Weber Chapter 8 - Comprehensive Vital Signs and General Survey: Equipment, Assessment, and Interpretation

Thermometer

Types include tympanic, temporal artery, electronic oral/axillary, rectal.

Protective disposable covers

Used for thermometer.

Sphygmomanometer

Can be aneroid, mercury, or electronic BP equipment.

Stethoscope

Used to listen to internal body sounds.

Watch with second hand or phone timer

Used to time pulse and respiratory rates.

Mobile monitoring system

Example: DINAMAP, used for simultaneous vital signs measurement.

Advantages of mobile monitoring systems

Measure multiple vital signs quickly, often include thermometer, BP monitor, pulse, and oxygen saturation.

General survey

Assesses client's overall appearance, body build, fat distribution, posture, gait, dress, hygiene, gender, sexual development, and apparent age vs. stated age.

Routine assessment

Includes observation, body development, vital signs, oxygen saturation, pain assessment.

Focused assessment

Involves use of Doppler for difficult pulses, detailed cardiac or irregular pulse assessment.

Normal body proportions

Arm span ≈ height; distance crown → pubis ≈ pubis → sole.

Abnormal body proportion findings

Includes hypopituitary dwarfism, achondroplastic dwarfism, gigantism, acromegaly, extreme weight loss (anorexia), Marfan syndrome (arm span > height), obesity types (endogenous/exogenous), abnormal fat distribution (Cushing).

Apparent age vs. chronologic age

Older appearance may indicate chronic illness, alcoholism, smoking, outdoor labor; younger appearance may indicate slow maturity, genetics, or rare progeria syndromes.

Normal skin color observations

Even color; underlying red tones for healthy glow; light-skinned: beige-pink; dark-skinned: tan, brown, or olive.

Abnormal skin color findings

Extreme pallor, flushed, yellow in light-skinned; ashen gray or cyanosis in dark-skinned.

Normal posture and gait

Erect, comfortable; rhythmic, coordinated, arms swing naturally.

Abnormal posture/gait

Includes curvatures (lordosis, scoliosis, kyphosis), stiff or rigid movements, slumped shoulders, tripod position in COPD, altered gait in older adults (wider/narrow base, waddling, decreased arm swing).

Factors determining temperature measurement route

Age, health status, consciousness, medical treatment, physical condition.

Normal tympanic temperature range

36.7°C-38.3°C (98.0°F-100.9°F).

Normal oral temperature range

35.9°C-37.5°C (96.6°F-99.5°F).

Normal axillary temperature range

35.4°C-37.0°C (95.6°F-98.5°F).

Normal temporal artery temperature range

36.3°C-37.9°C (97.4°F-100.3°F).

Normal rectal temperature range

36.3°C-37.9°C (97.4°F-100.3°F).

Abnormal temperature findings

Hypothermia: <36.7°C (98.0°F); Hyperthermia: >38.3°C (100.9°F); Causes include infection, trauma, endocrine disorders, starvation.

Older adult considerations for temperature

Lower metabolism → lower body temperature; slight fever (>35.8-37.5°C) may indicate infection.

Normal adult radial pulse

60-100 beats/min

Tachycardia

>100 bpm (fever, stress, meds, dysrhythmias)

Bradycardia

<60 bpm (athletes, heart block, prolonged sitting)

How to assess pulse

Radial pulse with pads of 1st & 2nd fingers; count 15 sec ×4 or 30 sec ×2; full minute if irregular. Confirm with apical pulse if abnormal.

Assess pulse rhythm and amplitude

Rhythm: regular or irregular (regularly irregular vs. irregularly irregular). Amplitude: smooth, rapid upstroke; gradual downstroke. Weak, bounding, or delayed upstroke is abnormal.

Older adult considerations for pulse

Arteries may feel rigid, hard, less elastic.

Normal respiratory rate

12-20 breaths/min; older adults 15-22 breaths/min

Bradypnea

<8-12/min

Tachypnea

>24/min

Hyperventilation

Rapid, deep breaths

Apnea

Absence >10 sec

Dyspnea

Labored/difficult breathing

Normal SpO₂

92-99%; 85-89% may be acceptable in chronic lung disease

Normal BP

<120/80 mmHg

BP classifications (per new guidelines)

Normal: <120/<80; Elevated: 120-129/<80; Stage 1: 130-139 / 80-89; Stage 2: ≥140 / ≥90; Hypertensive crisis: >180 / >120 (emergency)

Older adult considerations for BP

Stiffer arteries → higher systolic → isolated systolic hypertension (>130/<80)

Orthostatic hypotension criteria

Drop ≥20 mmHg systolic from sitting to standing → risk for dizziness/falls. Pulse increases to compensate.

Pulse pressure normal range

30-50 mmHg; lower or higher may indicate cardiovascular disease

Korotkoff sounds phases

Phase I: First faint tapping → systolic; Phase II: Muffled/swishing, may have auscultatory gap; Phase III: Crisp, loud sounds; Phase IV: Muffled, soft; Phase V: Disappearance → diastolic (common measurement)

Safety tips for accurate BP measurement

Avoid smoking, caffeine, exercise, anxiety, tight/loose cuff, crossed legs, arm below heart. Avoid noisy environment, poor stethoscope placement.

How to assess pain

Observe comfort, posture, facial expression; ask client; explore using COLDSPA mnemonic.

Normal pain findings

Client relaxed, facial expression pleasant, no subjective report of pain.

Abnormal pain findings

Grimacing, frowning, bracing body, labored breathing.

How to use collected data

Identify strengths, abnormalities, cluster data, make informed clinical judgments.

Examples of client concerns & risks

Risk for falls → orthostatic hypotension; Risk for infection → skin lesion; Unstable BP → inconsistent meds; Hypothermia → cold exposure; Poor communication → language barrier or aphasia; Inability to ambulate → deconditioning.

Collaborative problems

RC Hypertension, RC Hypotension, RC Dysrhythmias, RC Hyperthermia, RC Hypothermia, RC Brady/Tachycardia, RC Dyspnea, RC Hypoxemia.