Nursing 202

• 1) Measure height, weight, BP and TPR
• 2) Provides an exam gown; ask pt if he/she needs assistance, otherwise repect pt privacy
• 3) Wash hands before having contact with the pt
• 4) Explain each step
• 5) Give encouragement as you proceed
• 6) Organize the exam for optimal efficiency and patient comfort
• 7) Use a systematic approach so as not to forget anything
• 8) Give a summary of findings and give an opportunity for questions

• 1) Physical Appearance
• - age
• - sex
• - skin
• - facial features
• - signs of acute distress
• - personal hygiene

• 2) Body Structure
• - stature
• - nutrition
• - symmetry
• - posture
• - position
• - body build and contour
• - physical deformities

• 3) Mobility
• - gait
• - ROM

4) Metal Status and Behavior

• 1) normal ranges (e.g. B/P, P, R)
• 2) client's recent values and serial reading (e.g. daily weights for fluid monitoring in heart failure)
• 3) diagnosis (e.g. with cancer, you may expect the pt to be underweight)

• 1) remove shoes and heavy clothing
• 2) take serial weights

• 1) overeating or decreased activity
• 2) fluid volume excess
• - 2.2 pound weight gain
• - more than 2-3 lbs/wk is significant (may be related to heart failure)
• 3) hypothyroidism (slows metabolism)
• 4) Drug therapy
• 5) diabetes

• 1) Anorexia or decreased intake
• 2) dehydration
• 3) increased metabolic rate
• 4) diabetes (new onset or poor control)
• 5) malignancy, etc.

• 1) diurnal cycle (1-1.5 F change)
• - peak: late afternoon (4 pm)
• - trough: early am (4 am)
• 2) menstrual cycle (temp increase 0.5- 1.0 starting at midcycle ovulation through menses due to progesterone secretion
• 3) moderate/heavy exercise
• 4) age
• - children under 8 yo have high fevers with minor illness (e.g. 103-105 F)
• - older adults (increased risk for hypothermia)
• 5) illness
• 6) prolonged exposure to cold

• Oral: 98.6 F (range- 96.4-99.1)
• 37 C ( range- 35.8-37.3)
• rectal: 1 F or 0.5 C higher than oral
• tympanic: 1 F or 0.5 C higher than oral
• axillary: 1 F or 0.5 C lower than oral

101-101.5 F or 38-38.5 C

• 1) Oral temp(use blue tip probe)
• - insert at base of tongue (sublingual pocket)
• - wait 15 minutes after hot/cold fluids, 2 min after smoking
• 2) Rectal (use red tip probe)
• - insert 1 in (use lubricant)
• 3) tympanic (use tympanic ear tip)
• - unreliable with ear infection or local inflammation (tooth)
• 4) axillary (use red tip probe)

pulse increases with inspiration and decreases with expiration (common in children and young adults)

apical pulse, then radial count x 1 min

• bradycardia <60 bpm
• tachycardia >60 bpm

• 1) age (higher in children)
• 2) female
• 3) exercise
• 4) anxiety
• 5) pain
• 6) fever
• 7) dehydration
• 8) anemia

• pulse deficit: difference between apical and radial pulse
• - a healthy heart the apical rate should be the same as the radial rate.
• - if the apical rate is higher than the radial rate, then this indicates a cardiac arrhythmia

pulse strength: force created in the artery by the stroke volume

• 4+ bounding
• 3+ full (norm during exercise)
• 2+ normal
• 1+ weak, thready
• 0 absent

• 1) assess rhythm
• - if rhythm is regular: count for 30 sec and multiply by 2
• - if the rhythm is irregular: count for 60 seconds
• - children: count for 60 seconds
• 2) rate (varies with age and fitness)
• - children: age specific variations
• - adult norms: 10-20/min
• 3) depth
• - shallow, moderate, or deep.
• 4) Character
• - thoracic (women)
• - abdominal (men and infants)
• 5) abnormal patterns (hyperventilation, hypoventilation, apnea, dyspnea, etc.)

• blood pressure: force exerted against walls of peripheral vessels during cardiac cycle
• systolic pressure: maximum pressure exerted on arterial walls during ventricular contraction
• pulse pressure: difference between systolic and diastolic B/P
• mean arterial pressure: (pressure forcing blood into the tissues averaged over the cardiac cycle)
• - MAP= DPB + 1/3 pulse pressure

• 1) Cardiac Output
• 2) Volume of Circulating Blood
• 3) Blood viscosity (increased pressure with thicker blood)
• 4) Peripheral Vascular Resistance (PVR)- increased pressure is generated to pump against constricted blood vessels.
• 5) sympathetic nervous system stimulation (stress--->stimulates SNS---> vasoconstriction--> increased blood pressure)
• 6) elasticity of vessels walls (increased pressure with stiffer vessels; occurs with arteriosclerosis)

• prehypertension: SBP 120-139; DBP: 80-89
• hypertension: SBP more than or equal to 140; DBP more than or equal to 90

less than 130/80

• - document B/P until the diagnoses is mad; requires serial B/Ps to establish the diagnosis of HTN
• - check B/P in both arms (use the highest reading)

• 1. Age
• 2. Male gender
• 3. Race (e.g. African Americans)
• 4. Diurnal Rhythm: highest in late afternoon and lowest in early am
• 5. Obesity
• 6. Exercise
• 7. Emotions, stress and pain (stimulation of SNS)
• 8. Smoking (wait 30 min before taking B/P)
• 9. ETOH
• 10. Meds (NSAIDS, pseudoephedrine [decongestants]
• 11. white coat syndrome

use the highest B/P reading

If present, there can be an unusually long silence (ranging from 10-40 mm) between the 1st and 2nd heart sound.

• Normally the difference in SBP between inspiration and expiration = 5 mm Hg
• paradoxical pulse: If the difference is > then 10 mm Hg
• -this could mean cardiac tamponade, constrictive pericarditis or great respiratory effort (emphysema)

• a significant drop in blood pressure that occurs when changing positions (from standing to sitting to standing)
• - results from peripheral vasodilation w/o compensatory increase in CO
• - check B/P and pulse when lying, then reassess B/P and pulse in sitting and
• standing positions..
• - wait 5 minutes between position changes before rechecking B/P and pulse

a drop in SBP >20 mm Hg or pulse increase of >20 bpm between lying, sitting and or standing positions

• 1) hypovolemia (dehydration)
• 2) bedrest
• 3) medications (vasodilators)