General Survey

Measurement
and
Vital Signs
CC2433 07/09/09
Ella Yu (VL)
Documentation guidelines
 Look at the example:
 Client: Mary Lee’s axillary temperature is 37C at 1000
07/09/2009
 Her pulse rate is 70 bpm
 Non Invasive Blood pressure (NIBP) is 120/60
 Respiratory rate: 20 bpm
 SaO2: 99%
 Now please chart her findings.
Learning Outcomes
 Identify the aspects in general survey,
measurement and vital signs
 Discuss the major issues in gathering the
vital signs
 Document the data correctly
General Survey
 Physical appearance
 Body structure

 Mobility

 Behavior

 Parental bonding for infants and children

General Survey
Physical appearance
 Age

 Sex

 Level of consciousness
 Skin color

 Facial features

 Signs of acute distress

General Survey
Physical appearance
 Level of consciousness
 Alert
 Awake or readily aroused
 Lethargic (or somnolent)
 Not fully alert, drifts off to sleep when not stimulated, but can be aroused to name
when called in normal voice but drowsy, respond appropriately but slow thinking
 Obtunded
 Sleeps most of the time, loud shout to arouse
 Stupor or semi coma
 spontaneously unconscious, respond only to persistent and vigorous shake or pain
 Coma
 Completely unconscious, no responds to pain or any external or internal stimuli
 Light coma- reflexive response
 Deep coma- no motor respond
General Survey
Body structure
 Stature- ? Excessively short or tall
 Nutrition- cachectic, emaciated vs simple
obesity, truncal obesity
 Symmetry- ? Atrophy/ hypertrophy

 Posture

 Position

 Body build, contour

Abnormalities in Body Height and Proportion:
Endogenous Obesity—Cushing's Syndrome.
General Survey
Mobility
 Gait

 Range of motion
General Survey
Behavior
 Facialexpression
 Mood and affect

 Speech

 Dress

 Personal hygiene
Measurement
 Weight

 Height/ length
 Head/ Chest circumference for infant and
children
 Please refer to textbook for the reference
values
 Height and weight
 Head circumference
Measurement
 Head circumference
 At birth and up to age 2
 Prominent frontal and occipital bones
 Newborn- 32 to 38 cm, 2 cm larger than the chest
circumference
 6 months to 2 years- head Vs chest almost the
same
 After 2 years, chest> head
Vital signs
 Temperature

 Pulse

 Respiration

 Blood pressure
Temperature
 Cellular
metabolism requires a stable core,
temperature of a mean 37.2°C (99°F).
 Hyperthermia
 Fever
 Pyrogens secretion
 Neurologic disorder
 Hypothermia
 Prolonged exposure to cold
 purposefully
Temperature
 Orally- 35.8°C to 37.3°C
 Posterior sublingual pockets

 3 to 4 minutes- 8 minutes

 Wait 15 minutes after food or drink and 2 minutes

after smoking
Temperature
 Rectal- 0.4°C to 0.5°C higher than oral temperature
 2 to 3 cm (1 in) into adult rectum

 2½ minutes

 Axillary- 5 ½ minutes
Temperature
 Tympanic membrane
 core temperature

 Shares same vascular supply that perfuse the

hypothalamus- the internal carotid artery
Factors influence the
temperature
A diurnal cycle
 The menstruation cycle

 Exercise

 Age
 Elderly- mean of 36.2°C
Thermometer
 Mercury-in-glass thermometer
 Electronic thermometer

 Tympanic membrane thermometer (TMT)

 Infrared emissions
Conversion
 Degree C= 5/9 (F-32)
 Degree F = (9/5 x C) + 32
When do we check the
temperature?
Alteration in Body temperature
 Pyrexia

 Hyperthermia

 Fever

A very high fever, such as 41C (105.8F) , is

called hyperpyrexia
 The client who has a fever- febrile

 The one who has not is afebrile

Four common type of fevers
 Intermittentfever
 Remittent fever

 Relapsing fever

 Constant fever

 Fever spike
Four common type of fevers
 Intermittent fever
 Alternates at regular intervals between periods of
fever and periods of normal temperatures
 Remittent fever
 A wide range of temperature fluctuations (more
than 2C (3.6F) occurs over 24-hours periods, all
of which are above normal
 Relapsing fever
 Short febrile periods of a few days are interspersed with
periods of 1 or 2 days of normal temperature
 Constant fever
 Fluctuates minimally but always remains above normal
 Fever spike
 Rises to fever level rapidly following a normal temperature
and then returns to normal within a few hours
 What are the clinical signs of fever?
 How about hypothermia?
Pulse
 Stroke volume- about 70 ml in the adult
 The heart pumps the stroke volume into the aorta.
 The force flares the arterial walls and generates a
pressure wave
 Normal pulse- 60 to 100 beats per minutes (bpm)
 Radial pulse- at the flexor aspect of the wrist
laterally along the radius bone
 Count the number of beats in 30 seconds and
multiply by 2
Pulse
A peripheral pulse
 Is a pulse located far from the heart
 The apical pulse
 Is a central pulse, that is located at the apex of
the heart
Peripheral
Pulse
Peripheral
Pulse
Apical pulse
Factors affecting the pulse
 Age
 Gender
 Exercise
 Fever
 Medication
 Hypovolemia
 Stress
 Position change
 Pathology
Pulse
 Rate
 Bradycardia- heart rate less than 60
 Except well-trained athlete
 Tachycardia- over 100 bpm
 Rhythm
 Normally has an even tempo
 Irregularity- arrhythmia
Pulse
 Force
 3+ Full, bounding
 2+ Normal
 1+ Weak, thready
 0 Absent
 Elasticity
 Springy, straight, resilient
 Old people- feel twisted (tortuous), irregular
Resting heart rate
Age or fitness level Beats per minute
(bpm)
Babies to age 1 100–160

