Chapter 6: General Survey and Vital Signs Assessment

Chapter 6: General Survey and Vital Signs Assessment Vital Signs: · Temperature · Pulse · Blood Pressure (BP) · Respirations & O2 saturation Urgent Assessment · Indicators: anxiety, acute distress, pallor, cyanosis, and a change in mental status ↳ you then obtain vital signs Risk Assessment and Health Promotion · Teaching and educating patients about health and health factors eg. Teach patients taking cardiac medications how to take their own pulse rates eg. Ensure patients undergoing surgery and those with decreased ventilation know to perform coughing and deep breathing exercises eg. Educate about risks of hypertension: obesity, cigarette smoking, heavy alcohol consumption, prolonged stress, high cholesterol, family history, etc. · Primary prevention: includes lifestyle modifications such as weight loss, regular exercise, dietary modifications, etc. · Every interaction is a teaching opportunity General Survey · Begins when first meeting the patient and continues through the assessment ↳ global impression of the person · Make note of physical appearance, overall behaviour and mobility ② Behaviour ③ Mobility ① Physical appearance ↳ level of consciousness (LOC) ↳ posture ↳ overall appearance ↳ facial expression ↳ range of motion (ROM) ↳ hygiene and dress ↳ speech ↳ gait ↳ breathing ↳ position of comfort ↳ skin colour and lesions ↳ body structure and development LOC · should know person, place, time = orientated Assessing LOC · confusion 1. spontaneous: enter room and observe · agitation 2. usual voice: state the patients name and ask them politely · restlessness Getting worse! to open their eyes · drowsiness 3. loud voice (both ears!): repeat what you said > lethargy 4. tactile: touch the patient's arm or shoulder > obtunded 5. pressure: put pressure on the patients nail bed. Do no harm. · stupor Observe for eye opening · coma 6. pain: Trapezius pinch. Do no harm. Observe for movement - - Anthropometric Measurements: · Height Helpful for evaluating nutrition, fluid gain/ · Weight loss, and calculating medication dosages · BMI Initial Data · forms the baseline · height, weight, nutrition, hydration, medications, health status, etc. - - Vital Signs · Temperature, pulse, respirations, BP, pain, functional ability (older adults) · Vital signs reflect health status, cardiopulmonary function, and overall body function. Vital signs are indicators of physiological state and response to physical, environmental, and psychological stressors ↳ establish a baseline, monitor the patients condition, evaluate responses to treatment, and assess health risks - - - - - - When do we take Vital Signs? · during a health visit · upon administration · before, during/after invasive or surgical procedures · before/during/after medication administration · critical thinking (like when pt looks bad) · Physician/NP/routine orders Why do we take Vital Signs? · screening · baseline data · response to treatment · change in health status · monitoring for complications · Before taking vital signs: check patient, general survey, health history, associated signs and symptoms, and make sure to check your technique (if you get weird results do it again) Temperature Conversion: Temperature · hypothalamus regulates temperature · diurnal pattern: varies 0.5 to 1 degree over the day, lowest in morning and highest in evening · expected: 36.5-37.5*C · fever: >38.0*C (oral) · other routes of measurement: ↳ axillary 0.5* lower → farther away from core is cooler ↳ tympanic & rectal 0.5* higher · Wait 15 minutes if exposed to heat or cold to get accurate reading Oral Temp · sublingual placement · wait 15 minutes after smoking, eating, or drinking · make sure mouth closes over device, tongue pressed down on thermometer, and wait recommended time (TempaDOT 1 min) Pros: · Accessible · Easy · Comfortable · Accurate Cons: · oral intake may alter reading · body fluid precautions · assess LOC!!! · axillary recommended for newborns Axillary Temp · axillary fold placement · wait 30 mins after washing armpit · against torso, completely covered (TempaDOT 3 mins) Pros: · Accessible · Easy · Safe Cons: · slow (1-2 min) · reflects skin temp not core temp · accuracy not as good Rectal Temp · adults 2-3 cm · TempaDOT 3 min Pros: · super accurate · ongoing monitoring possible · best for infants and unconscious patients Cons: · invasive · body fluid precautions · not newborns or GI issues · privacy Other Sites for Temperature: · Tympanic membrane: an ear thermometer that measures the heat of the tympanic membrane, very quick reading (2-3 sec) so used in emergency, pediatrics, and hospitals · Temporal artery: infrared sensors measure body temp from