any recent injury to
  the skin.
• Turgor Is the skin elasticity which can be
  diminished by edema or dehydration, (done by
  pinching skin between the thumb and forefinger
  and released)
• Normally skin return immediately to its position.
  
• Failure of this process means dehydration.
• Vascularity Assessment of circulation of skin.
  E.g. petechiae may indicate serious blood
  clotting disorders, drug reactions, or liver
  disease.

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• Edema "Build up of fluid in tissues".
• Edematous areas should be inspected for location,
  color, and shape.
• Edema separates the skins surface from the
  pigmented and vascular layers masking skin color.
  
• palpate areas of edema to determine mobility,
  consistency, and tenderness.
• lesions If lesion present, inspection must be
  done for color, location, size, shape, type,
  grouping, and distribution.
• N.B cancerous lesions frequently undergo changes
  in color and size

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Hair and Scalp

• Assess for lesions or lice are probable, the
  nurse wears disposable gloves to avoid infection.
  
• Types of hair covering the body
• - Terminal hair (long, coarse, thick) and easily
  visible on the scalp, axillae, and pubic areas.
• - Vellus hair (small, soft, tiny) covering the
  whole body except palms and soles.
• Assessment done for distribution, thickness,
  texture, and lubrication of the hair.
• Some events which affect the distribution of hair
  over the body e.g. client with hormone disorders,
  woman with hirsutism.

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Hair and Scalp cont.

• Normal color of terminal hairs black, red,
  yellow, or variations of these colors.
• Older men lose facial hair but older women may
  develop hair on chin and upper lip.
• Amount of hair covering extremities may be
  reduced as a result of aging and arterial
  insufficiency especially in lower limbs.
• Scaliness or dryness of the scalp is frequently
  caused by dandruff or psoriasis (???????).

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Nails Assessment

• Nails reflect an individual's general state of
  health, state of nutrition, and occupation.
• Vascularity of the nail bed creates the nails
  underlying color.
• Nails are normally transparent, smooth, and
  convex.
• The surrounding cuticles are smooth, intact and
  without inflammation.
• Nail bed is normally firm on palpation.
• Nails normally grow at a constant rate.
• Nail abnormalities Hemorrhage, transverse band,
  and abnormal thickness.

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Nails Assessment cont.

• N.B "vitamins, proteins and electrolytes changes
  can result in various lines or band forming on
  the nail beds".
• The color of nails is an indicator of blood
  oxygenation
• Bluish color means cyanosis.
• White or pallor means anemia.
• Palpation of the nails determines the adequacy of
  circulation or capillary refill.
• Calluses are commonly found on the toes or
  fingers

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Some Abnormalities of the nails

• Paronychia inflammation surrounding the nail.
• Anonychia complete absence of nail.
• Platunychia flatting of the nails.
• Kolilonychia nails spoon like shape.
• Racketnail flattened and expanded nails (signs
  of secondary syphilis).
• Onycholysis nails separated from nail bed.
• Leukonychia Totalis white nails (entire plate).
• Melanonychia brown color in nails plate.

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