Online Companion: Fundamentals of Nursing Standards and Practice 2E

Chapter Summary

In Chapter 27, the student learns about the cognitive and technical skills nurses use to gather data on the client'’ physiologic functioning. Measuring vital signs and doing a physical examination are common assessment activities in all clinical settings. The vital signs that are routinely measured are the client’s body temperature (T), the pulse (P), respirations (R), and the blood pressure (BP). It is important to establish baseline values of the client for each vital sign so that the client’s “normal” measurements can be compared with variations that may indicate potential problems. The physiologic basis for temperature regulation, respiration and hemodynamic function are reviewed in the chapter as prelude to describing the mechanisms that result in variation from normal values. Age is a factor that influences vital signs; age-related variations in each vital sign are presented in Chapter 27. The nurse gathers the equipment used to measure vital signs, selecting type and size according to individual client factors. The detailed procedure for measuring each vital sign is described and the rationale for each step is given. The prompt and accurate documentation of vital signs is an important nursing action.

The physical examination is used to gather specific, pertinent assessment data about the client's physiologic functioning. The data are also used to identify risk factors in the client to determine areas of preventive nursing. The exam is done in a sequential, head-to-toe fashion to assure that each body system is assessed. At the beginning of the exam, the nurse is prepared to proceed in an organized manner, gives the client information and reassurance and provides for privacy, comfort and safety in the environment. The general survey assesses any specific discomfort or distress the client is experiencing; the client's overall appearance, ability to move freely, and to communicate are carefully observed. The vital signs, height and weight are routinely measured before the exam begins. This general survey also provides a time period in which the nurse can establish a beginning relationship and rapport with the client. The nurse uses the senses of sight, hearing, smell, and touch when gathering information during the physical exam. The techniques of inspection (sight and smell), auscultation (hearing), percussion and palpation (touch) are used to examine the client.

Beginning at the head, the nurse proceeds systematically to examine the neck, the chest, axillae and breast areas, the sounds from the lungs and heart are auscultated, using the head-to-toe sequence. The details of exam techniques, normal and abnormal findings are described for each system in Chapter 27. The nurse observes carefully for the client's fatigue during the exam and may need to offer a rest period. The nurse records data during the exam. After the exam, the nurse assesses the client for comfort or other needs, disposes of soiled articles in a proper container, and thanks the client for his cooperation. A complete documentation note and reporting of pertinent data completes the procedure.