HEALTH

ASSESSMENT
Introduction to Health
Assessment
(DOLORES L. ARTECHE, DSN)
A. Overview of Nursing Process
(ADPIE)
Nursing Process
a scientific method used by nurses to ensure the quality of
patient care.
 You wake up on Monday morning after a late night of studying
for your nursing exam, and you know that you’re going to need an
Assessment extra big cup of coffee. Because it took a little longer to brew,
you’re running 10 minutes late to class. You pour that delicious,
warm drink into your thermos, frantically throw it in your
backpack, and book it to school. When you finally make it to class,
you grab your computer out of your bag and open it up, but it
won’t turn on. What do you do first?

Well, first, you’re going to assess the situation (the “A” in ADPIE).

Why isn’t the computer turning on? Why is it all wet? And why is
your thermos empty and everything smells like coffee?
 Now the “D” in ADPIE stands for diagnosis, and
Diagnosis that brings us to our next step after gathering that
data.

“Well,” you say to yourself, “it seems to me from

all my evidence here, that my coffee must’ve
leaked out onto my computer, and therefore my
computer is not working because it has gotten
soaked with coffee!”
 Now that brings us to “P” in the acronym, which
Planning stands for planning.

When you look at your computer and have

figured out the cause, you now have to make a
quick plan. What are you going to do to fix the
problem? You decide here that you need to run to
get this computer fixed by a professional. “Let’s
see,” you think, “I have to call to see if the store
is open, make an appointment, find out if my
computer was backed up, leave school, take the
bus to 33rd street, walk two blocks…”
Implementation
Next comes the “I” in ADPIE;
the implementation portion of
the process.
Implementation is the action
part of your plan; where you
actually get up and bolt to the
computer store to fix this, fast!
 And finally, we evaluate; the “E” in the ADPIE
Evaluation nursing process.

As the final step, you are done carrying out your

plan, and here’s where you are waiting anxiously
at the computer store, and the person helping you
comes out to tell you, “Well my friend, it’s your
lucky day. It was almost too late, but we saved
your computer and it works like it’s brand new
again. Now, remember, keep liquids far away!”
 ASSESSMENT
 The first step of the nursing process is assessment.
 During this phase, the nurse gathers information about a
patient's psychological, physiological, sociological, and spiritual
status.
 This data can be collected in a variety of ways. Generally, nurses
will conduct a patient interview.
 Physical examinations, referencing a patient's health history,
obtaining a patient's family history, and general observation can
also be used to gather assessment data.
 Patient interaction is generally the heaviest during this evaluative
phase.
 DIAGNOSIS
 The diagnosing phase involves a nurse making an educated judgment
about a potential or actual health problem with a patient.
 Multiple diagnoses are sometimes made for a single patient.
 These assessments not only include an actual description of the
problem (e.g. sleep deprivation) but also whether or not a patient is at
risk of developing further problems.
 These diagnoses are also used to determine a patient's readiness for
health improvement and whether or not they may have developed a
syndrome.
 The diagnoses phase is a critical step as it is used to determine the
course of treatment.
 PLANNING
 Once a patient and nurse agree on the diagnoses, a plan of action can
be developed.
 If multiple diagnoses need to be addressed, the head nurse will
prioritize each assessment and devote attention to severe symptoms
and high risk factors.
 Each problem is assigned a clear, measurable goal for the expected
beneficial outcome.
 For this phase, nurses generally refer to the evidence-based Nursing
Outcome Classification, which is a set of standardized terms and
measurements for tracking patient wellness.
 The Nursing Interventions Classification may also be used as a
resource for planning.
 IMPLEMENTATION
 The implementing phase is where the nurse follows through on
the decided plan of action.
 This plan is specific to each patient and focuses on achievable
outcomes.
 Actions involved in a nursing care plan include monitoring the
patient for signs of change or improvement, directly caring for
the patient or performing necessary medical tasks, educating and
instructing the patient about further health management, and
referring or contacting the patient for follow-up.
 Implementation can take place over the course of hours, days,
weeks, or even months.
 EVALUATION
 Once all nursing intervention actions have taken place, the nurse
completes an evaluation to determine of the goals for patient
wellness have been met.
 The possible patient outcomes are generally described under
three terms: patient's condition improved, patient's condition
stabilized, and patient's condition deteriorated, died, or
discharged.
 In the event the condition of the patient has shown no
improvement, or if the wellness goals were not met, the nursing
process begins again from the first step.
B. Health Assessment in Nursing
Practice
Four Basic Types of Assessment:
• Initial Comprehensive Assessment
• On-going or Partial Assessment
• Focused or Problem-oriented Assessment
• Emergency Assessment
 Initial Comprehensive Assessment

