Signs and Symptoms the Basics of Assessment

A sign is objective, tangible and measurable. If you remember “vital signs”, you will begin to understand the
differences. Signs include:

• Temperature

• Respirations

• Blood pressure

• Pulse

• Blood sugar

• Bleeding

• Bruising

A symptom on the other hand is subjective. It is what the patient reports about his condition of disease. Symptoms
include:

• Palpitations

• Shortness of breath or difficulty breathing

• Nausea

• Vertigo

• Feeling hot or chills

Pain can be considered both a sign and a symptom.

Essential to Diagnosis and Treatment

Both signs and symptoms are essential to diagnosing as well as treating an illness, injury or disease. Accurate
documentation by the health care team is important to the diagnostician in determining the effectiveness of a
treatment as well as the status of the condition and the eventual outcomes.

Signs and Symptoms and the Nursing Process

Signs and symptoms are also essential to nurses in determining nursing diagnoses and in implementing the nursing
process. Again careful and accurate documentation is essential to the successful outcomes for the patient.
A Checklist for Nursing Procedures

• Verify the physician’s order

• DO NO HARM!!! Ask for help if you’ve never done this before

• Gather all necessary equipment (charge it out as appropriate)

• Identify the patient

• Introduce yourself and explain the procedure to the patient

• Wash your hands

• Don necessary protective equipment (gloves, gowns, goggles, etc.)

• Provide for patient privacy including draping as necessary

• Perform procedure according to protocol

• Utilize proper body mechanics

• Position patient for comfort

• Explain each step to the patient

• Observe patient’s response to all steps

• Clean and position patient for comfort

• Return bed to original position and adjust side rails. Leave call light within reach.

• Remove all equipment and clean or dispose of per protocols

• Document findings and outcomes

• Notify MD of any unusual findings or change in condition

• Instruct patient in aftercare protocol

• Answer patient’s questions or direct them to resources for answers (such as the MD)

How to Perform a Head to Toe Assessment

1. Wash your hands and assemble equipment. Greet the patient and explain what you need to do. Provide for
privacy.

2. Begin with the 5 vital signs: Temperature, Pulse, Respirations, BP and Pain. Ask the patient how he/she
feels and observe the environment. As you assess the body by systems observe for mobility and ROM.

a. HEENT: Head: shape and symmetry; condition of the hair and scalp, Eyes: conjunctiva and sclera,
pupils; reactivity to light and able to follow a finger or light,
 pupils; reactivity to light and able to follow a finger or light, Ears: hearing aids, pain, hears whispers,
comprehension, Nose: drainage, congestion, difficulty breathing or with sense of smell, Throat and
mouth: mucous membranes, any lesions, teeth or dentures, odor, swallowing, trachea, lymph nodes

3. As you examine all body systems observe the integumentary system for any breaks in the skin, scars,
lesions, wounds, redness or irritation. Also note turgor, the color, temperature, and moisture of the skin.

4. Thoracic region. Assess lung sounds and cardiac sounds. Front and back: assess for character and quality as
well as the presence or absence of appropriate sounds. Palpate the chest wall and breasts for any tenderness,
lumps.

5. Abdomen: Listen to bowel sounds throughout the four quadrants. Palpate for tenderness or lumps. Palpate
the bladder. Ask about intake and appetite, and output both urinary and bowels Genetalia: assess for
tenderness, lumps or lesions.

6. Extremities: Assess for temperature, capillary fill and ROM. Palpate pulses. Note any edema, lesions,
lumps, pain.

7. Ask the patient how he/she feels. Has anything changes recently? Any pain, burning, SOB, chest pains,
change in bowel or bladder habits, change in sleep habits, cough, discharge from any orafice, depression,
sadness, change in appetite.