Children ages 1 to 10 60–140

Children age 10+ and adults 60–100

Well-conditioned athletes:40– Well-conditioned

60 athletes:40–60
Respiration
 Neonate 30-40 breaths per minutes (R/R)
 Adult 10-20 breaths per minutes (R/R)

 Count for 30 seconds and then multiply by 2

after the pulse, do not need to mention to the
client
 Abnormalities of respiration- refer to
Laboratory notes
Blood pressure
 Is the force of the blood pushing against the
side of the vessel wall
 Blood pressure is measured in millimeters of
mercury (mmHg) and recorded as a fraction.
 Systolic pressure/ Diastolic pressure
 Blood pressure: 120/80

The systolic pressure The diastolic pressure

 The systolic pressure
 The maximum pressure felt on the artery during
left ventricular contraction, or systole
 The diastolic pressure
 The elastic recoil, or resting, pressure that the
blood exerts constantly between each contraction
Blood pressure
 The pulse pressure
 The difference between the systolic and diastolic
pressure
 Reflect the stroke volume
 The mean arterial pressure (MAP)
 The pressure forcing blood into tissues
 Diastolic pressure + 1/3 the pulse pressure
How to measure
A blood pressure cuff
 A sphygmomanometer

 A stethoscope
Blood pressure
 Factors influence the blood pressure
 Age
 Sex
 Race
 Diurnal rhythm
 Weight
 Exercise
 Emotions
 stress
Factors controlling the blood
pressure
 Cardiac output
 Heart failure
 Peripheral vascular resistance
 Vasoconstriction Vs vasodilatation
 Volume of circulating blood
 Haemorrhage Vs fluid overload
 Viscosity
 Elasticity of vessel walls
 arteriosclerosis
Blood pressure
 Arm Pressure
 Thigh Pressure

 Average BP is 120/80mmHg

 Hypotension
 Low BP
 Hypertension
 High BP
 Orthostatic hypotension
Blood Pressure
Please refer to laboratory notes for the
following points:
 Korotkoff’s sounds

 An auscultatory gap

 Abnormalities in blood pressure

OXYGEN SATURATION
 Pulse oximeter
 a noninvasive device that measures a client’s
arterial blood oxygen saturation (SaO2) by
means of a sensor attached to the client’s
finger, toe, nose, earlobe or forehead
 detect hypoxemia
OXYGEN SATURATION
Pulse oximeter
 Sensor
 LEDs- two light emitting diodes, one red, the other infrared,
transmit light through nails, tissue, venous blood or arterial
blood
 A photodetector placed directly opposite the LEDs to detect
the amount of red and infrared light absorbed by oxygenated
and deoxygenared haemoglobin in arterial blood
 Normal SpO2- 95% to 100%
 SpO2 < 70% is life threating
 Pulse rate detection
Developmental Consideration
 Infantsand children
 The aging adult
Documentation guidelines
 Make sure the following points:
 right patient
 right date
 right time
 Use red pen for pulse rate
 Label AR as apical rate
 Use black or blue pen for temperature
 Make sure you write down the route of taking the
temperature
 E.g. R stands for rectal temp.
 A stands for axilla temp.
Documentation guidelines

 Use black or blue pen for blood pressure

 Chart respiratory rate according to the
ward practice
 Once detect abnormal finding, report to
the in charge nurse immediately.
 The charting method may vary in different
ward setting, do ask clearly before you do
the documentation.
Documentation guidelines
 Look at the example:
 Client: Mary Lee’s axillary temperature is 37C at 1100
07/09/2009
 Her pulse rate is 70 bpm
 Non Invasive Blood pressure (NIBP) is 120/60
 Respiratory rate: 20 bpm
 SaO2: 99%
 Now please chart her findings.
References
 Jarvis, C. (2008). Physical examination and health
assessment (5th ed.). Philadelphia: W. B. Saunders.
 Kozier, B., Erb, G., Berman, A. J., & Snyder, S. (2008).
Fundamentals of nursing; Concepts, process, and
practice (8th ed.). New Jersey: Prentice Hall Health.
 Potter, P. & Perry, A.(2004). Basic Nursing: Essential for
Practice (5th ed.). Philadelphia: W. B. Saunders.