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
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.

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.)

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

21. 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

22. 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

23. Cultural Variations Potential cultural variations
Mexican American patients
Asian cultures
Southeast Asian patients: “krun”
Arab cultures
East African
Obesity in U.S. populations

24. 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

25. 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.

26. 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.