8. Wash your hands. Document your findings. Report any significant changes or findings to the MD.

Terms to be used in Charting

Factor to be Charted Used Suggested Terms to Be

BLEEDING
Spurting of blood in spurts (usually arterial if spurting)
very little oozing
nosebleed epistaxis
blood in vomitus hematemesis
blood in urine hematuria
spitting of blood hemoptysis
when bleeding is stopped hemorrhage controlled

BREATH
unpleasant halitosis
foul fetid
with sweet fruit-like odor fruity
smells of alcohol alcoholic

BREATHING
act of breathing respiration
act of inhaling inspiration
act of exhaling expiration
difficult breathing dyspnea, labored
absence of apnea
inability to breathe while lying down orthopnea
normal breathing eupnea
rapid breathing hyperpnea
increasing dyspnea with periods pf apnea Cheyne-Stokes respiration
Large volume of air inspired and expired deep breathing
Small volume of air inspired and expired shallow breathing
abnormal variations in rhythm irregular respiration
snoring stertorous

CHILL
blanket applied to help warm the patient external heat applied, e.g., warming blanket
type as to severity severe moderate, or slight

COUGH
coughs all the time continuous cough
coughing over long period of time persistent cough
coughs up material productive cough
cough without sputum dry or non-productive cough

DEFECATION
bowel movement (material) feces, stool
bowel movement (act of) defecation
liquid defecation diarrhea
cery dry stool constipation
gray colored stool clayupcolored stool
dark brown liquid stool dark brown liquid stool
formed, yet soft stool soft formed stool
formed with hardened feces hard formed stool

DIZZINESS
dizziness vertigo

DRAINAGE
watery, from nose coryza
contain pus purulent
bloody sanguineous
Consists of feces fecal
of lymphatic fluid serous
contains mucus and pus mucopurulent
tough, sticky tenacious
from vagina (after delivery) lochia

DRESSINGS
a second dressing added to the first dressing reinforced
dressing removes, another applied dressing changed
drain tubes cut off drain tubes shortened (number of inches)

EMESIS
produced by effort of patient induced
ejected to few feet distant projectile
if blood is only noticeable blood-tinged
agent given to produce emesis emetic

GAS
gas in digestive tract flatus
having gas in the digestive track flatulence

GUMS
inflammation of the gums gingivitis

HEAD
forehead frontal region
region over temple temporal region
back of head occipital region
base of skull basilar region

HIVES
hives urticaria
itching puritis

JOINTS
bending flexion
to straighten extension
turn downward pronation
turn upward supinatioin
revolve around rotation
move away from median line abduction
move toward median line adduction

ODOR
not unpleasant aromatic
like ammonia ammoniacal
like fruit fruity
very unpleasant offensive
belonging to particular drug, etc. characteristic

PAIN
great pain severe
little slight
comes in seizures paroxysmal
spreads to distant areas radiating
started all at once sudden onset
hurts worse when moving increased by movement

PARALYSIS
of the muscles of the face facial
of the legs paraplegia
of one side of the body hemiplegia
of a single limb monoplegia

PULSE
number of beats per minute rate
rhythm regular or irregular
over 100 beats per minute (adult) rapid
one scarcely perceptible thready, weak, feeble
forceful full, bounding

SKIN
normal healthy
pink, hot flushed
blue in color cyanotic
very white extreme pallor
shines glossy
raw surface excoriation
yellow in color jaundiced
torn lacerated
containing colored areas pigmented
wet moist
scraped abraided, abraised, abrasion
small ecchymosis of skin petchia

SLEEP
slept very little very little, for short periods
tired when wakens awakens fatigued
moans while sleeping sleep disturbed -- moaning
inability to sleep insomnia
TEETH
false teeth dentures
decay of dental caries
collection of foul material sores

URINE
color: 1.1 yellow; 1.2 concentrated 1.1 straw; 1.2 dark amber
amount amount (measured in cc's)
odor strong, ammonia foul
urinary drainage: catheter
4.1 act of urination 4.1 voids
4.2 voids in bed 4.2 incontinent
4.3 voids in bedpan or toilet 4.3 continent
4.4 painful urination 4.4 dysuria
4.5 lack of urination 4.5 anuria
4.6 blood in urine 4.6 hematuria