KAMPALA INTERNATIONAL UNIVERSITY-WESTERN CAMPUS

MASTERS IN NURSING SCIENCE 1.1,2024

COURSE UNIT: ADVANCED PHYSICAL AND HEALTH ASSESSMENT

LECTURER: [Link] ALHASSAN SAED

NAME:TAYEBWA NOBERT

REGISTRATION NUMBER:2024-08-26782

ASSIGNMENT

1. VITAL SIGNS

[Link] SURVEY

3.a) TEPID SPONGING

b)PRINCIPLES O TEPID SPONGING

 ANSWERS
1 . Vital Signs/Cardinal signs
Vital signs reflect the body’s physiologic status and provide information critical to evaluating
homeostatic balance. The term “vital” is used because the information gathered is the clearest
indicator of overall health status.
Vital signs Include T (temperature), PR (Pulse Rate), RR (Respiratory Rate), and BP (Blood
Pressure)
Purpose of taking vital signs
• To obtain base line data about the patient condition
• To aid in diagnosing patient condition that is for diagnostic purposes
• For therapeutic purpose so as to intervene accordingly
Equipment used
Vital signs tray
Stethoscope
Sphygmomanometer
Thermometer
Watch
Pen
Cotton swab in bowel
Disposable gloves
kidney dish

When to take vital signs

1. On admission – to obtain baseline date
2. When a client has a change in health status or reports symptoms such as chest pain or
fainting
3. According to a nursing or medical order

4 Before and after the administration of certain medications that could affect respiratory
rate,blood pressure and the cardio vascular system

5. Before and after surgery or an invasive diagnostic procedures

6. Before and after any nursing intervention that could affect the vital signs forexample.
ambulation
7. According to hospital or other health institution policy.

Temperature
Body temperature is the measurement of heat inside a person’s body (core temperature)
it is therefore balance between heat produced and heat [Link] the body
Normal body temperature measurement is appropriately 370 celsius or 98.6 0 F.

There are two Kinds of body temperature

1. Core Temperature
This is the Temperature of the deep tissues of the body, such as the cranium, thorax,
abdominal cavity,and pelvic cavity and it remains relatively constant
 Is the Temperature that we measure with thermometer
2. Surface Temperature:
This is the temperature of the skin,subcutaneous tissue and fat.

Alterations in Body Temperature

Pyrexia: a body temperature above the normal ranges 38 0c – 410 c (100.4 – 105.8 F)
Hyper pyrexia: a very high fever, such as 41 0 C > 42 0 c leads to death.
A client who has fever is referred to as febrile; the one who has not is afebrile.
Hypothermia: – body temperature between 34 0c – 35 0 c, < 34 0c is death

Common types of fevers

1. Intermittent fever: the body temperature alternates at regular intervals between periods
of fever and periods of normal or subnormal temperature.
2. Remittent fever: a wide range of temperature fluctuation (more than 2 0c) occurs over
the 24 hr period, all of which are above normal
3. Relapsing fever: short febrile periods of a few days are interspersed with periods of 1 or
2 days of normal temperature.
4. Constant fever: the body temperature fluctuates minimally but always remains above
normal
Factors Affecting Body Temperature
1. Age
Children’s temperature continue to be more labile than those of adults until puberty
Elderly people, particularly those > 75 are at risk of hypothermia
Normal body temperature of the newborn if taken orally is 37 0C.
2. Diurnal variations (circadian rhythms)
Body temperature varies throughout the day
The point of highest body temperature is usually reached between 8:00 p.m. and
midnight and lowest point is reached during sleep between 4:00 and 6:00 a.m.
3. Exercise
Hard or strenuous exercise can increase body temperature to as high as 38.3 – 40 c –
measured rectally
4. Hormones
In women progesterone secretion at the time of ovulation raises body temperature by
about 0.3-0.60C above basal temperature
5. Stress
Stimulation of skin can increases the production of epinephrine and nor epinephrine –
which increases metabolic activity and heat production.
6. Environment
Extremes in temperature can affect a person’s temperature regulatory systems.

Measuring Body Temperature

Sites to Measure Temperature
Oral
Rectal
Axillary
Tympanic
Thermometer: is an instrument used to measure body temperature
Types of thermometers
1. Oral thermometer
Has long slender tips
2. Rectal thermometer
Short, rounded tips
3. Axillary
Long and slender tip
4. Tympanic
Rectal Temperature:
Readings are considered to be more accurate, most reliable, is >
0.650 c (1 0F) higher than the oral temperature.