 Collection of subjective data about the client’s perception of his

or her health of all body parts or systems, past health history,
family history, lifestyle, health practices as well as objective data
 On-going or Partial Assessment

 Consists of data collection that occurs after the comprehensive

database is established
 Focused or Problem-oriented
Assessment

 Performed when a comprehensive database exists for a client

who comes to the health care agency with a specific health
concern
 Emergency Assessment

 Rapid assessment performed in life-threatening situations

 C. Nurse’s Role in Health
Assessment
Evolution of Nurse’s Role in Health
Assessment
Late 1800s-Early 1900s
 Nurses relied on their natural senses
 Palpation was used to measure pulse rate and
quality and to locate the fundus of the
puerperal woman
1930-1949
 Documents routine client and
home inspection by public health
nurses
 Prevention of communicable
diseases, and routine use of
assessment skills in poor inner city
areas were performed
1950-1969
 Nurses were hired to
conduct pre-employment
health stories and physical
examination for major
companies
1970-1989
 Prompted nurses to develop
an active role in the
provision of primary health
services and expanded the
professional nurse role in
conducting health histories
and physical and
psychological assessments
1990-PRESENT
 Information - Health assessments are used by nurses to gather information about a patient's condition. This
information is used to formulate a nursing plan of care for the patient.
 Nursing Diagnoses and Care Planning - A nurse takes note of actual or potential problems her patient may
have during a health assessment. From the list of problems, she formulates diagnoses, which she uses to create a
care plan.
 Managing Problems - The nurse continuously does a health assessment on her patient to see if her care plan is
having the desired effect. If not, she makes changes to her care plan to address the patient's health problems.
 Evaluation - Evaluation of a patient's health status is done through health assessments. Evaluations determine if
a patient has responded to nursing care sufficiently enough to be recommended for discharge.
 Discharge Teaching - During a health assessment, a nurse may become aware that a patient is lacking
information that may help improve his condition. This provides the nurse with an opportunity to impart this
information before he is discharged.
 Advocate - When a nurse performs a health assessment, she may find a problem that requires the expertise of
other members of the health care team. In this case, the nurse notifies the proper health care team member of the
problem and makes sure the patient receives the expert care that they need. Here, she becomes an advocate for
her patient.
 Steps in Health Assessment
A. Collection of Subjective Data through Interview and Health
History
BIOGRAPHIC DATA
REASONS FOR SEEKING
HELP CARE
Chief Complaint
History of Present Illness
1. When did you first notice the pain in your back?
• How long have you experienced it?
• Has it become worse, better, or stayed the same since it first
occurred?
2. What does the pain feel like?
• Where does it hurt the most?
• Does it radiate or go to any part of your body?
• How intense is the pain?
• Do you have any other problems that seem related to this back
pain?
3. What do you think caused this problem to start?
4. What makes your back hurt more?
• What makes it feel better?
• Have you tried any treatments to relieve the pain?
5. How does the pain affect your life and daily activities?
6. What do you think will happen with this problem?
• Do you expect to get well?
• What about your job
• Do you think you will be able to continue working?
Past Health History
1. Can you tell me how your mother described your birth?
• Where there any problems?
• As far as you know, did you progress normally as you grew to
adulthood?
• Where there any problems that your family told you about or
that you experienced?
2. What diseases did you have as a child such as measles or mumps?
• What immunizations did you get and are you up to date now?
3. Do you have any chronic illnesses?
• When was it diagnosed?
• How is it treated?
• How satisfied have you been with the treatment?
4. What illnesses or allergies have you had?
