General Survey Assessment

Begins when first meet client

Physical appearance

Mental Status

Mobility

Behavior

Attention to detail - clues to problems for further assessment

General appearance: healthy, obvious conditions

Age: close to stated age

Skin: color (variations), lesions

Hygiene: cleanliness, grooming, odors

Stature: height appropriate for age

Nutritional status: well nourished,

cachectic, obese

Symmetry: R/L sides similar

While client is responding to

questions and giving information

about history

Affect and mood

Level of anxiety

Orientation to person, place & time

Speech

Body movement

Gait

Posture

Range of Motion

Dress and Grooming

Body odors

Facial expression

Mood and affect

Ability to make eye contact

Level of anxiety

Ask client first before getting

measurements

Helps establish baseline data and

helps determine health status

Medication dosage calculation

Adult height attained between 18 and

20 years

Baseline indicators of a client’s health status

A change can indicate a change in physiological function

Vital Signs:

T = Temperature

P = Pulse

R = Respiratory Rate

BP = Blood Pressure

O2 sat = Oxygen Saturation

Pain

Nurse’s responsibility/delegation

Knowledge of equipment

Knowledge of client’s range

Knowledge of client’s history and current status

Environmental factors

Systematic approach

Approach with the client

Frequency of assessment

Assessment for medications

Analysis and verification of results

Communication of results

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

Stays relatively constant despite

environmental changes and physical

activity

Age

Diurnal variations:

Lowest in early morning (0100-0400), higher in late afternoon/evening (max @ 1800)

Menstrual cycle: temp and persists until ovulation (due to progesterone )

Exercise also increases temp (metabolism)

Stress temperature

Oral: glass, paper, or electronic thermometer (normal 98.6F/37C)

Axillary: glass or electronic thermometer (normal 97.6F/36.3C)

Rectal or "core“: glass or electronic thermometer (normal 99.6F/37.7C)

Tympanic: electronic thermometer (normal 99.6F/37.7C)

Of these, axillary is the least and rectal is the most accurate.

Normal 97 – 99.9F

Delay 10 minutes if ingested hot/cold liquids

Electronic thermometer (sheathed): under

tongue, place in either right or left posterior

sublingual pocket (15-30 seconds)

Safe for children/confused adults

Don’t take oral temp if had oral surgery or

lesions

Normal 99.6F/37.7C

Probe covered, placed in external ear

canal; in contact with all sides of canal (2-

3 seconds)

Questionable reliability in children

(direction of beam)

Less than 3 years: pull down

Over 3 years: pull up

Adults: pull up and back

Normal 97.6F/36.3C

Common site for infants and children

Not close to major blood vessels

Low sensitivity to detect fever (febrile patients)

Electronic: middle of axilla with arms folded

Alternative site for those with oral inflammation,

wired jaws, oral surgery, mouth breathers

(nasal surgery)

Normal 99.6F/37.7C (.7 to .8o higher)

Used less frequently with newer methods

Used more common in comatose or seizing clients

Do not use if client had rectal surgery, hemorrhoids or lower GI disorders

Adults: less comfortable, more time, increased risk of infectionSims’ position

1.5 inches into rectum (electronic)

Children: last resort1 inch

Newborns, Infants: risk of rectal perforation½ inch

Shake down, verify

Insert cover, position properly

Wait 2-3 minutes

Read correctly

2 opportunities

Pat the axilla dry if moist

Bulb is placed in the middle of the

axilla

Wait 6-9 minutes

Compare reading to oral (one degree

less than oral)

Wear gloves, water soluble lubricant

Position in Sims or lateral

Insert ½ to 1 ½ inches depending on

age

(½ infant; 1 child; 1-1 ½ adult)

Wait 2-3 minutes

Compare reading to oral (one degree

higher than oral)

Know how to document on flow sheet

Terminology:

Hyperthermia: very high fever

Febrile: fever

Hypothermia: low fever

Afebrile: no fever

Factors Affecting Temperature:

Diurnal variation

Menstrual cycle

Exercises

Stress

Valuable information about cardiovascular system

Information regarding strength of the pulse and perfusion of blood to various parts of the body

Indirect reflection of heart contraction

Measure:

