General Survey and Vital Signs

What are the four components of a general survey?

Physical appearance, mental status, mobility, and patient behavior.

What is assessed under physical appearance during a general survey?

Immediate and important cues including affect, color, build, and posture.

What is assessed under mental status during a general survey?

Affect, mood, level of anxiety, orientation, and speech.

What is assessed under mobility during a general survey?

Gait, posture, and range of motion.

What is assessed under patient behavior during a general survey?

Dress and grooming, body odors, facial expressions, mood/affect, eye contact, and engagement during the assessment.

What are the major vital signs and measurements included in this PowerPoint?

Temperature, respiratory rate, heart rate/pulse, blood pressure, pain assessment, and pulse oximetry/SpO2.

What does VS stand for?

Vital signs.

Why are vital signs called "vital signs"?

Because they reflect the patient's physiological status and provide information about homeostasis.

What does T stand for when documenting vital signs?

Temperature.

What does BP stand for?

Blood pressure.

What does HR stand for?

Heart rate.

What does P stand for?

Pulse.

What does R or RR stand for?

Respiratory rate.

When should vital signs be assessed?

During physical exams; during screenings such as health fairs and blood donations; during home visits; before and after diagnostic or surgical procedures; upon admission and discharge from a healthcare facility; and before administration of certain medications.

Why is documentation of vital signs important?

Documentation establishes a baseline, allows trends to be identified over time, and facilitates communication.

What is thermoregulation?

The body's process of balancing the amount of heat produced with the amount of heat lost.

What are the two types of body temperature discussed in the PowerPoint?

Core temperature and surface temperature.

What body structure plays a major role in regulating temperature?

The hypothalamus.

What other structures are involved in temperature regulation?

Deep body and peripheral thermal regulators/receptors.

What body systems or structures help with additional heat production or heat loss?

Blood vessels, sweat glands, and skeletal muscles.

What is the ideal temperature range listed for infants?

97-100°F.

What is the ideal temperature range listed for children?

98.6-99.6°F.

What is the ideal temperature range listed for adults?

98.6-99.6°F.

What is the ideal temperature range listed for older adults?

96.9-98.3°F.

What factors can influence body temperature?

Age, circadian rhythms, hormones, stress, environment, nervous system impairment, circulatory impairment, skin impairment, infection, and exercise.

What is hypothermia according to the PowerPoint?

A body temperature of approximately 86-89.6°F.

What are two types of hypothermia listed?

Induced hypothermia and accidental hypothermia.

What is hyperthermia?

A temperature above the patient's normal range.

What is pyrexia?

Fever; the PowerPoint lists 98.8-104.7°F.

What is hyperpyrexia?

A very high fever, listed in the PowerPoint as over 105.8°F.

What NANDA diagnoses are associated with temperature?

Hyperthermia, hypothermia, risk for hypothermia, risk for imbalanced body temperature, ineffective thermoregulation, and risk for perioperative hypothermia.

What temperature-monitoring method is no longer used?

A mercury-in-glass thermometer.

What type of thermometer is commonly used instead?

A digital electronic thermometer.

What sites can be used with digital electronic temperature monitoring?

Oral, axillary, rectal, and tympanic membrane sites.

What does respiration mean?

The mechanism of exchange of gases between the atmosphere and the cells.

What is respiratory rate?

The number of full inspirations and expirations, or breaths, in one minute.

What should be evaluated in addition to respiratory rate?

The work of breathing.

What structures help regulate respiration?

Chemosensitive areas of the pons and medulla oblongata and chemoreceptors in the carotid and aortic bodies.

What three processes are associated with respiration?

Ventilation, diffusion, and perfusion.

What factors influence respiratory rate?

Exercise, stress, altitude, medications, the central nervous system, and the patient being aware that you are counting.

What is tachypnea?

An abnormally rapid respiratory rate.

What is bradypnea?

An abnormally slow respiratory rate.

What is apnea?

Absence of breathing.

What is Cheyne-Stokes respiration?

An abnormal respiratory pattern characterized by cyclic changes in breathing; the PowerPoint lists it as a diagnostic variation.

What is orthopnea?

Difficulty breathing when lying flat; the PowerPoint lists it as a respiratory diagnostic variation.

What is dyspnea?

Difficulty or discomfort with breathing; the PowerPoint lists it as a respiratory diagnostic variation.

What NANDA diagnoses are associated with respiration?

Impaired gas exchange, ineffective airway clearance, and ineffective breathing pattern.

What are the four routes of respiratory assessment listed?

Inspection, palpation, auscultation, and an apnea monitor.

What is the normal respiratory rate for a newborn to 6 weeks?

30-60 breaths/min.

What is the normal respiratory rate for an infant 6 weeks to 6 months?

25-40 breaths/min.

What is the normal respiratory rate for a toddler 1-3 years?

20-30 breaths/min.

What is the normal respiratory rate for young children 3-6 years?

20-25 breaths/min.

What is the normal respiratory rate for older children 10-14 years?