• How were the illnesses treated?
5. Have you ever been pregnant and delivered a baby?
• How many times have you been pregnant/delivered?
6. Have you ever been hospitalized or had surgery?
• If so, when?
• What were you hospitalized for or what type of surgery did you
have?
• Where there any complications?
7. Have you experienced any accidents or injuries?
8. Have you experienced pain in any part of your body?
9. Have you ever been diagnosed with/treated for emotional or
mental problems?
• If so, please describe their nature and any treatment received.
• Describe your level of satisfaction with the treatment?
Family Health History
Current Medications
Review of Systems for Current
Health
Skin, Hair, and Nails
Head and Neck
Eyes
Ears
Mouth, Throat, Nose, and Sinuses
Thorax and Lungs
Breasts and Regional Lymphatics
Heart and Neck Vessels
Peripheral Vascular
Abdomen
Male Genitalia
Female Genitalia
Anus, Rectum, and Prostate
Musculoskeletal
Neurologic
Lifestyle
Description of Typical Day
• Please tell me what an average or typical day is for you?
Nutrition and Weight Management
• What do you usually eat during a typical day?
• Please tell me the kinds of foods you prefer, how often you eat
throughout the day, and how much you eat?
• Do you eat out at restaurants frequently?
• Do you eat only when hungry?
• Do you eat because of boredom, habit, anxiety, depression?
• Who buys and prepares the food you eat?
• Where do you eat your meals?
• How much and what types of fluids do you drink?
Activity Level and Exercise
• What is your daily pattern of activity?
• Do you follow a regular exercise plan?
• What types of exercise do you do?
• Are there any reasons why you cannot follow a moderately
strenuous exercise program?
• What do you do for leisure and recreation?
• Do your leisure and recreational activities include exercise?
Sleep and Rest
• Tell me about your sleeping patterns?
• Do you have trouble falling asleep or staying asleep?
• How much sleep do you get each night?
• Do you feel rested when you awaken?
• Do you nap during the day?
• How often and for how long?
• What do you do to help you fall asleep?
Medication and Substance Use
• What medications have you used in the recent past and currently, both
those that your doctor prescribed and those you can buy over the
counter at a drug or grocery store?
• For what purpose did you take the medication?
• How much and how often did you take the medication?
• How much beer, wine, or other alcohol do you drink on the average?
• Do you drink coffee or other beverages containing caffeine?
• Do you now or have you ever smoked cigarettes or used any other
form of nicotine?
• How long have you been smoking/ did you smoke?
• How many packs per week?
• Have you ever taken any medication not prescribed by your
healthcare provider?
• If so, when, what type, how much, and why?
• Have you ever used, or do you now use, recreational drugs?
• Do you take vitamins or herbal supplements?
Self-Concept and Self-Care Responsibilities
• What do you see as your talents or special abilities?
• How do you feel about yourself ? About your appearance?
• Can you tell me what activities you do to keep yourself safe,
healthy, or prevent disease?
• Do you practice safe sex?
• How do you keep your home safe?
• Do you drive safely?
• How often do you have medical checkups or screenings?
• How often do you see the dentists or have your eyes examined?
Social Activities
• What do you do for fun and relaxation?
• With whom do you socialize most frequently?
• Are you involved in any community activities?
• How do you feel about your community?
• Do you think that you have enough time to socialize?
• What do you see as your contribution to society?
Relationships
• Who is (are) the most important person(s) in your life? Describe your
relationship with that person?
• What was it like growing up in your family?
• What is your relationship like with your spouse?
• What is your relationship like with your children?
• Describe any relationships you have with significant others.
• Do you get along with your in-laws?
• Are you close to your extended family?
• Do you have any pets?
• What is your role in your family? Is it an important role?
• Are you satisfied with your current sexual relationships?
Values and Belief System
