Health Assessment

• Temperature


  The core body temperature, measured internally, is approximately 37°C (98.6°F) and fluctuates approximately 1°C over the course of the day

  
• Body temperature


  A measurement of how hot the body is, can be measured from several different areas of the body
• Body temperature is lowest in the early morning and highest in the afternoon and evening. Women have a wider range of normal temperature than men
• Fever (Pyrexia)


  When body temperature is elevated
• Hyperpyrexia


  When temperature is at 41°C
• Afebrile


  When body temperature is normal, without fever
• Hypothermia


  Abnormally low temperature, below 35°C (95°F) rectally
• Types of Fever


  • Intermittent
  • Remittent
  • Relapsing
  • Constant
• Process of heat loss


  1. Radiation

  2. Conduction

  3. Convection

  4. Evaporation

  5. Elimination
• Factors that might alter core body temperature


  • Infection
  • Age
  • Temperature of the environment
  • Diurnal variations (circadian rhythms)
  • Amount of exercise
  • Metabolism
  • Trauma such as surgery or crush injuries
  • Malignancy
  • Drug reactions, and immune disorders
  • Hormones
• Oral temperatures


  Generally lower than the core body temperature, lower than rectal temperatures by an average of 0.4 to 0.5°C (0.7 to 0.9°F), and higher than axillary temperatures by approximately 1°
• Axillary temperatures


  Take 5 to 10 minutes to register and are considered less accurate than other measurements
• Tympanic membrane temperatures


  Can be more variable than oral or rectal temperatures
• Oral and temporal artery temperatures


  Correlate more closely with the pulmonary artery temperature, but are about 0.5°C lower
• Different types of Thermometer or Temperature Measurement


  • Oral temperature measurement
  • Axillary temperature measurement
  • Rectal temperature measurement
  • Temporal temperature measurement

  
• Clinical signs of fever


  • Onset (Cold or Chill Stage)
  • Course of Fever
• Pulse


  A wave of blood created by contraction of the left ventricle of the heart, a throbbing sensation palpated over a peripheral artery
• Peripheral Pulse


  Pulse located away from the heart, for example the foot, wrist, neck etc.
• Apical Pulse


  Central pulse, that is located in the apex of the heart
• Bradycardia


  Adult pulse rate below 60 beats/min
• Tachycardia


  Adult pulse rate above 100 beats/min
• Pulse rhythm


  Pattern of the beats and intervals between them
• Dysrhythmia/ arrhythmia


  Pulse with irregular rhythm
• Pulse volume


  Pulse strength or amplitude
• Pulsus regularis


  Equal rhythm
• Premature beat


  Beat that occurs between normal beats
• Heart rhythm


  Time interval between each heartbeat
• Assessment Parameters / Characteristics of Pulse


  • Rate
  • Rhythm
  • Volume/amplitude
• Pulse Deficit


  Difference between the apical and radial counts taken simultaneously
• Grading of pulses by amplitude


  • 0 absent
  • 1+ greatly diminished, feeble/ thready: difficult to feel & easily obliterated by pressure
  • 2+ slightly diminished, weak
  • 3+ normal
  • 4+ Bounding: felt by exerting only light pressure over artery
• Peripheral Pulses


  • Radial pulse
  • Temporal pulse
  • Carotid pulse
  • Brachial pulse
  • Femoral pulse
  • Popliteal pulse
  • Dorsalis pedis pulse
  • Posterior tibial pulse
• Apical Pulse


  Measured by listening over the apex of the heart on the left side of the chest, using a stethoscope
• Apical-radial pulse


  Used when patient has a cardiovascular disorder, done by two nurses simultaneously taking both pulses for one full minute
• Pulse deficit


  Difference between apical and radial pulses, radial pulse usually lower than apical; means some contractions of the heart are not so strong enough to push a wave of blood that can be felt at the radial site
• Factors that might alter pulse rate


  • Age
  • Gender
  • Exercise
  • Stress
  • Position changes
  • Application of heat or cold
  • Medications
  • Fever
  • Emotions
  • Hemorrhage
  • Heart disease
• Respiration


  The act of breathing, including inspiration (intake of air) and expiration (breathing out or the movement of gases from the lungs to the atmosphere)
• Eupnea


  Used to describe respirations that have normal rate and depth

  
• Dyspnea


  Breathing difficulty
• Cheyne-Stokes respirations


  A gradual increase and decrease in the rate and depth of respirations, usually including a period of apnea at the end of each cycle
• Normal respiration


  12-20 cpm, regular