Procedure
• Explain the procedure to the patient
• Wash hands and assemble necessary equipment and bring to the patient bedside.
• Position the person laterally;
• Apply lubricant 2.5 cm above the bulb
• Insert the thermometer 1.5 – 4 cm into the anus. For an infant 2.5cm, for a child 3.7 cm
– for an adults 4 cm
Measured for 2-3 minutes
Remove the thermometer and read the finding
Clean the thermometer with tissue paper
A rectal thermometer record does not respond to changes in arterial temperature as
quickly as an oral thermometer
Contraindications
Rectal or perineal surgery;
Fecal impaction – the depth of the thermometer insertion may be insufficient.
Rectal infection
Neonates –can cause rectal perforation and ulceration

Oral temperature
Procedure
Explain the procedure to the patient
Wash hands and assemble necessary equipment and bring to the patient bedside.
Position the person comfortably and request the patient to open the mouth;
Hold the thermometer firmly with the thumb and fore finger; shake it with strong wrist
movements until the mercury line falls to at least 35 oc .
Place the bulb of the thermometer well under the client’s tongue. Instruct the client to
close the lips (not the teeth) around the bulb.
Ensure that the bulb rests well under the tongue, where it will be in contact with blood
vessels close to the surface.
Remove the thermometer after 3 to 5 minutes, according to the agency guidelines.
Remove the thermometer, wipe it using it once a firm twisting motion
Hold the thermometer at eye level. Read to the nearest tenth
Dispose the tissue. Wash the thermometer in lukewarm, soapy water.
Dry and replace the thermometer in a container at bedside. Wash your hands.
Record temperature on paper or flow sheet. Report an abnormal reading to the
appropriate person.
Contraindications
• Child below 7 yrs
• If the patient is delirious, mentally ill
• Unconscious
• Uncooperative or in severe pain
• Surgery of the mouth
• Nasal obstruction
• If patient has nasal or gastric tubes in place
Axillary
Procedure
Wash hands
Make sure that the client’s axilla is dry, If it is moist, dry gently before inserting the
thermometer.
After placing the bulb of the thermometer in to the
axilla, bring the client’s arm down against the body as tightly as possible, with the
forearm resting across chest.
Hold the glass thermometer in place for 8 to 10 minutes. Hold the electronic
thermometer in place until the reading registers directly
Remove and read the thermometer. Dispose of the equipment [Link] hands
Record the reading
N.B. The axillary method is safest and most noninvasive.

Tympanic Temperature
The tympanic temperature is placed snugly in to the client’s outer
ear canal It records temperature in 1 to 2 [Link] pediatric and intensive care
units use this type of thermometer because it records a temperature so rapidly.

Procedure
Wash the hands
Explain the procedure to the client to ensure cooperation and understanding
Hold the probe in the dominant hand. Use the client’s same ear as your hand (e.g. use
the client’s right ear when you use your right hand).
Select the desired mode of temperature. Use the rectal
equivalent for children under 3 years of age Wait for “ready” message to display.
With your nondominant hand, grasp the adult’s external ear at the midpoint. Pull the
external ear up and back. For a child of 6 years or younger, use your nondominant hand
to pull the ear down and back.
Slowly advance the probe in to the client’s ear with a back
and forth motion until it seals the ear canal.
Point the probe’s tip in an imaginary line from the client’s
sideburns to his or her opposite eyebrow.
As soon as the instrument is in correct position, press the button to activate the
thermometer.
Keep the probe in place until the thermometer makes a sound or flashes a light.
Read the temperature and discard the probe cover.
Replace the thermometer and wash your hands.
Record the temperature on the client’s record.
For a child of 6 years or younger, use your nondominant hand to pull the ear down and
back.
• Slowly advance the probe in to the client’s ear with a back and forth motion until it
seals the ear canal.
• Point the probe’s tip in an imaginary line from the client’s sideburns to his or her
opposite eyebrow.
• As soon as the instrument is in correct position, press the button to activate the
thermometer.
• Keep the probe in place until the thermometer makes a sound or flashes a light.
• Read the temperature and discard the probe cover. Replace the thermometer and
wash your hands.
• Record the temperature on the client’s record.
Pulse
It is a wave of blood created by contraction of the left ventricle of the heart that is . the
pulse reflects the heart beat or is the same as the rate of ventricular contractions of the
heart in a healthy person.
In some types of cardiovascular diseases heartbeat and pulse rate differ FOREXAMPLE
Client's heart produces very weak or small pulses that are not detectable in a peripheral
pulse far from the heart
Peripheral Pulse: is a pulse located in the periphery of the body e.g. in the foot, and or
neck
Apical Pulse (central pulse): it is located at the apex of the heart
The PR is expressed in beats/ minute (BPM)
Pulse Deficit- It is a difference that exists between the apical and radial pulse

