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 False 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.)

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

Lifespan Considerations: Older Adults General survey: normal, unexpected findings Height/weight: normal, unexpected findings Vital signs: normal, unexpected findings Temperature Pulse Respirations Pulse oximetry Blood pressure

Cultural Variations Potential cultural variations Mexican American patients Asian cultures Southeast Asian patients: “krun” Arab cultures East African 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 C. No significant variation by race/ethnicity. 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.