Ch 10 - General Survey, Measurement, and Vital Signs

General Survey

• Physical Appearance

  • Age

  • Sex

  • Level of consciousness

  • Skin colour

  • Facial features

• Body structure

  • Stature

  • Nutrition

  • Symmetry

  • Posture

  • Position

  • Body build

  • Contour

• Mobility

  • Gait

  • Range of motion

• Behaviour

  • Facial expression

  • Mood and affect

  • Speech

  • Dress

  • Personal hygiene

Measurement

• Weight (in kg, g for babies)

• Height (m, cm)

• Body Mass Index (weight/(height)²) (<18.5: underweight, 30.3-34.9: obese)

• Waist-to-Hip Ratio (nearest part of waist, above umbilical) (widest part of hips and butt) (> 102cm men, >88cm women risk of: type 2 diabetes, hypertension, chronic heart disease)

Vital Signs

1. Temperature (T)

2. Pulse (P) aka Heartrate (HR)

3. Respiratory Rate (R)

4. Blood Pressure (BP)

5. Oxygen Saturation (SpO2)

6. Pain Assessment

Interpretation of Vital Signs

• Patterns and trajectories (we get baseline from patient and compare through shift)

• Medication's (intended and side effects)

• Health/conditions

• Age

• Technique/equipment (calibration, faulty, power outage, wrong size, if in doubt to take it again)

Average Temperatures

Oral: 35.8 - 37.3°C

Rectal: 0.4 - 0.5°C higher

Temperature Influences:

• Diurnal variance

• Menstruation cycle, pregnancy

• Exercise

• Age, fatigue, stress

Temperatures

• Oral - sublingual

  • Accurate and convenient

  • Cooperative and follow directions

  • Smoking and eating

• Tympanic - eardrum

  • Can be inconvenient

  • Non-invasive, efficient

• Temporal - forehead (temp of temporal artery)

  • Common and critical settings now

  • Non-invasive

  • Won't work with diaphoresis (sweating)

• Axilla - armpit, under arm

  • Lower expected findings and other roots (can be 0.3 - 0.6°C lower)

  • Usual route for infants and young children

• Rectal - rectum

  • Root of choice for newborns - 2yrs old

  • Time-consuming and uncomfortable for patient

  • Only to use when other roots are not practical

How to Palpate Pulse

• Palpate using the pads of first three fingers

• Don't use thumb

• Palpate for both rhythm and rate

• Established the rhythm first to accurately determine rate

• 30 to 60 seconds

Pulse Wave

• Rate (30 seconds x 2 or 60 seconds)

  • Range 60-100 bpm

  • Bradycardia (less than 50)

  • Tachycardia (more than <95-100)

• Rhythm

  • Regular, regularly irregular, irregularly irregular, sinus arrhythmia

• Force

  • 0-3+

3+ full, bounding

2+ normal

1+ weak, thready

0 absent

• Equality

  • Bilateral (should be equal and palpable on both sides)

Apical Pulse

• Fifth intercostal space at midclavicular line

• Auscultate

  • Rate and rhythm

  • Compare to peripheral pulse

• This pulse is used to pronounce patient dead

• Gold standard for counting a pulse

Pulse Deficit

Mismatched between apical and peripheral pulse

Respiration

• Assessed for 30-60 seconds

• Normal range 1 to 20 breaths (inspiration and expiration) per minute

  • Bradypnea - less than 10

  • Tachypnea - greater than 20

• Rate, rhythm, depth (shallow, weak, deep, slow, fast, interrupted, snoring, wheezing, difficult, steady, regular)

Oxygen Saturations

• Measures percentage of oxygen bound to the haemoglobin

• Expected findings of greater than 95%

• Requires equipment to be able to read

• Adult use finger probe or ear

• Infants probe taped to large toe

Blood pressure

Systolic Blood Pressure - pressure on artery from left ventricle contracting

Diastolic Blood Pressure - pressure on artery at rest

Pulse Pressure - difference between systolic and diastolic

Mean Arterial Pressure - SBP + 2 x DBP 3

Blood Pressure Influences

• Age

• Stress

• Gender

• Daily variations

• Medication

• Activity

• Obesity

• Smoking

• Family history

Blood Pressure Equipment

• Stethoscope

  • Bell or diaphragm (Bell for low pitch is technically better)

• Sphygmomanometer

  • Oscillometric (automatic)

  • Aneroid (manual)

• Sizing

  • Length (bladder of cuff in circle 80-100% of the upper arm circumference)

  • Width = 40% circumference of upper arm (too small=false high, too large=false low)

Blood Pressure Sites

• Sites to avoid

  • Dialysis grafts, IVs, mastectomy side, pain, bruising, infection

  • Ask the patient

• Preparing the patient

  • Never over top of clothing

  • Comfortable and relaxed (5 min rest prior to BP)

  • Sitting or lying

  • Bare arm supported at heart level

  • Legs uncrossed (false high)

  • Not to talk or move

Measuring Blood Pressure

• Considered three general stages

  • Fully compressed = silence

  • Partially compressed = sounds

  • Free-flowing = silence

• Korotkoff’s Sounds

  • Partially compressed

  • Sound changes in turbulent blood flow
    - Five stages
    - Stage 1 is where sound starts = systolic blood pressure
    - Stage 5 is where sound ceases = diastolic blood pressure

Auscultatory Gap

• Not expected

• Silence in middle of Korotkoff sounds

• If undetected - cause false reading

Assesin Orthostatic (Postural) Hypotension

• Supine for three minutes then take BP

  • This is the baseline

• Set them up and wait 2 to 3 minutes then take BP

• Have patient standing and wait 2 to 3 minutes and take BP

Normal Vital Ranges

Temperature: 35.8-37.3°C

Pulse: 60-100 bpm

Respiration Rate: 10-20 respirations per minute in adults

Blood Pressure: 120/80 mmHg

O2 Saturation: > 95% on RA

Geriatric Considerations

• Temperature less reliable indicator

  • More likely to be afebrile or hypothermic

• Irregular pulse

• Radial pulse may feel stiff, rigid, and tortuous

  • Does not indicate vascular disease in heart or brain

• Increased respiratory rate

• Increased systolic and diastolic due to hardened arteries