Islamic University of Gaza Faculty of Nursing

1. Islamic University of GazaFaculty of Nursing Chapter 6General Assessment Including Vital Signs

2. 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

3. Vital signs • Assessment of Temp., pulse, respiration and blood pressure are known as life signs. • Indicators of the body’s 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.

4. 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 .

5. 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.

6. 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.

8. 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.

9. 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.

10. 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 client’s sclera. • Erythema may indicate circulatory changes

11. Moisture of skin Moisture in the skin: related to the degree of client’s 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.

12. 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) • Normallyskin 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.

14. Edema: "Build up of fluid in tissues". • Edematous areas should be inspected for location, color, and shape. • Edemaseparates the skin’s surface from the pigmented and vascular layersmasking 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

15. 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.

16. 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 (الصدفية).

17. 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.

18. 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

19. 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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