Rate: beats per minute

Rhythm: regularity (time between

beats)

Strength: volume of blood ejected with

each beat

Equality: comparison of same pulse in

opposite extremities by taking

simultaneously

Rhythm:

Regular rhythm

Evenly spaced beats; 30” x 2; 15” x 4

Irregular rhythm

Full minute

Regularly irregular: regular pattern overall with

“skipped” beats

Irregularly irregular: chaotic, no real pattern, very

difficult to measure rate accurately

Strength:

Bounding, strong, weak or thready

Pulse assessment sites:

Temporal

Carotid

Apical

Brachial

Radial

Femoral

Popliteal

Posterior tibial

Pedal

WHAT IS A NORMAL PULSE?

Adult: 60 to 100

Newborn: 120-170

1 year: 80-160

3 years: 80-120

6 years: 75-115

10 years: 70-110

Average Pulse and Blood Pressure

in Normal Children

Age Birth 6mo 1yr 2yr 6yr 8yr 10yr

Pulse 140 130 115 110 103 100 95

Systolic BP 70 90 90 92 95 100 105

Most frequently measured

Arm is supported on a bed, chair or nurse’s arm

Wrist is extended (not bent)

Lightly compress tips of first 2 fingers against

radius, obliterate pulse initially, and then relax

pressure so pulse becomes easily palpable

For a regular pulse count for 30 seconds and

multiply by 2

Irregular pulse: count for a full 60 seconds

Apical pulse:

Auscultate for 1 minute

5th intercostal space midclavicular

line

Use stethoscope when assessing

Measure rate and rhythm

Brachial: located in groove

between the triceps and biceps

muscle medial to the biceps

tendon in the antecubital fossa

Carotid: located along the

medial edge of the

sternocleidomastoid muscle in

the lower third of the neck

Radial: Accurate count

Apical: 60 seconds

Apical/Radial: 60 seconds

2 opportunities for each

Know how to document on flow sheet

Factors affecting pulse:

with exercise, fever, stress

with males, age, athletes

Terminology:

Pulse sites

Rate: beats per minute

Rhythm: regularity (time between beats)

Pulse deficit: difference between radial and apical

Bradycardia: < 60 bpm

Tachycardia: > 100 bpm

Exchange of O2 and CO2: oxygen reaches body

cells and carbon dioxide is removed from the

cells

Respiration involves:

Ventilation: the movement of gases in and out of

the lungs

Diffusion: the movement of oxygen and carbon

dioxide between the alveoli and the red blood cells

Perfusion: distribution of red blood cells to and from

the pulmonary capillaries

Best done immediately after taking the patient's pulse. Do not announce that you are measuring respirations.

Without letting go of the patients wrist begin to observe the patient's breathing. Is it normal or labored?

Count breaths for 30 seconds and multiply this number by 2 to yield the breaths per minute.

In adults, normal resting respiratory rate is between 14-20 breaths/minute.

Note the rate, rhythm, depth and effort of

breathing

Rate = number of ventilatory cycles

(inhalation and exhalation) per minute

Males: diaphragmatic (abdominal)

Females: thoracic

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

Accurate count (best for 30 sec.)

2 opportunities

Document on flow sheet

Factors affecting respiration:

with exercise, fever, stress,

altitude

Varies with age

Terminology:

Rate: number of ventilatory cycles (inh + exh)

Rhythm: regularity of breathing (reg or irreg)

Depth: observation of excursion (movement of chest wall) deep or shallow

Effort: even, quiet effortless

Tachypnea: fast

Bradypnea: slow

Apnea: no breathing

Dyspnea: difficulty breathing

Orthopnea: diff lying

Retractions: intercostals or substernal

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 (ejection)

Diastolic: minimum pressure on arteries during ventricular relaxation

BP = CO x R

BP= blood pressure

CO=cardiac output (heart rate x stroke vol)

R = Peripheral vascular resistance

Resistance refers to the resistance to blood flow determined by the tone of vascular musculature and diameter of blood vessels

As resistance rises, arterial BP rises

As vessels dilate and resistance falls, BP decreases

Recorded = systolic/diastolic (not a fraction)

