Health Assessment: Vital Signs, Blood Pressure, Respiration and Skin Assessment

**[Health Assessment Week 3]** **Vital Signs** According to the American Heart Association (2024), stage 2 is a systolic of 140 or higher or a diastolic of 90 or higher. The diastolic reading, or bottom number, is the pressure in the arteries when the ventricles are at rest. The difference betwe...

**[Health Assessment Week 3]** **Vital Signs** According to the American Heart Association (2024), stage 2 is a systolic of 140 or higher or a diastolic of 90 or higher. The diastolic reading, or bottom number, is the pressure in the arteries when the ventricles are at rest. The difference between systolic and diastolic pressure is the pulse pressure. The pressure in the aortic arch is not measured with blood pressure. The pressure during heart contraction is systolic pressure. Vital signs include temperature, pulse, respirations, blood pressure, and oxygen (O2) saturation, and are essential for assessing basic physiological functioning. Accurate measurement of vital signs is crucial, and these readings are often the basis for problem-solving in patient care. Nurses should take vital signs: - upon admission - as ordered by a provider - before and after surgical or diagnostic procedures - before and after medications affecting cardiovascular or respiratory functions - when the client\'s condition changes - during specific interventions, like ambulation or tracheal suctioning While normal ranges for vital signs will be provided, it\'s important to remember that they may vary between individuals and situations, such as with athletes or those with chronic conditions. Holistic assessment is key to determining the normal range for each client.  Temperature measures the balance between heat production and loss. The hypothalamus in the brain regulates body temperature, ensuring this balance. Temperature is recorded in Fahrenheit (F) or Celsius (C), based on location and facility policy. It can be taken using various methods, and it's important to follow the manufacturer\'s instructions for device use, calibration, and cleaning, as baseline temperatures vary by site. Pulse is the rhythmic movement caused by the expansion and contraction of arteries, linked to the heart\'s ejection of blood. An adult\'s normal pulse rate ranges from 60 to 100 beats per minute, with an average of around 80. The radial and carotid arteries are the most common sites for pulse assessment, with the carotid being best for quick checks in emergencies. Pulses should be counted for one minute for accuracy, or for 30 seconds multiplied by 2, or for 15 seconds multiplied by 4 for quicker assessments. The force of the pulse is rated as follows: 3+ (full, bounding) 2+ (normal) 1+ (weak, thready) 0 (absent).  The respiratory cycle consists of two parts: inspiration and expiration, regulated by the medulla oblongata. An increase in metabolism raises the body\'s oxygen demand and respiratory rate, which for adults ranges from 12 to 20 breaths per minute, with some sources noting 10--20 as normal. The depth of respiration is about 500 milliliters of air per breath, varying by individual size and age. Normal respiration is regular and quiet, with occasional sighs being typical. Healthcare providers should assess the rate, depth, quality, and rhythm of breathing, as well as observe for signs like obstructed airways, cyanosis, restlessness, and abnormal sounds. The ideal time to check respirations is right after measuring the pulse to avoid affecting the client\'s breathing patterns. Tachypnea- A rapid respiration rate above 20 respirations per minute is called tachypnea. Exercise and fever can increase respiratory rate.  Bradypnea- A slow respiratory rate below 12 respirations per minute is called bradypnea. Hyperventilation- Is when the rate of ventilation exceeds normal metabolic requirements for exchange of respiratory gases. For example, during emotional trauma, volume and depth of respirations increase.  