• What is most important to you in life?
• What do you hope to accomplish in your life?
• Do you have a religious affiliation? Is this important to you?
• Is a relationship with God (or another higher power) an
important part of your life?
• What gives you strength and hope?
Education and Work
• Tell me about your experiences in school or about your education?
• Are you satisfied with the level of education you have?
• Do you have future educational plans?
• What can you tell me about your work?
• What are your responsibilities at work?
• Do you enjoy your work?
• How do you feel about your coworkers?
• What kind of stress do you have that is work related?
• Who is the main provider of financial support in your family?
• Does your current income meet your needs?
Stress Levels and Coping Styles
• What types of things make you angry?
• How would you describe your stress level?
• How do you manage anger and stress?
• What do you see as the greatest stressors in your life?
• Where do you usually turn for help in a time of crisis?
Environment
• What risks are you aware of in your environment such as in your
home, neighborhood, on the job, or any other activities in which
you participate?
• What types of precautions do you take, if any, when playing
contact sports, using harsh chemicals or paint, or operating
machinery?
• Do you believe you are ever in danger of becoming a victim of
violence? Explain.
Developmental Level
&
Psychosocial History
Young Adult: Intimacy Versus Isolation
Does the client
• Accept self: physically, cognitively, and emotionally
• Have independence from the parental home?
• Express love responsibly, emotionally, and sexually?
• Have close or intimate relationships with a partner?
• Have a social group of friends?
• Have a philosophy of living and life?
• Have a profession or a life’s work that provides a means of
contribution?
• Solve problems of life that accompany independence from the
parental home?
Middlescent: Generativity Versus Stagnation
Does the client
• Have healthful life patterns?
• Derive satisfaction from contributing to growth and development of
others?
• Have an abiding intimacy and long-term relationship with a partner?
• Maintain a stable home?
• Find pleasure in an established work or profession?
• Take pride in self and family accomplishments and contributions?
• Contribute to the community to support its growth and development?
Older Adult: Ego Integrity Versus Despair
Does the client
• Adjust to the changing physical self ?
• Recognize changes present as a result of aging, in relationships
and activities?
• Maintain relationships with children, grandchildren, and other
relatives?
• Continue interests outside of self and home?
• Complete transition from retirement at work to satisfying
alternative activities?
• Establish relationships with others his or her own age?
• Adjust to deaths of relatives, spouse, and friends?
• Maintain a maximum level of physical functioning through diet,
exercise, and personal care?
• Find meaning in past life and face inevitable mortality of self
and significant others?
• Integrate philosophical or religious values into self-
understanding to promote comfort?
• Review accomplishments and recognize meaningful
contributions he or she has made to community and relatives?
B. COLLECTION OF OBJECTIVE
DATA
1. Types of and operation of equipment needed for the
particular examination
2. Preparation of the setting, oneself, and the client for the
physical assessment
3. Performance of the four assessment techniques:
 Inspection
 Palpation
 Percussion
 Auscultation
Equipment Needed for Physical
Examinations
For All Examinations
GLOVES
For Vital Signs
SPHYGMOMANOMETER
STETHOSCOPE
THERMOMETER
WATCH WITH SECOND HAND
For Anthropometric
Measurements
SKINFOLD CALIPERS
FLEXIBLE TAPE MEASURE
PLATFORM SCALE WITH HEIGHT
ATTACHMENT
For Skin, Hair, and Nail
Examination
RULER WITH CENTIMETER
MARKINGS
MAGNIFYING GLASS
WOOD’S LIGHT
For Head and Neck
Examination
SMALL CUP OF WATER
For Eye Examination
PENLIGHT
SNELLEN CHART
OPHTHALMOSCOPE
COVER CARD
ROSENBAUM POCKET SCREENER
For Ear Examination
OTOSCOPE
TUNING FORK
For Mouth, Throat, Nose,
and Sinus Examination
PENLIGHT
TONGUE DEPRESSOR
PIECE OF SMALL GAUZE
OTOSCOPE WITH WIDE-TIP
ATTACHMENT
For Thoracic and Lung
Examination

