Weber Chapter 8 - General Survey and Vital Signs Assessment in Nursing

General Survey

The moment the nurse meets the client; it involves using observational skills during interaction and interview.

Purpose of the General Survey

To gain an overall impression of the client's physical, mental, and emotional status.

Key Areas Assessed in General Survey

- Physical development and body build

Gender and sexual development

Apparent age vs. reported age

Skin condition and color

Dress and hygiene

Posture and gait

Level of consciousness

Behaviors, body movements, and affect

Facial expression

Speech

Vital signs

Importance of Observing the Client

To detect distress, sadness, or pain that may be masked when the client knows they are being observed.

Action if Abnormalities are Observed

Perform an in-depth assessment of the affected body area (e.g., musculoskeletal assessment for abnormal gait).

Importance of Vital Signs

They are indicators of health and reflect the status of multiple body systems (cardiovascular, neurologic, peripheral vascular, respiratory).

Traditional Vital Signs

Temperature, pulse, respirations, blood pressure.

Fifth Vital Sign

Pain was added due to chronic undertreatment; however, its designation has been debated due to the opioid crisis.

Normal Core Body Temperature

36.5°C-37.7°C (96.0°F-99.9°F orally).

Factors Causing Variation in Temperature

Strenuous exercise, stress, ovulation, time of day (lowest 4-6 AM, highest 8 PM-midnight).

Hypothermia

<36.5°C (96°F); causes include cold exposure, hypoglycemia, hypothyroidism, starvation.

Hyperthermia

>38°C (100°F); causes include infections, malignancies, trauma, blood/endocrine/immune disorders.

Older Adult Temperature Considerations

Normal temperature may be 35-36.4°C (95-97.5°F); infections may not cause a classic fever.

Pulse

Shock wave from heart contraction traveling through arteries; reflects cardiovascular status.

Characteristics to Assess in Pulse

Rate, rhythm, amplitude/contour, elasticity.

Amplitude Scale

- 0: Absent

1+: Weak/diminished

2+: Normal

3+: Strong

4+: Bounding

Observations in Respirations

Rate, rhythm, depth.

Nurse Assessment of Respirations

Observe chest movement without alerting the client, ideally while palpating radial pulse.

Blood Pressure Measurement

Pressure in arteries during systole (ventricles contract) and diastole (ventricles relax).

Factors Affecting Blood Pressure

1. Cardiac output

2. Peripheral vascular resistance

3. Circulating blood volume

4. Blood viscosity

5. Elasticity of vessel walls

Other Influences on Blood Pressure

Time of day, caffeine/nicotine, exercise, emotions, pain, temperature, body/arm position.

Pulse Pressure

Difference between systolic and diastolic pressure; reflects stroke volume.

Importance of Assessing Pain

Early predictor of disability; inexpensive and noninvasive.

Assessment of Pain

Location, intensity, quality, duration, alleviating/aggravating factors.

Assessment Tools & Mnemonic for Pain

Likert 1-10 scale; COLDSPA mnemonic (Character, Onset, Location, Duration, Severity, Pattern, Associated factors).