Chapter 006
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General Inspection and Measurement of Vital Signs Chapter 6
General Inspection General Survey, General/Initial Observations • Begins when first meet client – Physical appearance, hygiene, body structure/ movement, emotional/mental status, behavior
• Attention to detail—clues to problems for further assessment • Physical appearance/hygiene – – – –
General appearance: healthy, obvious conditions Age: close to stated age Skin: color (variations), lesions Hygiene: cleanliness, grooming, odors
General Inspection • Body structure – Stature: height appropriate for age – Nutritional status: well nourished, cachectic, obese – Symmetry: R/L sides similar – Position/posture: sit/stand up straight, slumped, tripod position, guarding, fetal position
General Inspection • Body movement – Walk: with ease, balanced/smooth gait, symmetric movement, – Assist devices, ease in changing position – Move all extremities; limitations in ROM – Guarding/pain with movement – Involuntary movements
General Inspection • Mental status and behavior – Alertness, facial expressions, tone of voice, affect – Maintain eye contact – Conversation: congruency with facial expression/body language – Appropriate clothing/behavior
Vital Signs, Height, and Weight: Temperature • Regulated by hypothalamus: heat gain vs. heat loss – 96.4° to 99.1° F (36.8° to 37.3° C) – 98.6° F (37° C) core temp: cellular metabolism most efficient
• Diurnal variations: early morning, higher in late afternoon/evening – Menstrual cycle: temp higher at ovulation until end of menses (progesterone) – Exercise also increases temp
Vital Signs, Height, and Weight: Temperature • Oral temperature: safe and accurate – Delay 15 minutes if ingested hot/cold liquids, smoked
• Electronic thermometer (sheathed): under tongue, sublingual pocket (15-30 seconds) – Carotid artery blood supply: core temp – Safe for children/confused adults
Vital Signs, Height, and Weight: Temperature • Tympanic membrane temperature – Probe covered, placed in external ear canal; in contact with all sides of canal (2-3 seconds)
• Axillary temperature: ? accuracy – Not close to major blood vessels – Low sensitivity to detect fever (febrile patients) – Electronic: middle of axilla with arms folded
Vital Signs, Height, and Weight: Temperature • Rectal temperature: less frequently with newer methods • Safe for adults, less comfortable, more time, increased risk of infection – Sims’ position – 1.5 inches into rectum (electronic)
Vital Signs, Height, and Weight: Heart Rate (Pulse) • Valuable information about cardiovascular system • Indirect reflection of heart contraction – Rate: beats per minute – Rhythm: regularity (time between beats)
• Information regarding strength/perfusion • Palpated with finger pads firmly over pulse – Regular rhythm: 30” x 2; 15” x 4 – Irregular rhythm (regular/irregular); full minute
Vital Signs, Height, and Weight: Heart Rate • Radial pulse: most frequently measured (radial side of forearm/wrist) • Brachial/carotid common alternatives • Apical pulse: auscultate for 1 minute
Vital Signs, Height, and Weight: Respiratory Rate • Rate = number of ventilatory cycles per minute – Males: diaphragmatic (abdominal) – Females: thoracic
• Count breaths per minute: client unaware, not self-conscious (fingers left on pulse) – Age variations – Increased: fever, exercise, anxiety, altitude
Vital Signs, Height, and Weight: Respiratory Rate • Rhythm = regularity of breathing (equal space between breaths – Regular or irregular
• Depth = observation of excursion (movement) of chest wall – Deep (large amount of air); normal; shallow (small amount of air)
• Effort: even, quiet, effortless
Vital Signs, Height, and Weight: Blood Pressure • Force of blood against arterial wall – Relationship between cardiac output and peripheral resistance – BP dependent on blood volume/velocity, vessel elasticity
• Measured in mm Hg: height of mercury column from blood pressure – Systolic: maximum pressure on arteries during ventricular contraction – Diastolic: minimum pressure on arteries during ventricular relaxation
Vital Signs, Height, and Weight: Blood Pressure • Recorded = systolic/diastolic (not a fraction) – Pulse pressure: difference between them (3040 mm Hg)
• Direct: arterial catheterization • Indirect measurement – Sphygmomanometer and stethoscope (auscultation) – NIBPM: electronic sensing of vibrations, not sounds
Vital Signs, Height, and Weight: Blood Pressure • Blood pressure measurement • Upper arm most common site; thigh alternate site (10-40 mm higher) – Blood flow occluded by inflated cuff – Cuff deflated until sounds of pulsing blood return (1st Korotkoff sound); systolic pressure • Clear, rhythmic, thumping sound, increasing intensity – 2nd, 3rd, 4th Korotkoff sounds – swishing/thump sound – Pressure at which no sound heard indicates artery completely open (5th Korotkoff sound); diastolic pressure
