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Copyright © 2013 by Mosby, an imprint of Elsevier Inc. General Inspection and Measurement of Vital Signs DSN Kevin Dobi, MS, APRN
General inspection begins the moment nurse meets patient. Initial impressions guide nurse to areas requiring further examination : Physical appearance Hygiene Body structure and movement Emotional and mental status Behavior Copyright © 2013 by Mosby, an imprint of Elsevier Inc.2
Does patient appear healthy? Any obvious findings such as tremors or facial drooping? Does patient appear close to stated age? Note that patient may appear older or younger than stated age due to drug and alcohol use, excessive sun exposure, chronic disease, and endocrine disorders. Note color and condition of skin. Any variations or obvious presence of lesions? Is patient clean and well groomed or disheveled? Any odors detected? Copyright © 2013 by Mosby, an imprint of Elsevier Inc.3
Body structure and position: Stature and height appropriate for age. Nutritional status: Well nourished, cachectic, obese. Body symmetry and positioning. Body movement: Note how patient moves. Use of assistive devices. Are there limitations in range of motion? Are there any involuntary movements such as a tremor or tic? Copyright © 2013 by Mosby, an imprint of Elsevier Inc.4
Emotional and mental status and behavior: Note alertness, facial expressions, tone of voice, and affect. Does patient maintain eye contact as culturally appropriate? Does patient converse appropriately? Are facial expressions and body language appropriate for conversation? Is clothing appropriate for weather? Is behavior appropriate? Copyright © 2013 by Mosby, an imprint of Elsevier Inc.5
Baseline indicators of patient’s health status include measurement of temperature, heart rate, respiratory rate, blood pressure, oxygen saturation, height, and weight. Assessing presence of pain is considered standard baseline data collected for all patients and included with assessment of vital signs. Vital signs, pain assessment, height, and weight are usually assessed at start of physical exam or integrated into exam. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.6
Body temperature is regulated by the hypothalamus: Heat gained through processes of metabolism and exercise. Heat lost through radiation, convection, conduction, and evaporation. Expected temperature ranges from 96.4 F to 99.1°F (35.8°C to 37.3°C). Average is 98.6°F (37°C). This is stable core temperature at which cellular metabolism is most efficient. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.7
Temperature during menstrual cycle increases 0.5°F to 1.0°F (0.3°C to 0.6°C) at ovulation and remains elevated until menses cease because of progesterone secretion. Moderate to vigorous exercise increases temperature. Normal variations occur throughout the day. Diurnal variations of 1°F to 1.5°F occur, with the lowest temperature in the morning and highest in the late afternoon. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.8
Temperature measurement by oral route is safe and relatively accurate. Delay at least 10 minutes if patient ingested hot or cold liquids or smoked. Electronic thermometer (sheathed): under tongue in sublingual pocket for 15 to 30 seconds. This location receives blood supply from carotid artery; thus indirectly reflects core temperature. Safe for use in school-aged children or confused adults. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.9
Tympanic membrane temperature: Probe covered with protective sheath, placed in external ear canal in contact with all sides of canal for 2 to 3 seconds. Axillary temperature measurement has questionable accuracy. Rectal temperature is used less frequently due to newer methods. Less comfortable, but safe for use in adults. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.10
Palpation of arterial pulses provides valuable information about cardiovascular system. Pulse determines heart rate and rhythm: Heart rate is number of times in a minute a pulsation is felt. Rhythm refers to regularity of pulsations or time between each beat. Pulses also provide important information on strength of pulse and perfusion of blood to various parts of the body. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.11
To take a pulse, place fingers over artery and feel for pulsations and rhythm: Use finger pads of index and middle fingers; apply firm pressure over pulse, but not so hard that pulsation is occluded. If rhythm is regular, count number of pulsations for 30 seconds and multiply by 2, or count for 15 seconds and multiply by 4. If pulse rhythm is irregular, note any odd rhythm, and count pulsations for full minute. Document irregular pulse when recording vital signs. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.12
Radial artery is most frequently used to measure heart rate because accessible and easily palpated: Radial pulse found at radial side of forearm at wrist. Brachial and carotid arteries are common alternative sites to assess pulse rate: Brachial pulse is located in groove between biceps and triceps muscles, in bend of elbow. Carotid pulse is found along medial edge of sternocleidomastoid muscle in lower third of neck. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.13
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.14
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.15