Hypoventilation- Occurs when the rate of ventilation entering the lungs is insufficient for metabolic needs. Respiratory rate is below normal and depth of ventilation is depressed. Blood pressure measures the force of blood circulated by the heart, represented by two numbers: the systolic (high number) and diastolic (low number). The systolic pressure reflects the pressure during heart contractions, while the diastolic indicates pressure when the heart is relaxed. The difference between these readings is the pulse pressure, with a normal value being around 40 (e.g., 120/80 mmHg). To obtain a blood pressure reading, a cuff is placed around the upper arm and inflated to occlude blood flow. Using a stethoscope, the systolic pressure is noted when the pulse first becomes audible as the cuff deflates, and the diastolic pressure is recorded when the pulse is no longer heard. **Blood Pressure Considerations** The placement of the cuff depends on where the nurse is taking the blood pressure. The most common site is the upper arm. There are certain situations in which the upper arm site is contraindicated:​​ - in an arm that has intravenous (IV) fluids running​​ - in an arm with an arterio-venous (AV) graft or fistula for dialysis​​ - on a limb with a traumatic injury, burn, or cast - on the same side where breast or lymph node dissection surgery has been performed  Social determinants of health can have a significant impact on vital signs. Food insecurity, environmental factors, economic stability, and access to healthcare all determine health status. People in communities with poor social determinants of health are more likely to have abnormal vital signs, particularly abnormal blood pressure and pain.​ It is important to identify social determinants of health that may impact vital signs and include these in the nursing assessment. Here are some specific things that can create health disparities:​ food insecurity​ - housing insecurity​ - financial insecurity​ - reduced access to health services​ - drinking water contamination​ - household and outdoor air quality  **Infants** Infants and children can have unstable temperature regulation due to immature physiological mechanisms and body surface area. They have a much higher resting pulse rate that decreases with increased age. They have lower blood pressures that increase with age. Tips for collecting vital signs in infants and children: Palpate or auscultate apical pulse for children younger than 2 years. Count for a full minute. Measure respiratory rate accurately when the infant is sleeping. Count for a full minute. Routine blood pressure measurements are not usually taken until after age 3. **Women** Women generally have greater variations in body temperature than men due to hormonal changes during ovulation and menopause. During pregnancy, blood pressure and pulse rate can change due to increased blood volume. As the uterus enlarges during pregnancy, the chest wall configuration widens. It is more difficult to take deep breaths and respiratory rate may increase to compensate. **Older Adults** With advanced age, the body temperature measurement is lower. A body temperature of 95 degrees is not unusual. Elderly individuals can have increased sensitivity to temperature extremes due to deteriorating control of the mechanisms. Irregular rhythms are more common as arrhythmias develop due to common conditions in older adults like hypertension and atherosclerotic vascular disease. Respirations may be shallow or increased due to deteriorating lung function. As the arteries age, the vessels become stiff and narrowed thus causing increases in both blood pressure and pulse pressure (systolic -- diastolic blood pressure). **When to Notify** Notify the Provider - If a client has a high or low vital sign finding, first verify the abnormal finding and the normal ranges for the client, then notify the provider if: ​ - there is an increase in baseline temperature because this indicates infection - an absent pulse is confirmed by Doppler - shortness of breath or abnormal breathing pattern​ presents - a new onset of hypertension or hypotension presents - an oxygenation saturation is below 90% despite interventions - pain exceeds the client\'s pain intensity goal - Any time the provider is notified, make sure that the findings are confirmed first and that you document all the information necessary for the provider to select an evidence-based intervention.  **Skin and Nails** **Lifestyle Choices That Affect the Integumentary System​** **Diet​** Lean proteins, essential fats, iron, whole grains, fruits, and vegetables all support healthy skin, hair, and nails. ​ Water consumption helps the body get rid of toxins and hydrates the skin. ​ Some foods and drinks can aggravate skin conditions or cause reactions. It is important to be aware of triggers if a skin condition does exist. **Occupation​** Many chemicals are readily absorbed through the skin. According to the Centers for Disease Control and Prevention (CDC, 2022), absorption of chemicals can cause skin disorders, including rashes, cancers, and infections, as well as enter the circulation, causing organ damage. High-risk occupations are cosmetology, healthcare, agriculture, cleaning, painting, mechanics, printing/lithography, and construction.