Vital Signs, Height, and Weight: Blood Pressure • Factors that affect blood pressure measurements • Client characteristics – Age, gender, race – Diurnal variations – Emotions – Pain – Personal habits – Weight
Vital Signs, Height, and Weight: Blood Pressure • Common errors in BP measurement – Accuracy affected by technique – Research finds that providers incorrect technique results from lack of knowledge • False high/low measurements • Many errors due to wrong cuff size
Vital Signs, Height, and Weight: Oxygen Saturation • Included with vital signs • Pulse oximetry: oxygen saturation of hemoglobin – Probe on fingertip (other sites) – Digital readout
• Saturation levels less than 90% necessitate further evaluation • Caregiver’s knowledge deficiency in measurement and interpretation reported
Vital Signs, Height, and Weight: Weight • Body weight (mass) determined by genetics, diet, exercise, fluid volume – Genetics: height, body size (bone structure, muscle mass, gender – Important for nutritional assessment, changes over time, medication dosage calculation – Unintentional weight change significant • Fluid retention vs. cancer, disease process
• Balance scale
Vital Signs, Height, and Weight: Weight • Height determined by genetics, diet • Measured on platform scale • Adult height between 18 and 20 years
Age-Related Variations: Newborns and Infants • Recumbent length, weight, head circumference plotted to assess/evaluate growth (compare to infants of same age/gender) • Weight – Platform scale: nearest half oz or 14 g • 5 lb 8 oz to 8 lb 13 oz
– Lose 10% first week, gain back 10 to 14 days – Doubled by 4 to 5 months, tripled by 12 months
Age-Related Variations: Newborns and Infants • Recumbent length: top of head to heel; supine position – Measured in inches/centimeters; plotted on growth chart – Measuring devices unavailable; distance marked on paper
Age-Related Variations: Newborns and Infants • Head circumference – Every well-baby visit – Largest circumference above eyebrows/ pinna, occipital prominence; nearest 1/8 inch • Two times; if different do third time
– Plotted on growth curve: 1inch larger than chest • Increasing size suggests increased intracranial pressure • Less than 5th percentile suggests microcephaly
Age-Related Variations: Newborns and Infants • Chest circumference – Only measure if abnormal head or chest size – Measured at nipples: between inspiration and expiration (nearest 1/8 inch) – At birth, less than head circumference
Age-Related Variations: Newborns and Infants • Vital signs • Temperature – Infant: same as adult – Newborn: wide variations; less effective heat control • Safest: axillary, tympanic (tympanic less accurate) • Rectal avoided: rectal perforation
Age-Related Variations: Newborns and Infants • Pulse and respiration – Same qualities as adult: taken when quiet – Apical pulse for full minute and then respirations • Diaphragmatic breathers: full minute due to normal irregularity
Age-Related Variations: Children • Height and weight: routine to end of growth spurt (18-20) – Platform with movable headboard/measuring tape – Recorded/plotted on growth charts (inches/cm) – Weight monitoring essential • Comparison with population standard (percentile)
Age-Related Variations: Children • Head and chest circumference – Head measured until 2 years; every visit • Annually until 6 • At 2, head two thirds adult size • Compared with population standard
– Chest: not routine unless abnormality suspected – After 2, chest larger than head
Age-Related Variations: Children • Temperature – Oral (electronic) permissible – placed correctly – TM measurements: ? reliability (direction of beam) – Straighten ear canal • Younger than 3, pull down • Older than 3, pull up
– Rectal: last resort (inserted 1 inch)
Age-Related Variations: Children • Blood pressure – AHA recommends annually from 3 to adolescence – Appropriate cuff size – Explain to gain cooperation; if uncooperative, results may be inaccurate
Age-Related Variations: Adolescents • VS measurement same as adult: BP annually • Weight and height: annually – Before puberty: gender differences in composition minimal – Adolescent growth spurt: (fat increases) produces gender differences (skeletal, lean body mass, fat stores)
Age-Related Variations: Older Adults • Weigh less – Older than 80, decrease due to muscle wasting/chronic disease – Total body water decreases – Subcutaneous fat redistribution (face/extremities goes to abdomen/hips)
• Shorter – Decreased bone formation results in shortening of vertebrae, thinning of vertebral disks
Age-Related Variations: Older Adults • Vital signs – Measurement same as for adults – Lower temperature (97.2° F) – High blood pressure: arteriosclerosis • Rigid aorta results in increased systolic pressure • Diabetes (less compliance)
