The basic health assessment may include an interview and physical examination to determine functional, cultural, spiritual, and physical characteristics (Table 7-1). Basic health assessment may be the responsibility of many health care workers and is an ongoing process. The type and extent of assessment are determined by the role of the worker and the type of care being given. Some health care workers, such as the nurse assistant and licensed practical nurse, may collect data that will be analyzed and evaluated by another health care worker, such as the registered nurse.

TABLE 7-1

Physical Assessment

Assessment	Observations
Appearance	Physical, developmental, social development; general health; significant features; height, weight, posture; communication skills; grooming and hygiene
Hair	Color, texture, cleanliness, distribution
Nails	Color, texture, markings, shape, size
Skin	Color, temperature, turgor, lesions, mucous membranes, injury, edema
Neurological	Pupil reaction to light; motor and verbal responses; reflexes, gait, orientation
Musculoskeletal	Range of motion, gait, posture, injury
Cardiovascular	Heart rate and rhythm, peripheral pulses, temperature
Respiratory	Rate, rhythm, quality, breath sounds, sputum production or cough
Gastrointestinal	Abdominal contour, bowel sounds, nausea or vomiting, defecation frequency and consistency
Genitourinary	Urine color, amount, frequency, odor, clarity

The initial patient interview may include the health history, nature of the current complaint, and medication record. The medical or health history gathers subjective information about the patient’s health. The physical assessment uses techniques of inspection, auscultation, palpation, percussion, and smell (Table 7-2). Visual observations are used for inspection. Auscultation means listening to sounds, often with a stethoscope (Fig. 7-1). Palpation is using the hands to observe structures by touch (Fig. 7-2). Percussion is striking the body to assess the sound made (Fig. 7-3). The patient is positioned according to physician orders and for comfort during assessment (Fig. 7-4). Information that is gathered during the initial or admission health assessment is used to develop a nursing care plan (see Fig. II-3 in Appendix II on pp. 587−588). (See Skill List 7-1, Admitting, Transferring, and Discharging the Patient; and Skill List 7-2, Recording Observations, pp. 125−126).

TABLE 7-2

Characteristic Odors *

Area	Smell	Possible Cause
Mouth	Alcohol	Drinking alcohol
	Bad breath (halitosis)	Poor dental hygiene, gum disease
	Fruity, sweet	Diabetes acidosis, medication
	Feces	Intestinal obstruction
	Acid breath	Peptic ulcer
	Rotten eggs, garlic	Cirrhosis, medication
	Ammonia	Kidney failure
Rectal area	Feces	Incontinence
Skin (under arms and breasts)	Foul, body odor	Poor hygiene, excessive sweating
	Stale urine	Uremic acidosis
Skin (under cast)	Musty	Infection
Tracheostomy	Sweet, fetid	Bacterial infection (pseudomonas)
Urine	Ammonia	Urinary tract infection
	Foul	Urinary tract infection
Vomit	Feces	Bowel obstruction
Wound site	Feces	Abscess
	Sweet, heavy	Bacterial infection (pseudomonas)

^*Odor may also be due to food eaten, medication, and hygiene practices.

Case Study 7-1

While giving daily care to a patient, you notice the odor of alcohol from the patient’s mouth. What should you do?

Answers to Case Studies

are available on the Evolve website: http://evolve.elsevier.com/Gerdin

Vital Signs

Vital signs or life signs are values that can be used to measure changes in body function, general health, and the response to treatment. Vital signs include blood pressure (BP) and temperature, pulse, and respiration (TPR). The value of vital signs is affected by many factors, including age, activity, nutrition, emotion, fitness, medication, and illness. Height (ht), weight (wt), and fluid balance or intake and output (I&O) also may be used to assess the patient.

Vital signs are ordered with different frequency depending on the type of service being provided. Common orders for assessment include twice a day (bid), three times a day (tid), four times a day (qid), or routinely once a day (qd). Vitals may be ordered at regular intervals such as every 4 hours (q4h) or every 15 minutes (q15m).

Case Study 7-2

You notice a patient is scratching her arm repeatedly while you complete daily care. What should you do?

Answers to Case Studies

are available on the Evolve website: http://evolve.elsevier.com/Gerdin

Blood Pressure

Blood pressure (BP) is a measurement of the force of the blood against the walls of the arteries as it circulates through the body. It reflects the effort the heart exerts to circulate the blood to the tissues. Two units or values for BP are measured: the maximum pressure at which the pulse can be heard (systolic) and the minimum pressure at which it is audible (diastolic). The systolic reading occurs while the ventricles of the heart are contracting. The diastolic reading occurs during relaxation of the ventricles. Instruments that are used to determine the blood pressure are the stethoscope and sphygmomanometer (Fig. 7-5). The stethoscope amplifies the sound. The sphygmomanometer is an inflatable cuff that uses air (aneroid) or a liquid to measure pressure. Automated cuffs may be used to measure BP using the radial artery of the wrist (Fig. 7-6). Mercury is no longer used in thermometers because of its environmental and safety risks, but sphygmomanometers containing mercury are still in use.

FIGURE 7-5 The brachial artery is found to determine the correct placement of the stethoscope.

