Vital sign Assessment Flashcards
first steps when you enter the room
Wash Hands NOD ID Client Bed Brakes Bed Rails Working Height Privacy
4 Observation Steps
Physical
Body Structure
Mobility
Behavior
Physical Observation
Age : As Stated
Sex: Appropriate for age and gender
LOC: Alert, oriented
Skin Colour: Even tone, no abnormal pigmentations, lesions, color appropriate for ethnicity.
Facial Features : Symmetrical with movement
Distress: Are they in distress
Body Structure Observation
Stature: Height within range for age and genetic heritage
Nutrition: Weight within normal range for height and body build
Symmetry: Body parts equal bilaterally, relative proportion to each other
Posture: Standing or sitting comfortably. Ear, shoulder, Hip patella and ankle in line
Position: comfortably, eye contact.
Body Build: Appropriate proportions, body length proportional from crown to pubis, Pubis to sole.
Mobility Observation
Gait: Base width equal to Shoulder width, accurate foot placement, well balanced walk.
ROM: Full Mobility in each joint.smooth ,accurate, deliberate movements
Behavior Observations
Facial Expressions: Eye Contact,Expressions correct for situation.
Mood and Affect: Comfortable, cooperative.
Speech: Clear, understandable, articulate,
Dress: Appropriate for climate and occupation
Hygeine: Appearance clean, well groomed, makeup, appropriate for age, culture.
Temperature Range and Factors
35.8 - 37.3
Exercise
Age
Menstrual Cycle
Pulse Range/Force/ Rhythm &Factors
60- 100 BPM +2
+1+2+3
caffeine
Excercise
Stress
Respirations Rate/Factors/Type
10-20 Breaths per Min
thoracic
anxiety, smoking, Excercise
O2 Stats Range (for COPD as well )and factors
97%-100%
92%-100%
COPD : 88% - 92 %
Smoking, Cold fingers during examine any lung disease
Blood Pressure range and factors
135/85
Weight
Stress
Sex ( after puberty woman have lower BP generally.)
