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Chapter 9
General Survey and
Vital Signs
Copyright 2002, Delmar, A division of Thomson Learning
Competencies
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Describe initial assessment
observations.
Discuss factors affecting respiratory
rate.
Perform respiratory rate assessment.
Describe the characteristics that are
included in an assessment of pulse.
Measure apical, radial, and brachial
pulses.
(continues)
Copyright 2002, Delmar, A division of Thomson Learning
Competencies
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Discuss factors influencing body
temperature.
Compare oral, rectal, axillary, and
tympanic methods for temperature
measurement.
(continues)
Copyright 2002, Delmar, A division of Thomson Learning
Competencies
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Demonstrate body temperature
assessment techniques utilizing
glass, electronic, and tympanic
thermometers.
Describe factors influencing blood
pressure and blood pressure
measurement.
Describe two methods to measure
blood pressure.
Copyright 2002, Delmar, A division of Thomson Learning
General Survey
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Physical presence
Assess the patient’s
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Stated age vs. Apparent age
General appearance
Body fat
Stature
Motor activity
Body and breath odors
(continues)
Copyright 2002, Delmar, A division of Thomson Learning
General Survey
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Psychological presence
Observe the patient’s
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Dress, grooming, personal hygiene
Mood and manner
Speech
Facial expressions
(continues)
Copyright 2002, Delmar, A division of Thomson Learning
General Survey
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Distress
Assess for
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Labored breathing, wheezing, cough,
labored speech
Painful facial expressions, sweating,
guarding
Serious or life-threatening
complications
Emotional distress or anxiety
Copyright 2002, Delmar, A division of Thomson Learning
Vital Signs
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Respiration
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How to assess?
Count for 1 full minute
Normal findings
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Adult rate 12–20 per minute
Abnormal findings
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Tachypnea
Bradypnea
Apnea
(continues)
Copyright 2002, Delmar, A division of Thomson Learning
Vital Signs
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Pulse
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How to assess?
Count for 1 full minute
Rate
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Rhythm
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Normal range for adults = 60–100 bpm
Regular vs. Irregular
Volume
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Absent to bounding
Use 3- or 4-point scale for measuring
Copyright 2002, Delmar, A division of Thomson Learning
Factors Affecting Heart
Rate
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Age
Gender
Activity
Emotional status
Pain
Environmental factors
Stimulants
Medications
Copyright 2002, Delmar, A division of Thomson Learning
Peripheral Pulses
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Pedal
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Dorsalis pedis
Posterior tibialis
Popliteal
Femoral
Brachial
Carotid
Temporal
Copyright 2002, Delmar, A division of Thomson Learning
Pulses
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Radial
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Location?
How to find?
Count for 30 or 60 seconds
Apical
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Location?
How to find?
Count for 30 or 60 seconds
(continues)
Copyright 2002, Delmar, A division of Thomson Learning
Pulses
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Rate
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Rhythm
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Tachycardia
Bradycardia
Asystole
Regular vs. Irregular
Dysrhythmias
Volume
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Weak vs. Strong
Copyright 2002, Delmar, A division of Thomson Learning
Vital Signs
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Temperature
Celsius
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How to convert?
5/9 x (temp in °F – 32 degrees)
Fahrenheit
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How to convert?
(9/5 x temp in °C) + 32 degrees
Copyright 2002, Delmar, A division of Thomson Learning
Routes
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Oral
Average
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Range
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36–38° C or 96.8–100.4° F
Advantages
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37.0° C or 98.6° F
Convenient, accessible
Disadvantages
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Safety, physical abilities, accuracy
Copyright 2002, Delmar, A division of Thomson Learning
Rectal
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Average
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Range
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36.7–38.5° C or 98.0–101.6° F
Advantages
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0.7° C or 0.4° F higher than oral
Most accurate
Disadvantages
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Safety, invasive, uncomfortable
Copyright 2002, Delmar, A division of Thomson Learning
Axillary
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Average
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Range
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35.4–37.4° C or 95.8–99.4° F
Advantages
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0.6° C or 1° F lower than oral
Safe, noninvasive
Disadvantages
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Accuracy? Length of time to obtain
measurement
Copyright 2002, Delmar, A division of Thomson Learning
Tympanic
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Average
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Range
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Same as oral and rectal
Advantages
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Calibrated to oral or rectal scales
Convenient, fast, safe
Disadvantages
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Accuracy? Technique affects reading
Copyright 2002, Delmar, A division of Thomson Learning
Variables Affecting
Body Temperature
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Circadian rhythms
Hormones
Age
Exercise
Stress
Copyright 2002, Delmar, A division of Thomson Learning
Temperature Variations
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Hyperthermia
Hypothermia
Copyright 2002, Delmar, A division of Thomson Learning
Blood Pressure
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Force exerted by the flow of blood
pumped into the large arteries
Korotkoff sounds
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Phase I
Phase II
Phase III
Phase IV
Phase V
Copyright 2002, Delmar, A division of Thomson Learning
Measuring Blood
Pressure
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Systole
Diastole
Pulse pressure
Equipment
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Sphygmomanometer
Aneroid manometer
Mercury manometer
(continues)
Copyright 2002, Delmar, A division of Thomson Learning
Measuring Blood
Pressure
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Sites
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Brachial
Thigh
Avoid AV shunts or fistulas,
affected arm of postmastectomy
patient
(continues)
Copyright 2002, Delmar, A division of Thomson Learning
Measuring Blood
Pressure
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Documentation
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Normal findings
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Position of patient
Location where taken
100–140/60–90
Average = 120/80
Hypotension
Hypertension
Copyright 2002, Delmar, A division of Thomson Learning
Common Errors in
Blood Pressure
Measurements
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Incorrect cuff size
Unrecognized auscultatory gap
Incorrect cuff placement
Copyright 2002, Delmar, A division of Thomson Learning
Factors Influencing
Blood Pressure
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Stress
White coat syndrome
Medications
Hypervolemia
Hypovolemia
Copyright 2002, Delmar, A division of Thomson Learning