STETHOSCOPE
MARKING PENCIL AND
CENTIMETER RULER
For Heart & Neck Vessel
Examination
STETHOSCOPE
TWO CENTIMETERS RULER
For Abdominal
Examination
STETHOSCOPE
 MARKING PENCIL & TAPE
MEASURE WITH CENTIMETER
MARKINGS
TWO SMALL PILLOWS
For Female Genitalia
Examination
VAGINAL SPECULUM AND
LUBRICANT
SLIDES OR SPECIMEN CONTAINER, BIFID SPATULA,
AND COTTON-TIPPED APPLICATOR
 For Anus, Rectum, Prostate
Examination
LUBRICATING JELLY, SPECIMEN CONTAINER
For Peripheral Vascular Examination
STETHOSCOPE & SPHYGMOMANOMETER
FLEXIBLE TAPE MEASURE
COTTON BALL AND PAPER CLIP
TUNING FORK
DOPPLER ULTRASOUND PROBE BLOOD
For Musculoskeletal
Examination
TAPE MEASURE
GONIOMETER
For Neurologic
Examination
TUNING FORK
COTTON WISP & PAPER CLIP
SOAP & COFFEE
SALT, SUGAR, LEMON
TONGUE DEPRESSOR
REFLEX HAMMER
COIN OR KEY
PREPARING THE PHYSICAL
SETTING
1. Comfortable, warm room temperature
2. Private area free of interruptions from others
3. Quiet area free of distractions
4. Adequate lighting
5. Firm examination table or bed at a height that prevents
stooping
6. A bedside table/tray
PREPARING ONESELF
General Principles
1. Wash your hands before beginning the examination,
immediately after accidental direct contact with blood or other
body fluids, and after completing the physical examination.
2. Wear gloves
3. If a pin or other sharp object is used to assess sensory
perception, discard the pin and use a new one for your next
client.
4. Wear mask or protective eye googles
Approaching and Preparing the
Client
Positioning the Client
Standing
Sitting
Prone
Sims’
Supine (Horizontal Recumbent)
Dorsal Recumbent
Lithotomy
Knee-Chest
 Palpation
1. Is the examination of the body using the sense of touch.
2. Fingerpads
3. Ulnar or palmar surface
4. Dorsal surface
 4 Types of Palpation
1. Light palpation
2. Moderate palpation
3. Deep palpation
4. Bimanual palpation
 Percussion
1. The act of striking the body surface to elicit sounds that can be
heard or vibrations that can be felt.
2. Eliciting pain
3. Determining location, size, and shape
4. Determining density
5. Detecting abnormal masses
6. Eliciting reflexes
 3 Types of Percussion
1. Direct
2. Blunt
3. Indirect or mediate
 Percussion Sounds and Tones
Location: Muscle, bone
Sound: Flatness
Intensity: Soft
Pitch: High
Duration: Short
Quality: Extremely dull
Location: Liver, heart
Sound: Dullness
Intensity: Medium
Pitch: Medium
Duration: Moderate
Quality: Thudlike
Location: Normal Lung
Sound: Resonance
Intensity: Loud
Pitch: Low
Duration: Long
Quality: Hollow
Location: Emphysematous Lung
Sound: Hyperresonance
Intensity: Very loud
Pitch: Very low
Duration: Very long
Quality: Booming
Location: Stomach filled with gas (air)
Sound: Tympany
Intensity: Loud
Pitch: High
Duration: Moderate
Quality: Musical
 Auscultation
1. The process of listening to sounds produced within the body.
2. Direct
3. Indirect
4. Sounds are described according to:
• Pitch
• Intensity
• Duration
• Quality
Technique of Auscultation:
1. Eliminate distracting or competing noises from the
environment
2. Expose the body part you are going to auscultate
3. Use the diaphragm of the stethoscope to listen for high-
pitched sounds
4. Use the bell of the stethoscope to listen for low-pitched
sounds
Diagnostic Tests & Procedures
X-RAYS
 Used to evaluate the structure of bones and soft tissues
Basic Positions for X-RAYS
 AP (anterior-posterior)
X-ray passes through patient from front to back
 PA (posterior-anterior)
X-ray passes through patient from back to front
 Lateral
Patient is positioned on either side and so that the x-ray passes
from one side of the body through the other
 Oblique
X-ray is angled between PA and lateral positions
 General Patient
Preparation for Plain
X-rays
1. Determine if the patient is pregnant.
2. The reproductive organs are shielded during x-ray.
3. If scheduled for abdominal films, determine if the patient
has had a barium contrast study or taken medications
containing bismuth in the previous 4 days.
4. Tell the patient that he or she will have to stay very still
while films are being taken.
5. Remove metal objects and jewelry.
 Abdominal X-ray
 Assess cause of abdominal pain
 Evaluate liver or kidney size, shape, and position
 Bone Densitometry
 Identify risk for osteoporosis
 Monitor rate of bone loss in patients with osteoporosis
 Bone X-rays
 Assess for fractures, tumor, infection, structural
abnormalities, degenerative diseases
 Evaluate pain, loss of function, deformity
 Chest X-rays
 Assess lung fields, cardiac border, large arteries, clavicle, ribs,
diaphragm, and mediastinum
 Diagnose pulmonary or cardiac disorders including heart
failure, COPD, pneumonia, TB, and neoplastic disease.
 Evaluate placement of feeding tubes, chest tubes, central
venous catheters, pacemaker wires, endotracheal tubes, etc.
 Joint X-rays
 Assess for fracture, infection, cysts, tumor, degenerative
diseases
 Long Bone X-ray