General Inspection General Survey, General/Initial Observations • Begins when first meet client – Physical appearance, hygiene, body structure/ movement, emotional/mental status, behavior
• Attention to detail—clues to problems for further assessment • Physical appearance/hygiene – – – –
General appearance: healthy, obvious conditions Age: close to stated age Skin: color (variations), lesions Hygiene: cleanliness, grooming, odors
General Inspection • Body structure – Stature: height appropriate for age – Nutritional status: well nourished, cachectic, obese – Symmetry: R/L sides similar – Position/posture: sit/stand up straight, slumped, tripod position, guarding, fetal position
General Inspection • Body movement – Walk: with ease, balanced/smooth gait, symmetric movement, – Assist devices, ease in changing position – Move all extremities; limitations in ROM – Guarding/pain with movement – Involuntary movements
General Inspection • Mental status and behavior – Alertness, facial expressions, tone of voice, affect – Maintain eye contact – Conversation: congruency with facial expression/body language – Appropriate clothing/behavior
Vital Signs, Height, and Weight: Temperature • Regulated by hypothalamus: heat gain vs. heat loss – 96.4° to 99.1° F (36.8° to 37.3° C) – 98.6° F (37° C) core temp: cellular metabolism most efficient
• Diurnal variations: early morning, higher in late afternoon/evening – Menstrual cycle: temp higher at ovulation until end of menses (progesterone) – Exercise also increases temp
Vital Signs, Height, and Weight: Temperature • Oral temperature: safe and accurate – Delay 15 minutes if ingested hot/cold liquids, smoked
• Electronic thermometer (sheathed): under tongue, sublingual pocket (15-30 seconds) – Carotid artery blood supply: core temp – Safe for children/confused adults
Vital Signs, Height, and Weight: Temperature • Tympanic membrane temperature – Probe covered, placed in external ear canal; in contact with all sides of canal (2-3 seconds)
• Axillary temperature: ? accuracy – Not close to major blood vessels – Low sensitivity to detect fever (febrile patients) – Electronic: middle of axilla with arms folded
Vital Signs, Height, and Weight: Temperature • Rectal temperature: less frequently with newer methods • Safe for adults, less comfortable, more time, increased risk of infection – Sims’ position – 1.5 inches into rectum (electronic)
Vital Signs, Height, and Weight: Heart Rate (Pulse) • Valuable information about cardiovascular system • Indirect reflection of heart contraction – Rate: beats per minute – Rhythm: regularity (time between beats)
• Information regarding strength/perfusion • Palpated with finger pads firmly over pulse – Regular rhythm: 30” x 2; 15” x 4 – Irregular rhythm (regular/irregular); full minute
Vital Signs, Height, and Weight: Heart Rate • Radial pulse: most frequently measured (radial side of forearm/wrist) • Brachial/carotid common alternatives • Apical pulse: auscultate for 1 minute
Vital Signs, Height, and Weight: Respiratory Rate • Rate = number of ventilatory cycles per minute – Males: diaphragmatic (abdominal) – Females: thoracic
• Count breaths per minute: client unaware, not self-conscious (fingers left on pulse) – Age variations – Increased: fever, exercise, anxiety, altitude
Vital Signs, Height, and Weight: Respiratory Rate • Rhythm = regularity of breathing (equal space between breaths – Regular or irregular
• Depth = observation of excursion (movement) of chest wall – Deep (large amount of air); normal; shallow (small amount of air)
• Effort: even, quiet, effortless
Vital Signs, Height, and Weight: Blood Pressure • Force of blood against arterial wall – Relationship between cardiac output and peripheral resistance – BP dependent on blood volume/velocity, vessel elasticity
• Measured in mm Hg: height of mercury column from blood pressure – Systolic: maximum pressure on arteries during ventricular contraction – Diastolic: minimum pressure on arteries during ventricular relaxation
Vital Signs, Height, and Weight: Blood Pressure • Recorded = systolic/diastolic (not a fraction) – Pulse pressure: difference between them (3040 mm Hg)
• Direct: arterial catheterization • Indirect measurement – Sphygmomanometer and stethoscope (auscultation) – NIBPM: electronic sensing of vibrations, not sounds
Vital Signs, Height, and Weight: Blood Pressure • Blood pressure measurement • Upper arm most common site; thigh alternate site (10-40 mm higher) – Blood flow occluded by inflated cuff – Cuff deflated until sounds of pulsing blood return (1st Korotkoff sound); systolic pressure • Clear, rhythmic, thumping sound, increasing intensity – 2nd, 3rd, 4th Korotkoff sounds – swishing/thump sound – Pressure at which no sound heard indicates artery completely open (5th Korotkoff sound); diastolic pressure
