1. Chapter 5—Vital Signs and General Survey

2. 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

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

4. 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

5. 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

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

7. 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.

8. 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

9. 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

10. 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

11. 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

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

13. 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.

14. 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

15. 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

16. 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

17. 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

18. 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)

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

20. 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

21. 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

22. 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

23. 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.

24. 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.

25. 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

26. 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.

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

28. 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.

29. 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.

30. 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

31. 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.

32. 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.

33. 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.

34. 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

35. 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.

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

37. 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.

38. 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.

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

40. 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.

41. 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.

42. 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

43. 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.