Assessing General Health Status & Vital Signs CH8

General Health Status & Vital Signs

Objectives

To prepare the client for a general health survey and vital sign measurement, accurately perform a general survey, measure vital signs using correct techniques and modifications, differentiate between normal and abnormal findings, and analyze general survey and vital sign data to make accurate clinical judgments at the novice level.

General Survey

The general survey involves looking at the whole person, their general state of health, and obvious physical characteristics. It precedes the physical examination and begins immediately upon encounter with the client. The initial impression of the client is formed by observing four key areas:

• Physical Appearance: Includes physical development, body build, gender and sexual development, apparent age compared to reported age, skin condition and color, dress, hygiene, facial expression.

• Body Structure: Pertains to physical development and body build.

• Mobility: Involves posture, gait, and body movements.

• Behavior: Encompasses level of consciousness, overall behavior, and affect.

• Speech: How the client communicates.

• Vital Signs: Are also a component of the general survey.

Post-General Survey Measurements

After the initial general survey, additional measurements may be obtained:

• Weight: Measured by removing shoes and heavy clothing, ideally at the same time each day, and with similar clothing for consistency.

• Height: A standard measurement.

• Body Mass Index (BMI): Calculated from weight and height. A normal BMI is typically $19$ or greater and less than $25$.

• Waist Circumference: Important because excess abdominal fat is an independent risk factor for various diseases.

What are Vital Signs?

Vital signs are objective data—measurements taken to assess the most basic body functions. They are observable, measurable, and monitorable. Normal ranges for vital signs can change with age and medical condition.

When to Assess Vital Signs

Vital signs are assessed in several critical situations:

• Upon admission to any healthcare agency.

• Based on agency institutional policy and procedures.

• Any time there is a change in the patient’s condition.

• Before and after surgical or invasive diagnostic procedures.

• Before and after activities that may increase risk.

• Before and after administering medications that affect cardiovascular or respiratory functioning.

Importance of Vital Signs

Vital signs mark the beginning of the hands-on physical examination. They provide crucial data reflecting the status of key body systems:

• Cardiovascular System

• Neurologic System

• Peripheral Vascular System

• Respiratory System

Temperature

Temperature assessment involves measuring core body temperature.

• Core Temperature Range: $36.5^{\circ}C$ to $37.7^{\circ}C$ ($96.0^{\circ}F$ to $99.9^{\circ}F$ orally).

• Variations: Can occur due to strenuous exercise, stress, or ovulation.

• Hypothermia: Core temperature below $36.5^{\circ}C$ (or less than $96.0^{\circ}F$ orally).

• Hyperthermia: Core temperature above $38.0^{\circ}C$ (or greater than $99.6^{\circ}F$ orally).

Routes of Measurement and Normal Ranges

• Oral: Most convenient and accurate site. Normal is $98.6^{\circ}F$ with a range of $96.6^{\circ}F$ to $99.5^{\circ}F$.

• Rectal: Typically $0.7^{\circ}F$ to $1^{\circ}F$ higher than oral temperature. This is considered the most accurate route as it's closest to core temperature.

• Tympanic Membrane (TMT): Ear temperature.

• Temporal Artery (TAT): Forehead temperature.

Procedure for Taking Temperature

• Oral (Electronic): Place the probe in the sublingual pocket (base of the tongue, not in front) with lips closed for $15-30$ seconds. Wait at least $15$ minutes if hot or cold drinks were consumed, and $2$ minutes if the client smoked. Be aware of the difference between blue (oral) and red (rectal) probes.

• Rectal (More Invasive): Requires gloves and a lubricated probe cover. Insert no more than $1$ inch for an adult and do not let go of the probe. It offers the most accurate core temperature reading.

• Tympanic (Ear): A quick method, taking $2-3$ seconds.

• Temporal Artery: Slide the probe across the forehead and behind the ear. Take multiple readings and average them for accuracy.

Pulse

Pulse is created by the contraction of the left ventricle of the heart. The stroke volume (the amount of blood pumped with each beat) is normally $70$ ml/beat.

• Normal Adult Rate: $60$ to $100$ beats/min.

• Tachycardia: Pulse rate greater than $100$ beats/min.

• Bradycardia: Pulse rate less than $60$ beats/min.

Assessment Parameters

When palpating the pulse (using the $1^{st}$ $2-3$ fingers, commonly at the radial artery), assess:

• Rate: Is it normal?

• Rhythm: Is it regular or irregular?

• Strength/Volume/Force: Graded on a scale:

  • $0$: Absent

  • $1+$: Weak and thready

  • $2+$: Normal

  • $3+$: Full or Bounding

• Contour: The shape of the pulse wave.

• Elasticity: The resilience of the artery wall.

Factors Affecting Pulse Rate

• Increase Pulse Rate: Pain, fever, stress, exercise, bleeding, decrease in blood pressure, some medications.

• Decrease Pulse Rate: Rest, increased age, certain medications, thyroid gland problems.

Pulse Points (Locations)

• Temporal

• Carotid

• Apical

• Brachial

• Radial (most common site for routine assessment)

• Ulnar

• Femoral

• Popliteal

• Posterior Tibial

• Dorsalis Pedis

Respirations

Respirations involve the movement of air in and out of the lungs through inspiration (inhalation) and expiration (exhalation).

Assessing Respiration

When assessing respirations, the client should ideally be unaware of the counting. It is best done immediately after assessing the pulse.

• Rate: Normal adult rate is $12-20$ breaths/min. Count for $30$ seconds if normal, or a full minute if abnormal.

• Depth: Observe if breaths are shallow or deep.

• Rhythm: Is the breathing pattern regular or irregular?