​ **Hobbies** There are hobbies that expose people to mechanical trauma, extreme temperatures, biological entities, and chemical agents.​ Exposures to these materials can irritate or damage the skin, hair, and nails.​ **Smoking** Nicotine accelerates the aging process and exaggerates the appearance of wrinkles.​ Smoking discolors light-colored facial hair, fingers, and fingernails. ​ **UV Exposure​** UV exposure damages the skin and causes premature wrinkles and skin cancer. ​ The damage from UV exposure is cumulative and increases your skin cancer risk over time. ​ The integumentary system: - is the largest organ system of the body and includes the skin, hair, and nails - protects against trauma and infection - allows for perception, identification, and communication of emotions - helps the body adjust to changes in both internal and external temperatures - heals wounds - absorbs and excretes some metabolic wastes - produces vitamin D - Tools needed to assess the skin, hair, and nails include strong direct lighting, a small centimeter ruler, a penlight, and gloves. A magnifying glass may be needed if examining a suspicious lesion. **Color and Pigmentation​** Assess the skin for melanocyte content and consistency. Changes may be associated with genetic makeup or ultraviolet (UV) light exposure. The inside of the upper arm, which is rarely exposed to UV, is most representative of a person's baseline, or normal, skin tone.​ Evaluate for such things as cyanosis, erythema, and pallor. Watch for subtle skin tone changes. Inspect mucous membranes, lips, nail beds, and sclera for discoloration​.​ **Turgor** Turgor refers to the elasticity of the skin. The skin should be able to change shape and return to normal. To assess turgor, pinch the skin gently and release. The skin should promptly return to normal. If the skin remains "pinched," this could indicate dehydration and is termed "tenting." The best placement for this assessment varies by age. In the elderly, turgor is best assessed near the clavicle, in infants, the skin over the abdomen is the preferred location, and in all other patients, the skin on the dorsal portion of the hand is acceptable. **Moisture​** Note if client is anxious or hot, as that may cause diaphoresis. Touch several areas on the body with the palmar surface of your hand to assess for moisture, particularly in skin folds and other areas that may trap perspiration.​ **Integrity** Examine the skin for any breakdown, color variations, or moles. Note color, elevation, shape, size, location, and distribution on the body. Include the color, odor, consistency, and amount of any exudate. **Temperature​** Exposed skin should be warm or slightly cool. Note if there are extremes in the skin's temp. The temperature of the skin is often assessed when assessing moisture.​ According to the Skin Cancer Foundation (2022): - Skin cancer is the most common cancer​. - One in five people in the United States will develop skin cancer before the age of 70​. - More than two people die of skin cancer in the U.S. every hour. - Having five or more sunburns doubles your risk for melanoma. - When detected early, the 5-year survival rate for melanoma is 99 percent. - Squamous cell carcinoma, basal cell carcinoma, and melanoma are all types of skin cancer. - Melanoma is much less common than other types but is much more likely to invade nearby tissues and spread to other parts of the body. Most deaths from skin cancer are caused by melanoma. **Inspection: Nails** The nails and nail beds should be​: - free of clubbing​ - pink and white in color​ - free of infection​ - The nails should be assessed for shape, consistency, and color. Examination of the nails will give insight into possible systemic illnesses and overall grooming. **Yellowing of nails** Yellowing of nails is caused by cigarette use​. **Cyanotic nailbeds** Cyanotic nailbeds are caused by lack of oxygen to extremities​. **Jagged nails with torn cuticles** Jagged nails with torn cuticles might indicate nail-biting caused by stress and anxiety. **Nail clubbing** Nail clubbing is associated with heart and lung diseases. **Fungal nail infection** Fungal nail infection, or onychomycosis, causes nails to discolor, thicken, crack, and break. **Developmental Influences** Infants Infants lack subcutaneous fat and body hair. Therefore, they cannot prevent fluid loss or protect against temperature changes. Pregnancy Hormones cause pigment changes. Birthmarks, moles, and freckles may darken. ​ Stretching of the abdominal skin will result in striae (stretch marks). Older Adults Thinning of skin and loss of subcutaneous fat results in decreased temperature regulation, decreased protection from injury, and increased skin tears.