mod 4(2) 101

• Physical Appearance: AGE


  Normal: The patient appears his or her stated age
• Physical Appearance: SEX


  Normal: Sexual development is appropriate for gender and age
• Physical Appearance: LEVEL OF CONSCIOUSNESS


  Normal: The patient is alert, oriented, attends to questions and responds appropriately
• Physical Appearance: SKIN COLOR


  Normal: Color tone is even, skin is intact with no obvious lesions
• Physical Appearance: FACIAL FEATURES


  Normal: Facial features are symmetric with movement
• Physical Appearance: OVERALL


  Normal: No signs of acute distress present
• Body Structure: STATURE


  Normal: The height appears within normal range for age, genetic heritage
• Body Structure: NUTRITION


  Normal: The weight appears within normal range for height and body build; body fat distribution is even
• Body Structure: SYMMETRY


  Normal: Body parts look equal bilaterally and are in relative proportion to each other
• Body Structure: POSTURE


  Normal: The patient stands comfortably erect
• Body Structure: POSITION


  Normal: The patient sits comfortably in a chair or in the bed or examination table, arms relaxed at the sides, head turned to the examiner
• Body Structure: BODY BUILD, CONTOUR


  Normal: Arm span stretch your arms to the sides equals height
• Mobility: GAIT


  Normal: The base is as wide as the shoulder width; foot placement is accurate; the walk is smooth, even, and well-balanced; and associated movements, such as symmetric arm swing are present
• Mobility: RANGE OF MOTION


  Normal: Full mobility of each joint, movement is deliberate, accurate, smooth and coordinated. No involuntary, unpurposeful movement
• Behavior: FACIAL EXPRESSION


  Normal: The patient maintains eye contact, expressions are appropriate to the situation
• Behavior: MOOD AND AFFECT


  Normal: The patient is comfortable and cooperative with the examiner and interacts pleasantly
• Behavior: SPEECH


  Normal: The patient speaks clearly. The stream of talking is fluent, with an even pace. Word choice is appropriate
• Behavior: DRESS


  Normal: Clothing is appropriate to the climate, looks clean and fits the body, and is appropriate to age group
• Behavior: PERSONAL HYGIENE


  Normal: The patient appears clean and groomed appropriately for his on her age, occupation and socio economic group. Hair is groomed, brushed
• 4 Primary VITAL SIGNS

  • Temperature
  • Pulse
  • Respiration
  • Blood Pressure
• Body Temperature


  The balance between the heat produced by the body and the heat lost from the body
• Core Temperature


  Temperature of the deep tissues of the body. Measured by taking oral and rectal temperature

  
• Surface Temperature


  Temperature of the skin, subcutaneous tissue and fat. Measured by taking axillary temperature

  
• Factors Affecting Heat Production

  • Basal Metabolic Rate (BMR)
  • Muscle Activity
  • Thyroxine Output
  • Epinephrine, Norepinephrine and Sympathetic Stimulation
  • Increased temperature of body cells
• Processes involved in Heat Loss

  • Radiation
  • Conduction
  • Convection
  • Evaporation
• Factors Affecting Body Temperature

  • Age
  • Diurnal Variations
  • Exercise
  • Hormones
  • Stress
  • Environment
• Pyrexia


  Body temperature above normal range
• Hyperpyrexia


  Very high fever, 41ºc and above
• Hypothermia


  Subnormal core body temperature

  
• Types of Fever

  • Intermittent
  • Remittent
  • Relapsing
  • Constant
• Sites for measuring Body Temperature

  • Oral
  • Rectal
  • Axillary
  • Tympanic

  
• Oral Temperature


  Most accessible and convenient. Allow 15 mins. to lapse between a client's intake of hot or cold food or smoking. Shake the temp down to 35.5 C. Place under the tongue, directed towards the side. Wash before use, from the bulb to the stem. Take for 2-3 minutes
• Rectal Temperature


  Most accurate measurement. Lubricate before insertion. Insert by 0.5 – 1.5 inches. Instruct to take a deep breath before insertion. Hold in place for 2 mins. (neonates 5 mins). Do not force insertion
• Axillary Temperature


  Safest and most convenient method. Place the thermometer in the center of the armpit and hold the arm against the body for 5-10 minutes

  
• Types of Fever


  • Remittent - temperature fluctuates within a wide range over the 24 hour period but remains above normal range
  • Relapsing - temperature is elevated for few days, alternated with 1 or 2 days of normal temperature
  • Constant - temperature is consistently high. Could cause irreversible brain damage
• Sites for measuring Body Temperature

  • Oral
  • Rectal
  • Axillary
  • Tympanic

  
• Oral Temperature


  Most accessible and convenient. Allow 15 mins. to lapse between a client's intake of hot or cold food or smoking. Shake the temp down to 35.5 C. Place under the tongue, directed towards the side. Wash before use, from the bulb to the stem. Take for 2-3 minutes.
• Rectal Temperature


  Most accurate measurement. Lubricate before insertion. Insert by 0.5 – 1.5 inches. Instruct to take a deep breath before insertion. Hold in place for 2 mins. (neonates 5 mins). Do not force insertion.
• Axillary Temperature


  Safest and most non-invasive method. Pat dry the axilla. Place the arm tightly across the chest for 9 mins.
• Tympanic Temperature


  Useful with toddlers who squirm at the restraint needed for the rectal route. Useful for preschoolers who are not yet able to cooperate for an oral temperature and yet fear for the disrobing and invasion of a rectal temperature.