Factors Affecting Pulse Rates

1. Age: as age increases the pulse rate gradually [Link] new borns to 1 month the
range is 80-180 beats per [Link] normal range for heart rate of an adult is 60-100
BPM (beat per minute)
2. Sex: after puberty the average males pulse rate is slightly lower than that of a female
3. Exercise: pulse rate usually increases during strenuous exercises.
4. Fever: increases heart rate in response to the lowered blood pessure that results from
peripheral vasodilatation
5. Medications: digitalis preparation decreases pulse rate whereas Epinephrine increases
it.
6. Heat: increase pulse rate as a compensatory mechanism
7. Stress: increases the sympathetic nerve stimulation and therefore increases the rate
and force of heart beat
5. Medications: digitalis preparation decreases PR while Epinephrine increases PR
6. Heat: increase PR as a compensatory mechanism
7. Stress: increases the sympathetic nerve stimulation increases the rate and force of
heart beat
8. Position changes: when a patient assumes a sitting or standing position blood usually
pools in dependent vessels of the venous system. Pooling results in a transient decrease
in the venous blood return to heart and the subsequent decrease in blood
pressure,increases heart rate.

Pulse Sites
Temporal: is superior (above) and lateral to (away from the midline of) the eye
Carotid: at the side of the neck below tube of the ear (where the carotid artery runs
between the trachea and the sternoclidiomastoid muscle)
Temporal: the pulse is taken at temporal bone area.
Apical: at the apex of the heart,this is routinely used for infant and children below 3 yrs.
In adults – Left midclavicular line under the 4th, 5th, 6th intercostals space
Children < 4 yrs of the Lt. mid clavicular line
4. Brachial: at the inner aspect of the biceps muscle of the arm or medially in the
antecubital space (elbow crease)
5. Radial: on the thumb side of the inner aspect of the wrist,this is readily available and
routinely used
6. Femoral: along the inguinal ligament,this is commonly used in infants and children
7. Popiliteal: this is taken behind the knee by flexing the knee slightly
8. Posterior tibial: on the medial surface of the ankle
9. Pedal (Dorslais Pedis): palpated by feeling the dorsum (upper surface) of the foot on an
imaginary line drawn from the middle of the ankle to the surface between the big and 2 nd

toes
Method
Pulse: is commonly assessed by palpation (feeling) or auscultation (hearing)
The middle 3 fingertips are used with moderate pressure for palpation of all pulses
except apical; the most distal parts are more sensitive,
Assess the Pulse for;
Rate
• Rhythm
• Volume
• Elasticity of the arterial wall
Pulse Rate
• Normal range for an adult is 60-100 b/min (80/min)
• Tachycardia excessively fast heart rate that is >100 beats/min
• Bradycardia Is a heart rate that is < 60/min
Pulse Rhythm
The normal pulse rhythm is regular, meaning that the frequency of the pulsation felt by your
fingers follows an even tempo with equal intervals between pulsations. If you compare this to
music,it involves a constant beat that does not speed up or slow down, but stays at the same
[Link] the pattern and interval between the beats is random and irregular its
termed as a dysrythymia.
Pulse Volume: the force of blood with each beat
• A normal pulse can be felt with moderate pressure of the fingers and can be obliterated
with greater pressure.
• Full or bounding pulse forceful or full blood volume obliterated with difficulty
• Weak, feeble or thready readily obliterated with pressure from the finger tips
Elasticity of arterial wall
• A healthy, normal artery feels, straight, smooth, soft and pliable, easily bent after
breaking
• Reflects the status of the clients vascular system
If the pulse is regular, measure (count) for 30 seconds and multiply by 2
If it is irregular count for 1 full minute

Procedure for measuring radial pulse (the most common)

Wash hands
Explain the procedure to the client
Position the client’s fore arm comfortably with the wrist extended and the palm down
Place the tips of your first, second, and third fingers over the client’s radial artery on the
inside of the wrist on the thumb side.
Press gently against the client’s radial artery to the point where pulsation can be felt
distinctly

Using a watch,count the pulse beats for 30 seconds and multiply by two to get the rate
per minute
Count the pulse for full minute if it is abnormal in any way or take an apical pulse
Record the rate (BPM) on paper or the flow sheet. Report any irregular findings to
appropriate person
Again wash your hands