Blood pressure varies greatly among people. It is affected by the diameter and flexibility (elasticity) of the blood vessels, force of the heart contraction, and amount of blood in the vessels. Pressure on the area of the brain that controls BP can also change its value. Limits of the usual blood pressure for most individuals have been set. “Normal” blood pressure is commonly said to be 120/80 (systolic/diastolic) (Box 7-1). The range of BP is acceptable with a systolic pressure less than 119 and a diastolic pressure less than 80. (See Skill List 7-3, Taking a Blood Pressure, pp. 126–127).

BOX 7-1

Recommended Blood Pressure Levels

Normal value	119/79 or below
Prehypertension	120-139/80-89
High	140/90 or above

From the Joint National Committee (JNC7) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, DHHS, 2003.

Brain Byte

According to the CDC, about a fifth of the people with high blood pressure do not know it.

Case Study 7-3

You are taking vital signs on patients during morning rounds. You assess a blood pressure of 184/144 for one patient. What should you do?

Answers to Case Studies

are available on the Evolve website: http://evolve.elsevier.com/Gerdin

Temperature

Temperature is the measurement of the balance between the heat produced and lost by the body. Several methods are used to measure temperature. They include the mouth (oral), armpit (axillary), rectum (rectal), ear (temporal), and by infrared radiation (Fig. 7-7). Temperature may be measured with the Fahrenheit or Celsius (Centigrade) scale. The normal reading for temperature depends on the location used to assess it (Table 7-3). An elevation of temperature (fever) may indicate infection or inflammation in the body.

TABLE 7-3

Temperature

Method	Time	Normal
Oral	3 min*	97.6°-99.0° F (98.6° F = 37.0° C)
Axillary	10 min*	96.6°-98.0° F (97.6° F = 36.4° C)
Rectal	3-5 min*	98.6°-100.0° F (99.6° F = 37.5° C)
Temporal	*	96.4°-100.4° F (98.4° F = 36.9° C)
Infrared	*	97.6°-99.0° F (98.6° F = 37.0° C)

^*Time required to take temperatures may vary with the electrical instruments and is usually signaled by a sound from the device.

Several types of thermometers are available for measuring temperature. The most common type is made of glass with an expandable liquid filling. Glass thermometers are designed differently for oral or rectal use. The bulb of the rectal thermometer is rounded to prevent injury to the tissues of the rectum. The tip of the stem of the rectal thermometer is red, and that of the oral thermometer is blue or silver for easy identification (Fig. 7-8). Rectal thermometers should never be used in the mouth. Mercury thermometers are not commonly used because of environmental and health hazards resulting from the possibility of spilling mercury. Electronic and disposable chemical thermometers are used. (See Skill List 7-4, Taking an Oral Temperature; Skill List 7-5, Taking an Axillary Temperature; Skill List 7-6, Taking a Rectal Temperature; and Skill List 7-7, Taking an Infrared Temperature, pp. 127–130).

FIGURE 7-8 A, During the assessment of an oral temperature, the mouth should remain closed. B, Privacy is a primary consideration during assessment of the rectal temperature.

Pulse and Respiration

Pulse is the heartbeat that can be felt (palpated) on surface arteries as the artery walls expand. The pulse rate is usually counted using the radial artery near the wrist, but it may be found in other locations (Fig. 7-9).

The rate of the heartbeat must be adequate to supply blood and its nutrients to all parts of the body. The pulse of an infant is significantly faster than that of an adult (Table 7-4). The normal adult pulse rate can range between 60 and 100 beats per minute. In addition to the rate, it is important to assess the rhythm and character of the pulse. A regular rhythm is evenly paced. An irregular pulse may be fast or slow or may skip beats. Character, describing the force of the pulse, may be strong, weak, bounding, thready, feeble, or fleeting. (See Skill List 7-8, Taking a Radial Pulse and Measuring Respiration, p. 130).

TABLE 7-4

Pulse Ranges by Age Group

Age Group	Normal Pulse Rates (Beats/Min)	Abnormal Pulse Rates (Beats/Min)
Newborn	70-170
Infant	80-130
School age	70-110
Adult	60-100	<60 (bradycardia) >100 (tachycardia)

The pulse can be counted by listening to the heart through a stethoscope placed on the chest. This pulse is called an apical pulse (Fig. 7-10). The apical pulse may differ from the radial pulse in some conditions that affect the peripheral blood flow. (See Skill List 7-8, Taking a Radial Pulse and Measuring Respiration, p. 130).

FIGURE 7-10 Taking of an apical and radial pulse at the same time may be necessary with some circulatory disorders.

One respiration includes the inspiration and expiration of a breath. The normal rate for respiration is more rapid in infants than adults (Box 7-2). The rhythm and character of respiration are important observations. The rhythm of respiration describes its regularity. Character describes the depth and quality of the sound. Respirations that are difficult to see may be assessed by feeling the rise (expansion) and fall (contraction) of the chest or by using the stethoscope to listen for the respiratory or breath sounds.

BOX 7-2 Respiration in Adults

Rate per minute: 14-20

Rhythm: Regular

Character: Effortless, deep, quiet

Height and Weight

Health professionals use charts that are developed by insurance companies to determine healthy weight (Fig. 7-11). The insurance companies determine at which weight for a specific height an individual is predicted to live the longest (Fig. 7-12). According to the National Heart, Lung, and Blood Institute, an ideal weight is having a body mass index between 18.7 and 24.9 (Box 7-3). More information about weight and nutrition may be found in Chapter 8.