skin over the forehead, especially useful with children and unconscious patients · inguinal folds (groin) Technique for Assessing Pulse · esophageal · use the pads of your index fingers (never thumb!) · nasopharyngeal · press gently, not too hard to stop palpation · bladder · count for 30 sec and x2 to obtain bpm · vaginal ↳ if irregular do for a full minute Indicates perfusion Pulse · pulse: the throbbing sensation that can be palpated over a peripheral artery or auscultated over the apex of the heart (under left boob) ↳ note the rate, rhythm, strength (amplitude) of the pulse, and elasticity of the vessel ① Rate · HR = pulsations of heart/minute · Normal: 60-100 bpm (adult) · Tachycardia: > 100 bpm · Brachycardia: < 60 bpm · Asystole: no pulse - ② Rhythm · regular or irregular · pulse deficit (not enough blood ejected into peripheral circulation to create a pulse) ↳ sinus dysrhythmia ↳ sinus arrhythmia - ③ Strength (amplitude) · non-palpable vs. bounding · absent, weak, full, strong, bounding · 0-4+ (usual is 2+) - Respiration · respiration: the act of breathing by supplying oxygen and removing carbon dioxide ↳ inspiration: diaphragm & intercostals contract, active ↳ expiration: diaphragm & intercostals relax, passive · rate and depth of respiration may vary in patients due to exercise, smoking, positioning, LOC, medications, etc. · Technique: observe breaths (chest rise) for 30 sec (x2) ↳ note the rate, rhythm, depth, and quality Respiratory Rate in Adults · RR = breaths/minute · Normal: 12-20 breaths/minute · Adults 65+: 12-24 breaths/minute · Tachypnea: > 20 (persistent)/minute · Bradypnea: < 12/minute · Apnea: no breaths · Hyperventilation: deep and rapid · Hypoventilation: shallow and slow Rhythm, Depth, and Quality · rhythm: regular or irregular? · depth: shallow, moderate, deep? · quality: "easy", no accessory muscles used, no retractions or nasal flaring, tracheal tugging, use of shoulders, intercostal or subcostal retractions! · eupnea: expected rate, regular, moderate depth, and easy Oxygen Saturation · measures the percent of oxygen saturated (bound to) hemoglobin · Expected: > 92-100% · possible errors: wearing nail polish, movement, irregular heartbeats, sleep apnea, etc. · Eupnea: 12-20 breaths/minute, regular, easy, no accessory muscles used, SpO2 > 92% Auscultation Review Blood Pressure · For assessment of: · Blood pressure (BP): the measurement of the force exerted by ↳ BP reading the flow of blood against arterial walls during atrial contraction ↳ lung sounds - depth, adventitia? ↳ systolic vs. diastolic ↳ heart sounds - rate, murmur? · MAP: mean arterial pressure (need 60mmHg for perfusion) ↳ abdomen - bowel sounds · CPP = MAP-ICP · Stethoscope → no amplication, only conduction · pulse pressure = Systolic-diastolic (40-60mmHg) ↳ bell: low pitched sounds · multi-limb readings ↳ diaphragm: high pitched sounds · Factors affecting blood pressure: 1. Cardiac output 2. Peripheral vascular resistance 3. Circulating blood volume Technique 4. Viscosity · Step 1: Estimate the systolic blood pressure 5. Elasticity of vessel walls ↳ Support arm, at arm level, palm up ↳ palpate radial artery, inflate cuff, note when radial pulse disappears + 30mmHg more, slowly release valve and note when pulse comes back (deflate, rest 30 sec) · Step 2: Measure blood pressure ↳ Stethoscope on brachial artery ↳ inflate cuff 30mmHg above estimated SBP, slowly release valve (deflation 2mm/Hg per heart beat); listen! ↳ Note Korotkoff sounds - Sphygmomanometer · bladder width 40% arm circumference · bladder length 80-100% arm circumference · too large: false low reading · too small: false high reading Interpretation · desired in healthy adult: <120 & >80 mmHg SBP/<80 mmHg DBP · healthy pulse pressure: around 40-60mmHg · high expected: 130-139 SBP and/or 85-89 DBP · high: >140 SBP or >90 DBP · diabetes: Keep <130/80 · hypotension: <90 SBP or 30mmHg drop Screening for Hypertension · calm, warm environment · no exercise · no coffee, smoking · empty bladder + bowel · seated position w/back support · arm bare, supported, cuff at heart level · no talking · feet on floor Common Errors: · rounding error · missing the auscultatory gap · deflating too slowly /quickly · incorrect cuff size · examiner bias E Other: · Vital signs monitor · Doppler technique Lifespan Considerations · older adults and younger children have different calculations and averages for vital signs EMERGENCY: · acute change · agitation, restlessness · new/unresponsive chest pain · ABC ↳ increased SOB; stridor! ↳ RR <10 or >32/min ↳ O2 Stat <92% ↳ HR <55 or >120 bpm ↳ SBP <100 or >170 mmHg · Temperature <35° or >39.5°C · Oral Temperature >37.5°-38°C in neutropenic patients/transplant