15-20 breaths/min.

What is the normal adult respiratory rate?

12-20 breaths/min.

What should you do if a pediatric patient is panting and you need to count respirations?

Use a stethoscope to count the respirations.

Why can agitation cause an inaccurate respiratory rate?

Agitation can alter the patient's breathing pattern and therefore produce an inaccurate respiratory rate.

What should be completed first when obtaining pediatric vital signs?

The least invasive vital signs should be completed first.

Can respiratory rate reliably determine whether a patient has low oxygen levels?

No. Respiratory rate is not a reliable way to determine low oxygen levels.

What measurement should be used to assess oxygen saturation?

Pulse oximetry/SpO2.

What does SpO2 measure?

Blood oxygen saturation as measured by pulse oximetry.

What is the goal SpO2 listed in the PowerPoint?

100%.

What SpO2 level is generally considered acceptable according to the PowerPoint?

Anything greater than 90% is generally acceptable.

Where is a pulse oximeter commonly placed?

On the finger.

What are alternative locations for pulse oximetry?

Stickers or meters placed on the ear.

What is heart rate?

The beating of the heart.

How does the autonomic nervous system relate to heart rate?

The heart operates through the autonomic nervous system, including the sinoatrial (SA) node of the heart.

What cardiac structure is specifically mentioned in relation to contractility?

The left ventricle.

What factors influence pulse/heart rate?

Developmental state, gender, exercise, fever, medications, hemorrhage, stress, and position changes.

What pulse characteristics should be assessed?

Rate, pulse grade/strength, and rhythm.

What pulse variations may be abnormal?

Abnormal rates, abnormal pulse strength/grade, and abnormal pulse rhythms.

What NANDA diagnoses are associated with pulse/cardiovascular function?

Decreased cardiac output or risk for decreased cardiac output and risk for impaired cardiovascular function.

What methods can be used to monitor pulse?

Palpation, auscultation, Doppler auscultation, and electrocardiogram.

When should an irregular pulse be counted for a full 60 seconds?

Whenever the pulse rhythm is irregular or skipping.

What is an apical pulse?

A pulse obtained by listening to the heart with a stethoscope at the apex of the heart.

When should an apical pulse be obtained?

When the pulse is difficult to feel or count, when the pulse is very fast or very slow, in children under 2 years of age, or in anyone with a cardiac disorder.

Where is the apical pulse obtained?

By listening with a stethoscope at the apex of the heart.

When is an automated BP machine likely to provide an accurate pulse reading?

When the pulse is strong and normal.

When can an automated BP machine provide an inaccurate pulse reading?

With very fast or very slow pulses, weak/skipping/irregular pulses, arm movement, or agitation.

What should you do when you are unsure about an automated pulse reading?

Count the pulse yourself.

What did one study find regarding nurses' pulse-rate assessment?

One study found that 86% of nurses underestimated the pulse rate.

What are the normal pulse rates for babies up to age 1?

100-160 beats/min.

What are the normal pulse rates for children ages 1-10?

60-140 beats/min.

What are the normal pulse rates for children age 10+ and adults?

60-100 beats/min.

What is the normal pulse rate listed for well-conditioned athletes?

40-60 beats/min.

What is blood pressure?

The force or pressure of blood against the arterial walls.

What two pressures are measured when obtaining blood pressure?

Systolic pressure and diastolic pressure.

What is systolic blood pressure?

The maximum pressure the heart exerts while the ventricle is contracting.

What is diastolic blood pressure?

The pressure in the arteries between heart contractions.

What is pulse pressure?

A measurement of the force the heart generates with each contraction.

What factors regulate blood pressure?

Peripheral resistance, elasticity of vessel walls, pumping action of the heart, blood volume, and blood viscosity.

What factors can influence blood pressure?

Gender, stress, medications, circadian rhythms, race, exercise, body weight, body position, and blood volume.

What NANDA diagnoses are associated with blood pressure?

Risk for ineffective peripheral tissue perfusion, deficient fluid volume or risk for deficient fluid volume, excess fluid volume, and risk for imbalanced fluid volume.

What are the methods of blood pressure monitoring listed?

Auscultation, palpation, Doppler, electronic blood pressure meters, and direct measurement through an arterial line.

What effect can sitting without back support have on systolic blood pressure?

It can increase systolic BP by approximately 6-10 mmHg.

How can the effect of sitting without back support be corrected?

The patient's back should be supported while sitting in a chair.

What effect can a full bladder have on systolic blood pressure?

It can increase systolic BP by approximately 15 mmHg.

How can the effect of a full bladder be corrected?

The patient should empty their bladder before the blood pressure is taken.

How can tobacco or caffeine use affect systolic blood pressure?

It can increase systolic BP by approximately 6-11 mmHg.

What should be done regarding tobacco or caffeine before a BP measurement?

The patient should avoid tobacco and caffeine before the clinic appointment.

How should the patient's arm be positioned during a seated blood pressure measurement?

The arm should be straight out and supported, with the elbow at heart level.