 Evaluate bone pain or assess for fracture, tumor, infection,
joint or bone deformity
 Mammography
 Detect tumors, cysts, and other breast disorders
 Differentiate between malignant an benign lesions
 Obstruction Series
 Assess for bowel obstruction, paralytic ileus, bowel
perforation
 Orbital X-rays
 Assess for fracture, foreign body, tumor, congenital
abnormality
Paranasal Sinuses X-rays
 Assess for fracture, infection, cysts, tumor, foreign body
 Skull X-rays
 Assess for fracture, infection, tumor
 Computed Tomography
(CT Scans)
 A CT scan is a specialized x-ray that takes cross-sectional
pictures of all types of tissue.
 It is used extensively in diagnosing disease and injury
 Also used to diagnose cancers, including lung, liver, and
pancreatic cancer and measure tumor size and assess
involvement in other nearby tissues.
Magnetic Resonance Imaging
(MRI)
 MRI is a noninvasive imaging technology that gives detailed
pictures of internal structures.
 Done without using ionizing radiation
 Ultrasound (US)
 A noninvasive diagnostic procedure that uses sound waves
to create gray-scale images of internal structures.
Basic Components of
a Complete Medical
Record
Personal Identification
Information
Medical History
Family Medical History
Medication History
Treatment History
Medical Directives
Validation of Data
 Data Requiring Validation
1. Discrepancies or gaps between the subjective and objective
data.
2. Discrepancies or gaps between what the client says at one
time then at another time.
3. Findings that are very abnormal and/or inconsistent with
other findings.
 Methods of Validation
1. Recheck your own data through repeat assessment.
2. Clarify data with the client by asking additional questions.
3. Verify the data with another health care professional.
4. Compare your objective findings with your subjective
findings to uncover discrepancies.
 Identification of Areas
Where Data Are Missing
 Once you establish an initial database, you can identify areas
where more data are needed.
 You may have overlooked certain questions
 Additional information is needed
Documentation of Data
 Purpose of Documentation
1. Primary reason for documenting the initial assessment is to
provide the health care team with a database that becomes
the foundation for care of the client.
2. It helps to identify health problems, formulate nursing
diagnoses, and plan immediate and ongoing interventions.
 Information Requiring
Documentation
1. Nursing History
2. Physical Assessment
 Guidelines for Documentation
1. Document legibly or print neatly in non-erasable ink.
2. Use correct grammar and spelling.
3. Avoid wordiness that creates redundancy.
4. Use phrases instead of sentences to record data.
5. Record data findings, not how they were obtained.
6. Write entries objectively without making premature
judgments or diagnoses.
7. Record the client’s understanding and perception of
problems.
8. Avoid recording the word “normal” for normal findings.
9. Record complete information and details for all client
symptoms or experiences.
10. Include additional assessment content when applicable.
11. Support objective data with specific observations obtained
during the physical examination.
 Assessment Forms Used for
Documentation
1. Initial Assessment Form
2. Frequent or Ongoing Assessment Form
3. Focused or Specialty Area Assessment Form
General Survey, Mental
Status Exam,
and Vital Signs
 1. Overall Impression of
the Client
This impression requires your objective observation skills to
assess the client’s appearance, mobility, and body build.
 2. Mental Status Exam
Determining the client’s level of consciousness; noting posture and
body movements; and evaluating dress, grooming and hygiene, facial
expression, speech, mood, feelings, and expressions, thought processes
and perceptions, and cognitive abilities.
 3. Vital Signs
Provide data that reflect the status of several body systems
including but not limited to the cardiovascular, neurological,
peripheral vascular, and respiratory systems.
 Temperature
Babies and Children: 36.6 to 37.2
Adults: 36.1 to 37.2
Adults over age 65: lower than 36.2
Hypothermia- body core temperature below 35
Hyperthermia – elevated beyond normal
 Pulse
A shock wave is produced when the heart contracts and
forcefully pumps blood out of the ventricles into the aorta.
The shock wave travels along the fibers of the arteries and is
commonly called the arterial or peripheral pulse.
 Respirations
Notable characteristics of respiration are rate, rhythm, and
depth.
 Blood Pressure
Is a measurement of the pressure of the blood in the arteries
when the ventricles are contracted (systolic) and when the
ventricles are relaxed (diastolic).
The difference between systolic and diastolic pressure is termed
pulse pressure.
 4. Pain
Pain quality may be described as “dull,” “sharp,” “radiating,” or
“throbbing.” COLDSPA may help you to remember how to
further assess pain if present.