Chapter 5—Vital Signs and General Survey

Introduction General survey: begins during interview phase of health assessment Health history collected Nursing observations Initial impression development Data collection plan formulation Vital signs: important indicators of patient’s physiological status, response to the environment

Introduction—(cont.) Vital signs include Temperature Pulse Respirations Blood pressure Pain Covered in Chapter 6

Urgent Assessment Indicators of an urgent situation Extreme anxiety; acute distress Pallor; cyanosis; mental status change Interventions begin while continuing the assessment. Rapid response team may be called for An acute change in mental status Stridor Respirations <10 or >32 breaths/min Increasing effort to breathe is necessary

Urgent Assessment—(cont.) Rapid response team may be called for—(cont.) Oxygen saturation <92% Pulse <55 beats/min or >120 beats/min Systolic BP <100 mm Hg or >170 mm Hg Temperature <35°C or >39.5°C New onset chest pain Agitation Restlessness

Objective Data Collection Equipment Equipment needed Scale Height bar Stethoscope Thermometer Watch with second hand Sphygmomanometer Pulse oximeter Tape measure (for infants)

Objective Data Collection—(cont.) Preparation Environment Before measuring vital signs Have the patient rest at least 5 minutes. Assure patient has not eaten, drank, or smoked at least 30 minutes before measurement. Remove clothing constrictive to upper arm. Patient may be sitting or standing.

General Survey Begins with the first moment of the encounter with the patient and continues throughout the health history First component of the assessment Contributes to formation of global impression of the person Includes physical appearance, body structure, mobility, and behavior

General Survey—(cont.) Assess Physical appearance Overall appearance Hygiene, dress Skin color; body structure, development Behavior; facial expressions Level of consciousness; speech Mobility Posture; range of motion; gait

Anthropometric Measurements Height; weight Calculation of BMI Vital signs measurement purposes Reflects health status; cardiopulmonary, overall body function Need to assess patient medications first Frequency of measurement Provides baseline measurements Rationale for measurement of one vital sign Medication administration; elevated temperature

Body Temperature Normal range dependent upon route Rectal, temporal artery measurements are 0.4° to 0.5°C (0.7° to 1°F) > oral measurements Axillary measurement averages 0.5°C (1°F)< oral temperatures Diurnal cycle Thermometer types Electronic; disposable; tympanic; temporal artery Appropriate route selection: critical thinking Documentation

Question Is the following statement true or false? A temperature above 38.5°C in adults requires immediate assessment and rapid cooling measures.

Answer Rationale: Fever above 39.5°C (103°F) in adults requires immediate assessment and rapid cooling measures. Monitor rectal temperature constantly during cooling measures to prevent a hypothermic response.

Pulse Throbbing sensation palpated over peripheral artery, auscultated over cardiac apex Palpate arterial pulse points, measuring Rate; rhythm; amplitude; elasticity Abnormal findings Tachycardia; bradycardia; asystole Sinus arrhythmia; pulse deficit Assessment technique Documentation

Respirations Act of breathing Inspiration + Expiration = One respiration Respiratory rate: 12 to 20 breaths/min, regular (adult) Dependent upon various factors Eupnea Abnormal findings: dyspnea Bradypnea; tachypnea; apnea Documentation

Oxygen Saturation Percentage to which hemoglobin is filled with O2 Normal pulse oximetry (SpO2): 92% to 100% SpO2 <85%: inadequate oxygenation; possible emergency SpO2 of 85% to 89%: possibly acceptable for patients with specific chronic conditions Emphysema Potential measurement error causes Documentation

Blood Pressure Measurement of force exerted by blood flow against arterial walls Systolic blood pressure (SBP) Left ventricular contraction: maximum pressure Diastolic blood pressure (DBP) Left ventricular relaxation: minimum pressure Factors contributing to BP Cardiac output; peripheral vascular resistance Circulating blood volume; viscosity Vessel wall elasticity

Blood Pressure—(cont.) Variations occur normally Influencing factors Age; gender; ethnicity; weight; diurnal cycle Position; exercise; emotions; stress Medications; smoking Abnormal findings Hypertension (elevated BP) Hypotension (lower than normal limits BP)

Blood Pressure—(cont.) Equipment Sphygmomanometer Appropriate cuff size Stethoscope Measurement location Arm; thigh Orthostatic (postural) BP Pulse pressure; mean arterial pressure (MAP) Documentation

Risk Reduction and Health Promotion Patient education Daily weight Hypothermia/hyperthermia Self-measurement of vital signs Hypertension: risk factors; primary prevention strategies Vital signs monitor Doppler transducer technique

Cultural Variations Potential cultural variations Mexican American patients (expect nurses to show warmth to patients and family) Asian cultures (spoken and written order of the name is last name, first name; no comma) Southeast Asian patients: “krun” (translated as fever, but can mean “feeling ill”) Arab cultures (don’t disclose personal or sexual information) East African (skin decorations with henna; black henna causes errors in O2 sat readings) Obesity in U.S. populations

Evidence-Based Critical Thinking Nursing diagnoses Identify problem; facilitate planning individualized care Critical thinking strategies Collect data for initial database Monitor baseline trends Identify patterns Analyze findings

Question What is the prevalence of obesity among men in the United States? A. African American men have highest prevalence of obesity in United States. B. Caucasian men have highest prevalence of obesity in United States. C. No significant variation by race/ethnicity. D. Mexican American men have highest prevalence of obesity in United States.