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.16
Heart rate can also be assessed by auscultating heart, which is known as apical pulse, and counting heart sounds for 1 minute. Located over the fifth intercostal space at the mid clavicular line Must use a stethoscope to auscultate heart rate Copyright © 2013 by Mosby, an imprint of Elsevier Inc.17
Respiratory rate involves counting number of ventilatory cycles and inhalation and exhalation, each minute. Men usually breathe diaphragmatically, increasing movement of abdomen. Women tend to be thoracic breathers, noted with movement of chest. Count respiratory rate when patient is unaware to prevent self-conscious changing of breathing rate or pattern. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.18
Other factors that increase respiratory rate are fever, anxiety, exercise, and high altitude. Note rhythm, depth, and effort of breathing: Rhythm is pattern or regularity of breathing and described as regular or irregular. Depth assessed by observing excursion or movement of chest wall. Depth described as deep (full lung expansion with full exhalation), normal, or shallow. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.19
Shallow breathing, small volume of air movement in and out of lungs, may be difficult to observe. Observe effort that goes into breathing also. Normal breathing should be even, quiet, and effortless when patient is sitting or lying down. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.20
Blood pressure is force of blood against arterial walls. It reflects relationship between cardiac output and peripheral resistance. Cardiac output is volume of blood ejected from heart each minute. Peripheral resistance is force that opposes flow of blood through vessels; when arteries are narrow, peripheral resistance to blood flow is high, and reflected in elevated blood pressure. Blood pressure is dependent on velocity of blood, intravascular blood volume, and elasticity of vessel walls. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.21
Blood pressure measured in millimeters of mercury (mm Hg). Systolic blood pressure is maximum pressure exerted on arteries when ventricles eject blood from heart contracts Diastolic blood pressure represents minimum amount of pressure exerted on vessels when ventricles of heart relax. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.22
Blood pressure is recorded with systolic pressure written on top of diastolic pressure (e.g., 130/76), but it is not a fraction. Pulse pressure is the difference between systolic and diastolic pressures and normally ranges from 30 mm Hg to 40 mm Hg. Orthostatic blood pressures are a series obtained when the patient is lying, sitting, and then standing. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.23
Blood pressure can be measured directly or indirectly. Direct measurement done by inserting a small catheter into artery that provides continuous blood pressure measurements and arterial waveforms. Direct measurement done in critical care settings when continuous monitoring required. Indirect measurement in all other settings done by auscultation with sphygmomanometer and stethoscope or with noninvasive blood pressure monitor. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.24
Sphygmomanometer consists of gauge to measure pressure, a cuff enclosing an inflatable bladder, and bulb with valve used to inflate and deflate bladder within cuff. Stethoscope used to auscultate blood pressure. Listen carefully for Korotkoff sounds. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.25
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.26
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.27
Blood flows freely through artery until inflated cuff interrupts blood flow. As cuff pressure slowly released, nurse listens for sounds of blood pulsating through artery again. Initial sound is called first Korotkoff sound, characterized by a clear, rhythmic thumping that gradually increases in intensity. Pressure reading at which this sound is first heard indicates systolic pressure. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.28
Second Korotkoff sound is a swishing sound heard as cuff continues to deflate. Third Korotkoff sound is a softer thump than first. Fourth Korotkoff sound is muffled and low pitched as cuff is further deflated. Fifth Korotkoff sound marks cessation of sound and indicates artery completely open. Manometer pressure noted at fifth Korotkoff sound is diastolic pressure. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.29
Noninvasive blood pressure (NIBP) monitor is an electronic device attached to cuff. Because NIBP monitor is an electronic device, nurse does not auscultate Korotkoff sounds. It senses blood flow vibrations and converts them to electric impulses transmitted to digital readout. Readout indicates blood pressure, mean arterial pressure, and pulse rate. Not capable of determining quality of pulse such as rhythm or intensity. May be programmed to repeat measurements on a schedule and to sound alarm if readings are outside desired limits. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.30
Number of patient-related factors affect blood pressure and should be kept in mind when interpreting blood pressure measurements. Age: From childhood to adulthood there is gradual rise. Gender: After puberty, women usually have a lower blood pressure than men; however, after menopause, women’s blood pressure may be higher than men’s. Race: Incidence of hypertension is twice as high in black Americans as in whites. (Cultural) Copyright © 2013 by Mosby, an imprint of Elsevier Inc.31