Pulse pressure: difference between systolic and diastolic pressure 120/80=40 (usually 30- 40 mm Hg)

Direct: arterial catheterization

Indirect measurement

Sphygmomanometer and stethoscope (auscultation)

NIBPM: electronic sensing of vibrations, not Korotkoff sounds

Factors that affect BP measurements:Age: gradual rise

Gender: females males after puberty; females males after menopause;

Race: HTN 2x higher in African Amer

Diurnal variations: in early am; highest in late afternoon or early evening

Emotions: anxiety, stress or anger can

Pain: acute pain can

Personal habits: caffeine and smoking within 30 minutes before taking may

Weight: obese have

Medications

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/muffled-low pitch sound

Pressure at which no sound heard indicates artery

completely open (5th Korotkoff sound); diastolic

pressure

Phase 1: sharp thuds, start at systolic blood

pressure

Phase 2: blowing sound; may disappear

entirely (the auscultatory gap )

Phase 3: crisp thud, a bit quieter than phase 1

Phase 4: sounds become muffled

Phase 5: end of sounds -- ends at diastolic

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

False-high BP measurement:

Arm above level of heart

Cuff too narrow

Cuff too loose

Deflating cuff too slowly

Reinflating cuff without completely

deflating

Not waiting 1-2 minutes before repeat

measure

False-low BP measurement:

Arm below level of heart

Manometer higher than heart

Cuff too wide

Not inflating cuff enough

Deflating too rapidly

Pressing diaphragm too firmly on

brachial artery

Normal: <120/<80

Prehypertensive: 120-139/80-89

Stage 1 hypertension: 140-159/90-99

Stage 2 hypertension: >160/>100

Position the patient's arm so the antecubital fold is level with the heart. Support the patient's arm with your arm or a bedside table.

Center the bladder of the cuff over the brachial artery approximately 2 cm above the antecubital fold. Proper cuff size is essentialto obtain an accurate reading. Be sure the index line falls between the size marks when you apply the cuff. Position the patient's arm so it is slightly flexed at the elbow.

Palpate the brachial or radial pulse and inflate the cuff until the pulse disappears. Inflate an additional 20 mmHg higher and release cuff until you can again feel the pulse. This is a rough estimate of the systolic pressure.

Place the stethoscope over the brachial artery.

Inflate the cuff to 30 mmHg above the estimated systolic pressure.

Release the pressure slowly, no greater than 5 mmHg per second.

The level at which you consistently hear beats is the systolic pressure.

Continue to lower the pressure until the sounds muffle and disappear. This is the diastolic pressure.

Record the blood pressure as systolic over diastolic ("120/70" for example).

With fingers palpating radial or brachial artery, inflate

cuff rapidly until you can't feel the pulse, then 20 mm

higher

Release cuff at 2 to 3 mm Hg per second until you

again feel the pulse; this is the palpable systolic

pressure

Wait 30 seconds before measuring blood pressure

Measuring palpable pressure first avoids risk of

seriously underestimating blood pressure

Wash hands, clean stethoscope

Position patient

Obtain correct size BP cuff (40% width or 2/3 (80%) length)

Palpate brachial artery

Center bladder over artery

Wrap cuff securely, 1 inch above AC

Inflate cuff 30 above last heard or palpated systolic

Release valve slowly

Correct interpret readings (2 chances) within 4mmHg

Document on flow sheet

Factors affecting BP:

with age, after menopause, African Amer, in the PM, emotions, pain, caffeine, smoking, weight

after puberty and in the AM

Cuff size, medications, choice of arm

Terminology:

Systolic: top # (ventricle contracting)

Diastolic: bottom # (ventricle filling)

Pulse pressure: difference between systolic and diastolic

Orthostatic hypotension: drop in BP as you stand

When and why to avoid a certain arm:

Mastectomy

IV fluids or blood infusing

Burns

AV Grafts

Signs and symptoms of hypertension:

HA

Flushing

Ringing in the ears

Nose bleed

Signs and symptoms of hypotension:

Increased heart rate

Dizziness

Cool

Clammy

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

COLDSPAT

Character

Onset

Location

Duration (constant or intermittent)

Severity (On 0-10 scale)

Precipitating Factors

Alleviating Factors

Treatment