Health Skills I

Unit 102Vital Signs

Objectives

• Identify observational techniques for determining the health status of a patient.

Unit 102.1Observational Techniques

• Observation of Patient– observe physical signs and alertness– listen to patient and ask questions

Objective Data

• can be observed or tested by healthcare provider

• overt, not concealed• Examples:– observe that a patient refused to eat– measure an increased temperature– observe drainage from a wound– skin is warm to the touch– vomited 300 cc

Subjective Data

• information perceived only by the affected person

• Examples:– feels nervous– pain in the abdomen– nauseated– feels chilled

Senses to Collect Data

• Look – observe visible signs that indicate a problem

• Listen – patient’s complaints, description of the

problem in their words• Feel – degree’s in body temperature, pulse quality

• Smell– unusual odors

Collecting DataInspection

• visual examination – signs of movement and posture– skin color signs of distress– ability to maintain health practices (hygiene,

dress)– gait

Collecting Data Auscultation

• listening with use of a stethoscope– blood pressure– heart sounds and/or rate– lung sounds– bowel sounds– detecting bruits

Collecting Data Palpation

• examination of body parts through feeling with fingertips and hands to– assess skin temperature – determine pulse rate, quality,rhythm, absence or

presence– lumps/masses– abdominal tenderness/distention

Collecting Data Percussion

• tapping body parts with your fingers and listening to sounds produced to– detect presence of air– evaluate amount of fluid in a body cavity– determine size, borders and consistency of body

organs or masses

Purpose of Systematic Physical Assessment

• to determine physical and emotional changes through step by step observation

• NOTE:– apparent state of health, does patient seem

acutely ill?

Signs of Distress

• NOTE:• dyspnea (difficulty breathing)• vomiting • pallor • pain• crying• evidence of nervousness

Skin Color

• NOTE:– pink

• indicates adequate oxygen levels

– pallor (pale)• major organs being challenged with fluid or blood

loss, peripheral blood is being shunted to the core of the body to self protect them

– ashen (gray)• body systems begin to suffer due to decreasing

oxygen level in blood

Skin Color

• NOTE:– cyanotic (blue)

• indicates that body systems are in critical state due to an excessive amount of blood not carrying oxygen

– flushed (pink/red)• harmful levels of carbon monoxide or increased

carbon dioxide levels are present • Ketoacidosis (high blood glucose levels) will cause

flushing, as will hypertension (high blood pressure)

Stature & Build

• NOTE:– large/small body frame– obesity– congenital anomalies (changes from normal at

birth)

Posture, Motor Activityand Gait

• NOTE:– deformities – spine curvature– gait• shuffling• stable

Dress, Grooming and Hygiene

• NOTE:– if appropriate– clean– neat

OdorsBody and Breath

• NOTE:– breath for acetone odor (may be diabetic)– alcohol odor (may be cause of problem)– urine odor (incontinence)– poor hygiene (emotional disturbances or social

issues)

Relationships, Manner and Mood

• NOTE are they:– pleasant – smiling – making eye contact – initiating conversation – crying – appropriate

conversation – following directions

– depressed – anxious– agitated– elated– flat

Speech

• NOTE:– clarity– slurring

State of Awarenessand Consciousness

• NOTE, are they: – alert– oriented to:• person• place• time and significant others

– drowsy – is response time appropriate

Support or Monitoring Devices

• NOTE, does the patient use a:– walker – wheelchair– prosthesis– hearing aid– glasses– dentures– are these supports and devices working

properly and is the patient knowledgeable in using them?

Facial Expressions

• NOTE:– tension– grimacing– affect• happy• sad• flat

Reporting Observed Data

– reporting should be done promptly, accurately, and objectively

– identify need for emergency care– may play role in treatment plan by others– may indicate a need for medication changes – to know if patient is improving or not– documentation important for 3rd party

payment (Insurance)

Knowledge Assessment

• Compare and contrast objective and subjective data and give examples of each.

• Define and give examples of when inspection, auscultation, palpitation, and percussion are used.

• Describe items of a physical assessment. (Example skin color, stature and build)