Answer Rationale: The prevalence of obesity does not differ significantly by race/ethnic group in men (Ogden et al., 2007). Reduction of obesity is included in the Healthy People goals for many developed nations.

NCLEX-Style Review Questions The nurse assesses the following vital signs in a 78-year- old man: T 36.6°C, temporal; P 72 bpm, regular, 2+; R 18 breaths/minute, regular, no use of accessory muscles; BP 142/92 mm Hg. Which of the findings is abnormal? Pulse BP Respirations Temperature

NCLEX-Style Review Questions Rationale: In older adults, both the SBP and DBP increase due to increased stiffness of arterial walls. This finding is outside of the normal range. Temperature in the older adult tends to be at the lower range of normal.

NCLEX-Style Review Questions What are the four characteristics of respirations?

NCLEX-Style Review Questions The patient's radial pulse is weak and thready. The next action of the nurse is to transfer the patient to a critical care unit. notify the primary care provider. compare findings to previous findings and opposite extremity. assess vital signs every 15 minutes.

NCLEX-Style Review Questions Rationale: The popliteal pulse is often difficult to palpate. Comparing to previous findings and to the opposite extremity can assist to determine if any acute changes have occurred.

NCLEX-Style Review Questions Which of the following patients should not have a ­ temperature measured orally? An 84-year-old woman with diarrhea A 30-year-old patient with an earache A 45-year-old man with chest pain A 62-year-old woman who has had oral surgery

NCLEX-Style Review Questions Rationale: Oral temperature measurement is contraindicated in patients who have altered mental status, those who are mouth breathers, those who have had recent oral intake or who have recently smoked, and those who have recently undergone oral surgery.

NCLEX-Style Review Questions The nurse notes an irregular radial pulse in a patient. ­ Further evaluation includes assessing for a pulse deficit. the carotid pulse. for diminished peripheral circulation. the brachial pulse.

NCLEX-Style Review Questions Rationale: Assessing for a pulse deficit provides an indirect evaluation of the heart's ability to eject enough blood to produce a peripheral pulse. When a pulse deficit is present, the radial pulse is less than the apical pulse.

NCLEX-Style Review Questions Which actions will result in an inaccurate BP reading? Select all that apply. Obtaining a BP immediately after the patient has ­ entered the room Using a BP cuff 80% of the arm circumference Asking the patient to hold out his or her arm above heart level Pumping the cuff 10 mm Hg above the palpated ­systolic BP

NCLEX-Style Review Questions Rationale: Common errors in blood pressure measurements can ­occur because of physical activity, incorrect cuff size, and ­placing the heart above or below heart level and failure to auscultate above an auscultatory gap. It is recommended to pump the cuff 20 to 30 mm Hg above the last sound.

NCLEX-Style Review Questions Adult patients may have variations in pulse rates with respirations. food intake. heat. exercise.

NCLEX-Style Review Questions Rationale: Exercise will increase heart rate due to increased metabolic demands. Sinus arrhythmia, a variation in pulse with respiration, is common among children. The pulse rate varies with respiration, speeding up during inspiration and slowing down during expiration.

NCLEX-Style Review Questions An unconscious 22-year-old man arrives at the hospital after experimenting with hallucinogenic substances. His vital signs are T 37.2°C, po; P 142 bpm; R 20 breaths/min; BP 100/64 mm Hg. The patient is experiencing tachycardia. eupnea. auscultatory gap. asystole.

NCLEX-Style Review Questions Rationale: Tachycardia is a heart rate greater than 100 beats/min in an adult.

NCLEX-Style Review Questions An auscultatory gap is defined as a drop in the SBP of 15 mm Hg or more with position change. a period of silence heard between Korotkoff sounds. the difference between the apical and radial pulse. SBP minus the DBP.

NCLEX-Style Review Questions Rationale: The auscultatory gap is the period of no Korotkoff sounds during auscultation of a blood pressure. It is caused by stiffening of the arterioles and is common in the elderly and in those with chronic disease.

NCLEX-Style Review Questions Which of the following findings during the general ­survey may indicate a change in mental status? Select all that apply. Disheveled appearance Rapid speech Lethargy Asymmetrical movements

NCLEX-Style Review Questions Rationale: The general survey provides valuable clues to the patient's overall status. Changes in appearance, speech, and alertness may indicate a change in mental status and require further evaluation. Asymmetrical movements may indicate a stroke and a specific change in neurological status.