General Health Status and Vital Signs

When does the general survey begin and what is its primary technique?

It begins immediately when the nurse first encounters the client and primarily uses observation.

What does the nurse observe during the general survey?

Skin color, dress and hygiene, posture and gait, apparent age, level of consciousness, facial expression, speech, and behavior.

When are vital signs usually obtained during the physical examination?

At the beginning of the examination, generally after the client has rested for 5 minutes.

Why are vital signs important?

They reflect the functioning of multiple body systems and can indicate changes in the client's condition.

What subjective information may be collected during the general health assessment?

Biographical information, present health concern, personal health history and baseline information, family history, and lifestyle information.

What equipment may be used during the general health and vital signs assessment?

Thermometer, blood pressure cuff or DINAMAP, stethoscope, watch with a second hand, and pulse oximeter.

What objective information is assessed during the general survey?

Physical development, body build and fat distribution, stated versus apparent age, posture and gait, skin, and vital signs.

What are the five major vital signs included in the notes?

Temperature, pulse, respirations, blood pressure, and pulse oximetry.

What is failure to recognize and respond to a client's deterioration called?

Failure to rescue.

What factors should be considered when selecting a temperature measurement site?

Age, food or drink intake, surgery or procedures, wounds, mental status or level of consciousness, ability to follow commands, diaphoresis, and available equipment.

What are the normal temperature ranges by site in the notes?

Oral 35.9–37.7°C; tympanic 36.7–38.3°C; axillary 35.4–37.0°C; temporal 36.3–37.9°C; rectal 36.3–37.9°C.

What temperatures indicate hyperthermia and hypothermia according to the notes?

Hyperthermia is greater than 38°C; hypothermia is less than 35.9°C.

Can routine vital-sign measurement be delegated to unlicensed assistive personnel (UAP)?

Yes.

What should the nurse assess when evaluating a pulse?

Rate, rhythm, strength or amplitude, and elasticity.

What is the most commonly used pulse site for adults and children, and which site is preferred for infants younger than 2 years?

Radial pulse for adults and children; apical pulse for infants and children younger than 2 years.

How should the radial pulse be palpated?

Use the pads of the first and second fingers.

How long should the nurse count a pulse?

A regular adult pulse may be counted for 30 seconds and multiplied by 2; count for a full minute in children, cardiac clients, or when the rhythm is irregular.

What should the nurse assess when measuring respirations?

Rate, rhythm, and depth while observing the rise and fall of the chest.

How may respirations be counted?

Count chest rise and fall for 30 seconds and multiply by 2 when appropriate.

What does pulse oximetry measure and what normal range is given in the notes?

Peripheral arterial oxyhemoglobin saturation; the notes give a normal range of 90–100%.

When may pulse oximetry be especially useful?

During oxygen therapy, oxygen titration, hypoxia, hypoventilation, and postoperative monitoring.

What factors can interfere with pulse oximetry accuracy?

A blood pressure cuff on the same arm, gel nail polish, cold hands, and incorrect sensor placement.

Why should the pulse oximeter not be relied on alone for heart rate?

The notes state not to rely on the oximeter heart rate alone.

What cardiovascular factors influence blood pressure?

Cardiac output, peripheral vascular resistance, circulating blood volume, blood viscosity, and vessel elasticity.

What factors can cause inaccurate blood pressure measurements?

Crossed legs, incorrect arm position, incorrect cuff size, anxiety or tension, caffeine or medications, rapid cuff deflation, measuring over clothing, and incorrect cuff placement.

Which arms should be avoided when obtaining blood pressure?

An arm with a central or PICC IV, major injury, graft, dialysis fistula, mastectomy, pacemaker, or paralysis.

What blood pressure categories are given in the notes?

Normal 120/80; elevated 120–129 and <80; Stage 1 130–139 and 80–89; Stage 2 ≥140 or ≥90; hypertensive crisis >180 and/or >120 mmHg.

How many readings are used to determine blood pressure classification?

At least 2 readings on at least 2 occasions.

What is pulse pressure and how is it calculated?

The difference between systolic and diastolic blood pressure: SBP − DBP.

What is the normal pulse pressure range in the notes?

30–50 mmHg.

What is the correct sequence for obtaining orthostatic vital signs?

Supine for at least 3 minutes with BP and pulse → sit for 1 minute with BP and pulse → stand and obtain BP and pulse.

What findings indicate a positive orthostatic change according to the notes?

A systolic BP decrease greater than 20 mmHg or a diastolic BP decrease of 10 mmHg; heart rate may increase 10–20%.

What is an important nursing priority during orthostatic vital-sign assessment?

Client safety because position changes may increase fall risk.

What are the five Korotkoff phases?

Phase I: first clear tapping; Phase II: muffled/swishing; Phase III: loud/crisp; Phase IV: muffled; Phase V: sounds disappear.

What change in pulse may occur during childbearing?

Pulse may increase by 10–15 beats/min.

What measurements and findings should be monitored during childbearing?

Blood pressure, temperature, height, weight, sudden weight gain, and behavior.

What are the expected pulse and respiratory ranges for infants ages 28 days to 1 year?

Pulse 120–160 beats/min and respirations 30–60 breaths/min.

How should pulse be assessed in children?

Count for a full minute; the radial pulse may be used beginning at age 2 years.

What are the expected pediatric pulse ranges in the notes?

Ages 2–10 years: 70–110 beats/min; age 10 years and older: 55–90 beats/min.

What are the expected pediatric respiratory rates in the notes?

Ages 3–5: 20–28 breaths/min; ages 6–11: 18–25 breaths/min; ages 12–15: 12–20 breaths/min.

When should routine blood pressure measurement begin in children?

Annually beginning at age 3 years, using the correct cuff size.

What blood pressure formulas are provided for children ages 1–6 years?

Systolic BP = age + 90; diastolic BP = 53–66 mmHg.

What blood pressure formulas are provided for children ages 7–18 years?

Systolic BP = (2 × age) + 90; diastolic BP = age + 52.

What temperature range is identified for older adults in the notes?

95.0–97.5°F.

What pulse and blood pressure changes may occur in older adults?

The pulse may feel rigid, hard, or bent, and systolic BP may be higher because of arteriosclerotic changes in the arteries.

What is the purpose of an Early Warning Score (EWS)?

To identify clinical deterioration early so care can be escalated promptly.

What findings are included in the Early Warning Score?

Heart rate, respiratory rate, oxygen saturation, supplemental oxygen use, temperature, and mental status.

What conditions can an Early Warning Score help identify early?

Clinical deterioration such as sepsis, cardiac arrest, and respiratory failure.

What actions correspond to the Early Warning Score ranges in the notes?

0–4 = routine monitoring; 5–6 = increased monitoring frequency and nurse review; >7 = immediate clinical review.

What client concern is associated with orthostatic blood pressure changes?

Risk for falls.

What client concern may be associated with older age and dehydration?

Unstable body temperature.