Respiration Rate
Respiration is the act of breathing,it includes intake of oxygen and removal of
carbondioxide
Ventilation is another word, which refers to the movement of air in and out of the lungs.
Hyperventilation: very deep, rapid respiration
Hypoventilation: very shallow respiration

Types of Breathing
Costal /thoracic
• Involves the external muscles and other accessory muscles (sternoclodio mastoid
• Observed by the movement of the chest up ward and down ward. Commonly used for
adults
Diaphragmatic (abdominal)
• Involves the contraction and relaxation o
Assessment
• The client should be at rest
• Assessed by watching the movement of the chest or abdomen.
• Rate, rhythm, depth and special characteristics of respiration are assessed
ASSESS FOR
Rate:
A healthy adult’s respiratory rate ranges between 12- 20 breaths/cycles/min.
Terms used include:
Eupnea- normal breathing rate and depth
Bradypnea- slow respiration
Tachypnea - fast breathing
Apnea - temporary cessation of breathing
Rhythm: is the regularity of expiration and [Link] breathing is automatic and
effortless.
Depth: described as normal,deep or shallow.
Deep: a large volume of air inhaled and exhaled, inflates most of the lungs.
Shallow: exchange of a small volume of air minimal use of lung tissue.

BLOOD PRESSURE:
Blood pressure is the pressure exerted by blood against the wall of blood vessels. It
includes arterial,
venous and capillary pressures.
Arterial BP: it is a measure of a pressure exerted by the blood as it flows through the
arteries. Arterial blood pressure = cardiac output (CO) x total peripheral resistance
(TPR).
There are two types of blood pressure.
1. Systolic pressure: is the pressure that is as a result of
contraction of the ventricle
2. Diastolic blood pressure: is the pressure when the ventricles are at rest.

NOTE:
Blood pressure can be measured invasively or non-invasively (NIBP that is Non Invasive Blood
Pressure)
Pulse pressure: is the difference between the systolic and diastolic pressure
Blood pressure is measured in mm Hg and recorded as fraction. A number of conditions
are reflected by changes in blood pressure.
• An increase in blood pressure is called hypertension and a decrease is termed as
hypotension

Some conditions that affect Blood Pressure

Condition Effect
Fever Increases
Stress Increases

Arteriosclerosis Increases

Obesity Increases
Hemorrhage Decrease Decreases
Low haematocrit Decreases
External heat Decreases
Exposure to cold Decreases
Sites for Measuring Blood Pressure
Upper arm using brachial artery (commonest)
Thigh around popliteal artery
Fore arm using radial artery
Leg using posterior tibial or dorsal pedis

Methods of Measuring Blood Pressure

Blood pressure can be assessed directly or indirectly
Direct (invasive monitoring) measurement involves the insertion of catheter in to
the brachial, radial, or femoral artery. The physician inserts the catheter and the nurse
monitors the pressure reading. With use of correct placement, it is highly accurate.
Indirect (non invasive methods)
The auscultatory
 The palpatory
The auscultatory method is the commonest method used in health activities.
NOTE:
When taking blood pressure using stethoscope, the nurse identifies
five phases in series of sounds called Korotkoff's sound;

Phase 1: The pressure level at which the 1st joint clear tapping sound is heard, these
sounds gradually become more [Link] ensure that they are not extraneous sounds,
the nurse should identify at least two consecutive tapping sounds.
Phase 2: The period during deflation when the sound has a swishing quality
Phase 3: The period during which the sounds are crisper and more intense
Phase 4: The time when the sounds become muffled and have a soft blowing quality
Phase 5: The pressure level when the sounds disappear

PROCEDURE OF MEASURING BLOOD PRESSURE

Assessing Blood pressure
Purpose
o To obtain base line measure of arterial blood pressure for subsequent evaluation
o To determine the clients homodynamic status
o To identify and monitor changes in blood pressure resulting from a disease process
and medical therapy
EQUEPMENT USED
o Stethoscope
o Blood pressure cuff of the appropriate size
o Sphygmomanometer

Procedure
Prepare and position the patient appropriately
Make sure that the client has not smoked or ingested caffeine, with in 30 minutes prior
to measurement.
Position the patient in sitting position, unless otherwise specified. The arm should be
slightly flexed with the palm of the hand facing up and the fore arm supported at heart
level
Expose the upper arm Wrap the deflated cuff evenly around the upper arm.

Apply the center of the bladder directly over the medial aspect of the arm. The bladder
inside the cuff must be directly over the artery to be compressed if the reading to be
accurate.