​ The skin also decreases in elasticity, giving a loose appearance. **Genetic Influences on the Skin** Skin color is determined by the density and distribution of melanin, which is produced by melanocytes. Melanin density is determined by environmental and genetic factors and determines an individual's skin tone. High melanin density displays a darker skin tone, whereas low melanin density shows a lighter skin tone.​ High melanin density from genetic inheritance is protective against damage caused by sunlight (ultraviolet light \[UV\] exposure). This protection extends to some skin cancers, which increase with UV exposure. Artificially increasing melanin density by deliberate exposure to UV light (sunbathing or using a tanning bed) will increase skin cancer risk.​ Review the table shown here for facts about skin conditions and melanin distribution. ​​ Skin Condition Low Melanin Density High Melanin Density Hereditary Link ---------------- --------------------------------------------------- ----------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------- Skin Cancer More affected by UV exposure More natural protection; cancer less prevalent but, if discovered, more advanced cancer Several genes are linked to skin cancer. Age Spots More visible Less visible Variants in several genes regulating melanin increase the risk of developing age spots. Eczema More issues on skin creases where the joints meet Infants more likely to develop the condition in the first 6 months Recent research has suggested it is linked to a gene mutation. Acne Prevalent Prevalent but more prone to inflammation and hyperpigmentation No particular gene is identified, but the risk of acne as an adolescent is higher if both parents had it. Keloids Less prevalent Higher incidence Genetics play a major role in keloid development. ​**Common Skin Lesions** It is important to learn some basic language to describe lesions and rashes. In recording your findings, you should describe lesions as follows:​ - single or multiple​​ - raised, flat, or pus-filled​​ - distributed in a line or circle​​ - associated symptoms such as itching  Plaque Palpable, \> 10 mm in diameter, elevated or depressed -- example: psoriasis Bullae Clear, fluid-filled blisters \> 10 mm in diameter -- example: severe burns  Pustules Pus-filled vesicles -- example: acne​ Vesicles Clear, fluid-filled blisters \< 10 mm in diameter -- example: herpes  Papules Elevated, palpable, \< 10 mm in diameter -- example: wart Wheal Wheal: Elevated, palpable, irregular of varying size and color -- example: hives​  Macule Flat, nonpalpable, \< 10 mm in diameter -- example: freckles​ Nodule Firm papules extending into underlying tissue -- example: lipoma **Health Education** It is always important to assess risk factors and educate clients on how to care for the integumentary system. Educate clients about: - limiting sun exposure between the hours of 10 am and 3 pm​ - wearing broad hats, sunglasses, and protective clothing when in direct sun or seeking shade​ - using sunscreen with at least 30 SPF​ - staying hydrated by drinking enough fluids and using moisturizer​ - using gentle skin care products to remove dirt, germs, and dead cells​ - checking their skin for changing moles - scheduling an annual exam with a dermatologist - eating a diet rich in vegetables, fruits, whole grains, and lean proteins​ - refraining from smoking since this contributes to wrinkles - decreasing stress to reduce breakouts and hives​ - getting good sleep to allow the skin to heal​ - refraining from unsanitary tattooing or piercings **Nursing Application: Skin and Nails** The nurse uses the **ABCDEF mnemonic** to assess Tonia's mole. The dermatologist examines the mole as well and takes a biopsy. During the assessment, enlarged lymph nodes are palpated.  **A**symmetry​ Most melanomas are asymmetrical.​ **B**order​ Melanoma borders are uneven with scalloped or notched edges​. **C**olor​ Melanoma may have shades of brown, tan, or black. As it grows, the colors red, white, or blue may also appear​. **D**iameter​ It is a warning sign if the mole is greater than 6 mm​. **E**volving​ Changing size, shape, color, elevation, or feeling (burning, itching) may indicate melanoma.​ **F**unny Looking ​The lesion looks different than the other skin lesions the client has may indicate cancerous changes associated with melanoma.