Vital Signs, Height, and Weight: Blood Pressure • Factors that affect blood pressure measurements • Client characteristics – Age, gender, race – Diurnal variations – Emotions – Pain – Personal habits – Weight
Vital Signs, Height, and Weight: Blood Pressure • Common errors in BP measurement – Accuracy affected by technique – Research finds that providers incorrect technique results from lack of knowledge • False high/low measurements • Many errors due to wrong cuff size
Vital Signs, Height, and Weight: Oxygen Saturation • Included with vital signs • Pulse oximetry: oxygen saturation of hemoglobin – Probe on fingertip (other sites) – Digital readout
• Saturation levels less than 90% necessitate further evaluation • Caregiver’s knowledge deficiency in measurement and interpretation reported
Vital Signs, Height, and Weight: Weight • Body weight (mass) determined by genetics, diet, exercise, fluid volume – Genetics: height, body size (bone structure, muscle mass, gender – Important for nutritional assessment, changes over time, medication dosage calculation – Unintentional weight change significant • Fluid retention vs. cancer, disease process
• Balance scale
Vital Signs, Height, and Weight: Weight • Height determined by genetics, diet • Measured on platform scale • Adult height between 18 and 20 years
Age-Related Variations: Newborns and Infants • Recumbent length, weight, head circumference plotted to assess/evaluate growth (compare to infants of same age/gender) • Weight – Platform scale: nearest half oz or 14 g • 5 lb 8 oz to 8 lb 13 oz
– Lose 10% first week, gain back 10 to 14 days – Doubled by 4 to 5 months, tripled by 12 months
Age-Related Variations: Newborns and Infants • Recumbent length: top of head to heel; supine position – Measured in inches/centimeters; plotted on growth chart – Measuring devices unavailable; distance marked on paper
Age-Related Variations: Newborns and Infants • Head circumference – Every well-baby visit – Largest circumference above eyebrows/ pinna, occipital prominence; nearest 1/8 inch • Two times; if different do third time
– Plotted on growth curve: 1inch larger than chest • Increasing size suggests increased intracranial pressure • Less than 5th percentile suggests microcephaly
Age-Related Variations: Newborns and Infants • Chest circumference – Only measure if abnormal head or chest size – Measured at nipples: between inspiration and expiration (nearest 1/8 inch) – At birth, less than head circumference
Age-Related Variations: Newborns and Infants • Vital signs • Temperature – Infant: same as adult – Newborn: wide variations; less effective heat control • Safest: axillary, tympanic (tympanic less accurate) • Rectal avoided: rectal perforation
Age-Related Variations: Newborns and Infants • Pulse and respiration – Same qualities as adult: taken when quiet – Apical pulse for full minute and then respirations • Diaphragmatic breathers: full minute due to normal irregularity
Age-Related Variations: Children • Height and weight: routine to end of growth spurt (18-20) – Platform with movable headboard/measuring tape – Recorded/plotted on growth charts (inches/cm) – Weight monitoring essential • Comparison with population standard (percentile)
Age-Related Variations: Children • Head and chest circumference – Head measured until 2 years; every visit • Annually until 6 • At 2, head two thirds adult size • Compared with population standard
– Chest: not routine unless abnormality suspected – After 2, chest larger than head
Age-Related Variations: Children • Temperature – Oral (electronic) permissible – placed correctly – TM measurements: ? reliability (direction of beam) – Straighten ear canal • Younger than 3, pull down • Older than 3, pull up
– Rectal: last resort (inserted 1 inch)
Age-Related Variations: Children • Blood pressure – AHA recommends annually from 3 to adolescence – Appropriate cuff size – Explain to gain cooperation; if uncooperative, results may be inaccurate
Age-Related Variations: Adolescents • VS measurement same as adult: BP annually • Weight and height: annually – Before puberty: gender differences in composition minimal – Adolescent growth spurt: (fat increases) produces gender differences (skeletal, lean body mass, fat stores)
Age-Related Variations: Older Adults • Weigh less – Older than 80, decrease due to muscle wasting/chronic disease – Total body water decreases – Subcutaneous fat redistribution (face/extremities goes to abdomen/hips)
• Shorter – Decreased bone formation results in shortening of vertebrae, thinning of vertebral disks
Age-Related Variations: Older Adults • Vital signs – Measurement same as for adults – Lower temperature (97.2° F) – High blood pressure: arteriosclerosis • Rigid aorta results in increased systolic pressure • Diabetes (less compliance)