Diurnal variations: Pressure is lower in early morning and peaks in late afternoon or early evening. Emotions: Anxiety, anger, or stress may increase blood pressure. Pain: Acute pain may increase blood pressure. Personal habits: Caffeine or smoking within 30 minutes before measurement may increase reading. Weight: Obese patients tend to have higher blood pressures than nonobese patients. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.32
Accuracy of blood pressure measurement is significantly affected by nurse’s technique. Research indicates that many health care providers demonstrate incorrect technique or lack of knowledge associated with blood pressure measurement. Incorrect technique can result in false-low or false-high measurements. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.33
Measurement of oxygen saturation is included with vital signs in many settings: Oxygen saturation is measured by a pulse oximeter—a device that estimates oxygen saturation of hemoglobin in blood. Probe is taped or clipped to patient’s fingertip, toe, earlobe, or nose; oxygen saturation appears as a digital readout within 10 to 15 seconds after oximeter is placed. Oxygen saturation levels lower than 90% are considered abnormal and require further evaluation. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.34
Routine assessment of patient’s pain or comfort level is standard practice in all health care settings and often assessed with vital sign measurement. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.35
Body weight or mass is influenced by a number of factors, including genetics, dietary intake, exercise, and fluid volume. Genetics influence height and body size, including bone structure, muscle mass, and gender. Body weight is important for nutritional assessment, to determine changes in weight over time, and to calculate medication dosage. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.36
Unintentional weight change may be significant finding. Unexplained weight loss may be one indication of suspected malignancy or disease process. Measure weight using a balance scale by asking patient to stand on platform while large and small weights are balanced. Adjust smaller weight to balance scale reading weight to nearest quarter pound. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.37
Height is influenced by genetics and dietary intake; measured on a platform scale with a height attachment. Ask patient to stand on scale without wearing shoes; lower height attachment until horizontal headpiece touches top of patient’s head. Vertical measuring scale can measure in inches or centimeters. Adult height attained by age 18 to 20 years. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.38
Measurement of height (recumbent length), weight, and head and chest circumferences are important indicators of growth. Data are plotted on growth charts to assess growth patterns of infant and child and to compare growth to infants and children of same age and gender. Same process for general inspection and vital signs measurement among infants and children is followed as previously described. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.39
Measurement of height, weight, and vital signs in older adults is same as previously described. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.40
The nurse is working in a primary care clinic. She walks into the room, and the general inspection begins. What is not part of the general inspection? A. Patient’s facial expressions are consistent with verbalized emotions. B. Patient is wearing clothes that are normally worn by whites. C. Patient is staring down at the floor through most of the interview. D. Patient’s gait is strong and symmetrical. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.41
The nurse collects patient data through assessment of vital signs. Many nurses will delegate the performance of temperature data collection to unlicensed assistive personnel. As the nurse talks to the assistant, the nurse knows to teach that: A. Tympanic thermometers touch the tympanic membrane. B. Axillary temperatures are taken with the red probe on the electronic thermometer. C. Axillary temperatures are usually most accurate because of the local blood supply. D. Rectal thermometers are placed 2.8 cm to 3.5 cm into the rectum. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.42
A woman in labor suffers from preeclampsia. Nurses in the labor and delivery unit need to assess her blood pressure. The nurse explains to the patient that: A. Using a cuff that is too narrow will give a reading that is inaccurate and high. B. Deflating the cuff too quickly will make the reading inaccurate and high. C. Deflating the cuff 5 mm Hg per second will make the reading inaccurate and high. D. Waiting 3 minutes before repeating the blood pressure measurement will result in a false-high blood pressure measurement. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.43
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.44
Copyright ©2012 Delmar, Cengage Learning. All rights reserved. Chapter 38 Vital Signs and Measurements.
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