For adults, place the lower border of the cuff approximately 2 cm above antecubital
space.
For initial examination, perform preliminary palipatory determination of systolic
pressure
Palpate the brachial artery with the finger tips
• Close the valve on the pump by turning the knob clockwise.
• Pump up the cuff until you no longer feel the brachial pulse
• Note the pressure on sphygmomanometer at which the pulse is no longer felt
• Release the pressure completely in the cuff, and wait 1 to 2 minutes before making
further measurement
Position the stethoscope appropriately
• Insert the ear attachments of the stethoscope in your ears so that they tilt slightly fore
ward.
• Place the diaphragm of the stethoscope over the brachial pulse; hold the diaphragm
with the thumb and index finger.
. Auscultate the client's blood pressure
• Pump up the cuff until the sphygmomanometer registers about 30 mm Hg above the
point where the brachial pulse disappeared.
• Release the valve on the cuff carefully so that the pressure decreases at the rate 2-3
mmHg per second.
• As the pressure falls, identify the manometer reading at each of the five phases
• Deflate the cuff rapidly and completely
Repeat the above step once or twice as necessary to confirm the accuracy of the
reading.
Remove the cuff from the client’s arm
For initial determination, repeat the procedure on the client's other arm, there should
be a difference of no more than 5 to mmHg between the arms. The arm found to have
the higher pressure, should be used for subsequent examinations
Document and report pertinent assessment data, report any significant change in
client's blood pressure to the nurse in charge.
Also report these finding:
A. Systolic blood pressure (of adult) above 140 mmHg.
B. Diastolic blood pressure (of an adult) above 90 mmHg
C. Systolic blood pressure of (an adult) below 100mmHg

Qn.2

GENERAL SURVEY

The general survey is your first impression of the patient. This includes data like their appearance, mental status,
behavior, mood, pain level, speech, mobility and body type. to go through during clinical.

Assessment questions to ask yourself

Are they easily awakened?

Is the patient well groomed?

Do they look older/younger/or about the same as their stated age?

Is their face symmetrical?

Are they responding appropriately?

Is their speech delayed or stuttered?

Are they calm or agitated?

Assessment questions to ask the patient

Can you tell me your name?

Can you tell me where you are right now?

Can you tell me what day it is?

What brought you into this facility?

What's your pain level?

What's the quality and location of your pain?

How do you normally get around (cane, front wheel walker, independently, etc.)?

Are they thin or overweight?

Things to look for

Is the patient safe in the position they're in?

Do they have IV fluids running?

Look at how many mL are left (think ahead to when you'll need to grab a new bag of fluids).

Is their bed alarm on?

How many rails are up on the bed?

What's their bedside table look like?

How many mL of juice did they drink since documented last?

GENERAL SURVEY CHECKLIST:

Appearance

 Deviation from stated age  Gender  Race

 Facial symmetry  Hygiene

Mental Status

 Easily awakened  Response  Aware of person, place, time,and situation

Behavior/Mood

 Calm, agitated, anxious, compliant, etc.

Pain

 Pain rating  Location  Quality

 Precipitating factors  Palliative factors  When did it start

Speech

 Clear, delayed, stuttered, slurred, mumbled

Mobility

 Ticks or tremors  Range of motion  Use of assistive devices

Body Type

 Thin, overweight, weight appropriate for height

Room Observations

 Safety  Bedside table assessment  IV fluids

 Call light, rails, bed lowered

Qn.3 TEPID SPONGING AND ITS PRINCIPLES

Definition:It is the application of lukewarm water to the surface of the body using a wash cloth,to provide
cooling measures to a patient with elevate temperature
The effects of giving Tepid Sponge were making vasodilatation of blood vessels, pores, of skin,
reducing of blood viscosity, improving metabolism, and stimulating impulse through skin receptor
sent to hypothalamus posterior to decrease the body temperature through evaporation technique. The
use of tepid sponge could reduce 1.4°C in 20 minutes

REFERENCES

[Link]. Prinsip Perawatan Demam Pada Anak. Yogyakarta: Pustaka Belajar; 2012.

[Link]. Efektifitas Kompres Dingin Dan Hangat Pada Penatalaksanaan Demam.

Jurnal Fakultas Sains dan Teknologi, UIN Maliki Malang; 2012.

[Link] N. Penatalaksanaan Demam Pada Anak. 2007. [accessed 10 Des 2017].

Available from: [Link] penatalaksanaan_demam_pada_anak.pd
[Link], B., R., and Mary T. K, (2003). Textbook of Basic Nursing,

[Link] Edition, Lippincott comp.

[Link],R.F.,& Hirnle, C.J. (2000). Fundamentals of nursing:Human health and function (3rd ed.).
Philadelphia: Lippincott Williams & Wilkins.