Transcript Chapter 9
Chapter 9 General Survey and Vital Signs Copyright 2002, Delmar, A division of Thomson Learning Competencies Describe initial assessment observations. Discuss factors affecting respiratory rate. Perform respiratory rate assessment. Describe the characteristics that are included in an assessment of pulse. Measure apical, radial, and brachial pulses. (continues) Copyright 2002, Delmar, A division of Thomson Learning Competencies Discuss factors influencing body temperature. Compare oral, rectal, axillary, and tympanic methods for temperature measurement. (continues) Copyright 2002, Delmar, A division of Thomson Learning Competencies Demonstrate body temperature assessment techniques utilizing glass, electronic, and tympanic thermometers. Describe factors influencing blood pressure and blood pressure measurement. Describe two methods to measure blood pressure. Copyright 2002, Delmar, A division of Thomson Learning General Survey Physical presence Assess the patient’s Stated age vs. Apparent age General appearance Body fat Stature Motor activity Body and breath odors (continues) Copyright 2002, Delmar, A division of Thomson Learning General Survey Psychological presence Observe the patient’s Dress, grooming, personal hygiene Mood and manner Speech Facial expressions (continues) Copyright 2002, Delmar, A division of Thomson Learning General Survey Distress Assess for Labored breathing, wheezing, cough, labored speech Painful facial expressions, sweating, guarding Serious or life-threatening complications Emotional distress or anxiety Copyright 2002, Delmar, A division of Thomson Learning Vital Signs Respiration How to assess? Count for 1 full minute Normal findings Adult rate 12–20 per minute Abnormal findings Tachypnea Bradypnea Apnea (continues) Copyright 2002, Delmar, A division of Thomson Learning Vital Signs Pulse How to assess? Count for 1 full minute Rate Rhythm Normal range for adults = 60–100 bpm Regular vs. Irregular Volume Absent to bounding Use 3- or 4-point scale for measuring Copyright 2002, Delmar, A division of Thomson Learning Factors Affecting Heart Rate Age Gender Activity Emotional status Pain Environmental factors Stimulants Medications Copyright 2002, Delmar, A division of Thomson Learning Peripheral Pulses Pedal Dorsalis pedis Posterior tibialis Popliteal Femoral Brachial Carotid Temporal Copyright 2002, Delmar, A division of Thomson Learning Pulses Radial Location? How to find? Count for 30 or 60 seconds Apical Location? How to find? Count for 30 or 60 seconds (continues) Copyright 2002, Delmar, A division of Thomson Learning Pulses Rate Rhythm Tachycardia Bradycardia Asystole Regular vs. Irregular Dysrhythmias Volume Weak vs. Strong Copyright 2002, Delmar, A division of Thomson Learning Vital Signs Temperature Celsius How to convert? 5/9 x (temp in °F – 32 degrees) Fahrenheit How to convert? (9/5 x temp in °C) + 32 degrees Copyright 2002, Delmar, A division of Thomson Learning Routes Oral Average Range 36–38° C or 96.8–100.4° F Advantages 37.0° C or 98.6° F Convenient, accessible Disadvantages Safety, physical abilities, accuracy Copyright 2002, Delmar, A division of Thomson Learning Rectal Average Range 36.7–38.5° C or 98.0–101.6° F Advantages 0.7° C or 0.4° F higher than oral Most accurate Disadvantages Safety, invasive, uncomfortable Copyright 2002, Delmar, A division of Thomson Learning Axillary Average Range 35.4–37.4° C or 95.8–99.4° F Advantages 0.6° C or 1° F lower than oral Safe, noninvasive Disadvantages Accuracy? Length of time to obtain measurement Copyright 2002, Delmar, A division of Thomson Learning Tympanic Average Range Same as oral and rectal Advantages Calibrated to oral or rectal scales Convenient, fast, safe Disadvantages Accuracy? Technique affects reading Copyright 2002, Delmar, A division of Thomson Learning Variables Affecting Body Temperature Circadian rhythms Hormones Age Exercise Stress Copyright 2002, Delmar, A division of Thomson Learning Temperature Variations Hyperthermia Hypothermia Copyright 2002, Delmar, A division of Thomson Learning Blood Pressure Force exerted by the flow of blood pumped into the large arteries Korotkoff sounds Phase I Phase II Phase III Phase IV Phase V Copyright 2002, Delmar, A division of Thomson Learning Measuring Blood Pressure Systole Diastole Pulse pressure Equipment Sphygmomanometer Aneroid manometer Mercury manometer (continues) Copyright 2002, Delmar, A division of Thomson Learning Measuring Blood Pressure Sites Brachial Thigh Avoid AV shunts or fistulas, affected arm of postmastectomy patient (continues) Copyright 2002, Delmar, A division of Thomson Learning Measuring Blood Pressure Documentation Normal findings Position of patient Location where taken 100–140/60–90 Average = 120/80 Hypotension Hypertension Copyright 2002, Delmar, A division of Thomson Learning Common Errors in Blood Pressure Measurements Incorrect cuff size Unrecognized auscultatory gap Incorrect cuff placement Copyright 2002, Delmar, A division of Thomson Learning Factors Influencing Blood Pressure Stress White coat syndrome Medications Hypervolemia Hypovolemia Copyright 2002, Delmar, A division of Thomson Learning