• Use of Accessory Muscles: Note any labored breathing or use of neck/chest muscles not typically involved in quiet breathing.

• Oxygen Saturation ($SPO _2$): Measured via pulse oximetry. Normal range is $92\%$ to $99\%$. For individuals with chronic lung disease, $85\%$ to $89\%$ may be considered acceptable.

Blood Pressure

Blood pressure is the force required by the heart to pump blood from the ventric into the arteries.

• Systolic Pressure: Maximum pressure exerted during left ventricular contraction.

• Diastolic Pressure: Resting pressure exerted constantly between each contraction.

• Most Common Measurement Site: The arm (brachial artery).

Key Terms

• Hypertension ($HTN$): High blood pressure.

• Hypotension ($HPT$): Low blood pressure.

• Normotensive: Normal blood pressure.

2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults

Factors Affecting BP

Numerous factors can influence blood pressure readings:

• Physiological: Age, exercise, emotions (stress, fear, anger, pain), sex, medications, disease processes, weight (e.g., obesity), cardiac output, peripheral vascular resistance, blood volume, blood viscosity (thickness), elasticity of vessel walls.

• Procedural: Clothing, incorrect placement of arm/legs, incorrect size of BP cuff.

Assessing BP: Equipment and Procedure

• Equipment Needed: Stethoscope, sphygmomanometer.

• Procedure/Technique:

  • Appropriate Cuff Size: The width of the rubber bladder should equal $40\%$ of the arm circumference, and the length of the bladder should equal $80\%$ of the arm circumference. There are $6$ standard cuff sizes.

  • 2-Step Method: A common technique to avoid the auscultatory gap.

  • Korotkoff Sounds: Auscultated sounds during BP measurement:

    • $1^{st}$ sound: Systolic pressure.

    • Last sound: Diastolic pressure.

Common Errors in BP Measurement

• Faulty Arm Position:

  • Above heart level: Falsely low reading (eliminates effect of hydrostatic pressure).

  • Below heart level: Falsely high reading (additional force of gravity added).

  • Person supports own arm: Falsely high diastolic (sustained isometric muscular contraction).

• Faulty Leg Position: Legs crossed can lead to falsely high systolic and diastolic readings.

Ideal Client Position for BP Measurement

• Seated for $3-5$ minutes prior to measurement.

• Not talking.

• Legs uncrossed, feet flat on the floor.

• Right arm supported with the cubital fossa at heart level.

• Bare arm (no clothing under cuff).

• Cuff placed $2$ cm from the bend of the elbow.

Orthostatic (Postural) Vital Signs

Also known as serial measurements of pulse and BP, performed to assess for orthostatic hypotension.

• Take baseline pulse and BP after client rests supine for $2-3$ minutes.

• Repeat measurements with the client sitting, then standing.

• Normal Finding: A drop of up to $10$ mmHg in BP is expected.

• Abnormal Finding: A drop greater than $20$ mmHg in BP or an increase greater than $20$ beats/min in pulse rate.

  • Causes: Suspect hypovolemia (e.g., dehydration, blood loss), or clients taking anti-hypertensive medications.

  • An abnormal drop can lead to fainting or syncope.

Pain

Pain screening is an important assessment, although it is no longer considered the fifth vital sign by The Joint Commission.

• Assessment: Observe comfort level.

• Tools: Various tools are available, such as the $1$ to $10$ Likert scale.

• Identification: Document location, intensity, quality, duration, and any alleviating or aggravating factors.

Developmental Competence: Older Adult Considerations

Specific physiological changes occur with aging that impact vital signs and general health assessment.

• Temperature: May range lower, from $35.0^{\circ}C$ to $36.4^{\circ}C$ ($95.0^{\circ}F$ to $97.5^{\circ}F$).

• Body Structure: Osteoporosis can cause thinning and collapse of vertebrae, leading to kyphosis.

• Gait: Older men may have a wider base with arms held outward. Older women often have a narrow base and may waddle due to decreased balance. Steps shorten, and speed and arm swing decrease; gait may become rigid, and mobility may be reduced.

• Pulse: Arteries may feel more rigid, hard, and bent due to arteriosclerosis.

• Respirations: The respiratory rate may range from $15$ to $22$ breaths/min. The rate may increase with a shallower inspiratory phase because vital capacity and inspiratory reserve volume decrease with aging.

• Blood Pressure: More rigid, arteriosclerotic arteries contribute to higher systolic blood pressure. Isolated systolic hypertension is defined as systolic pressure over $140$ mmHg with diastolic pressure under $90$ mmHg. A widening of the pulse pressure (the difference between systolic and diastolic pressure) is also seen with aging due to less elastic peripheral arteries.

Electronic BP Monitoring

Automated vital signs monitors are used routinely in healthcare.

• Appropriate Use: Convenient for regular monitoring.

• Contraindications: Do not use if systolic BP is less than $90$ mmHg, or if the client is shivering, or experiencing seizures.

• Validation: If in doubt about an electronic reading, always validate with a manual BP measurement using a stethoscope.

Doppler Ultrasound

• Can be used to determine pressures, particularly in areas where pulses are difficult to palpate.

• Useful for locating peripheral pulse sites that are otherwise unpalpable.

Abnormal Findings Pertaining to General Survey

Specific conditions indicate abnormal findings during the general survey:

• Dwarfism: Abnormally small stature.

• Giantism: Abnormally large stature during childhood.

• Acromegaly: Excessive growth hormone secretion in adulthood, leading to enlargement of bones and skin.

• Anorexia Nervosa: Eating disorder characterized by an abnormally low body weight, intense fear of gaining weight, and a distorted perception of body image.

• Endogenous Obesity (Cushing Syndrome): Obesity caused by overproduction of cortisol, often leading to a characteristic