Transcript General Inspection and Measurement of Vital Signs

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NURSING 310:
HEALTH ASSESSMENT
Lecture 2
K.Hendrickson PhD, MSN, RN
Fall 2013
CHAPTER 4
General Inspection and
Measurement of Vital Signs
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General Inspection
• General inspection begins the moment nurse meets
patient.
• Initial impressions guide nurse to areas requiring further
examination:
• Physical appearance
• Hygiene
• Body structure and movement
• Emotional and mental status
• Behavior
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Physical Appearance
and Hygiene
• Does patient appear healthy? Any obvious findings such as
tremors or facial drooping? Does patient appear close to stated
age?
• Note that patient may appear older or younger than stated age
due to drug and alcohol use, excessive sun exposure, chronic
disease, and endocrine disorders.
• Note color and condition of skin. Any variations or obvious
presence of lesions?
• Is patient clean and well groomed or disheveled? Any odors
detected?
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Body Structure, Positioning, and
Movement
• Body structure and position:
• Stature and height appropriate for age.
• Nutritional status: Well nourished, cachectic, obese.
• Body symmetry and positioning.
• Body movement:
• Note how patient moves.
• Use of assistive devices.
• Are there limitations in range of motion?
• Are there any involuntary movements such as a tremor or tic?
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Emotional and Mental Status
and Behavior
• Emotional and mental status and behavior:
• Note alertness, facial expressions, tone of voice, and affect.
• Is patient oriented to person, place and time?
• Does patient maintain eye contact as culturally appropriate?
• Does patient converse appropriately?
• Are facial expressions and body language appropriate for
conversation?
• Is clothing appropriate for weather?
• Is behavior appropriate?
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Measurement of Vital Signs, Height, & Weight
• Baseline indicators of patient’s health status include
measurement of temperature, heart rate, respiratory rate,
blood pressure, oxygen saturation, height, and weight.
• Assessing presence of pain is considered standard
baseline data collected for all patients and included with
assessment of vital signs.
• Vital signs, pain assessment, height, and weight are
usually assessed at start of physical exam or integrated
into exam.
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Temperature
• Body temperature is regulated by the hypothalamus:
• Heat gained through processes of metabolism and exercise.
• Heat lost through radiation, convection, conduction, and
evaporation.
• Expected temperature ranges from 96.4F to 99.1°F (35.8°C to
37.3°C).
• Average is 98.6°F (37°C).
• This is stable core temperature at which cellular
metabolism is most efficient.
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Oral Temperature
• Temperature measurement by oral route
is safe and relatively accurate.
• Delay at least 10 minutes if patient
ingested hot or cold liquids or smoked.
• Electronic thermometer (sheathed): under tongue in
sublingual pocket for 15 to 30 seconds.
• This location receives blood supply from carotid artery; thus
indirectly reflects core temperature.
• Safe for use in school-aged children or confused adults.
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Alternative Temperature Techniques
• Tympanic membrane temperature:
• Probe covered with protective sheath,
placed in external ear canal in contact
with all sides of canal for 2 to 3 seconds.
•
Axillary temperature measurement has
questionable accuracy.
• Rectal temperature is used less frequently
due to newer methods.
• Less comfortable, but safe for use in adults.
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Heart Rate
• Palpation of arterial pulses
provides valuable information
about cardiovascular system.
• Pulse determines heart rate
and rhythm:
• Heart rate is number of times in a minute a pulsation is felt.
• Rhythm refers to regularity of pulsations or time between each
beat.
• Pulses also provide important information on strength of
pulse and perfusion of blood to various parts of the body.
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Heart Rate
• To take a pulse, place fingers
• over artery and feel for pulsations and rhythm:
• Use finger pads of index and middle fingers; apply firm
pressure over pulse, but not so hard that pulsation is occluded.
• If rhythm is regular, count number of pulsations for 30 seconds and
multiply by 2, or count for 15 seconds and multiply by 4.
• If pulse rhythm is irregular, note any odd rhythm, and count
pulsations for full minute.
• Document irregular pulse when recording vital signs.
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Most Common Pulse Location: Radial Pulse
- Located at radial side of forearm at wrist
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Alternative Pulse Locations: Brachial pulse
- located in groove between biceps and triceps muscles, in bend of elbow.
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Alternative Pulse Locations: Carotid Pulse
- medial edge of sternocleidomastoid muscle in lower third of neck.
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Heart Rate
• Heart rate can also be assessed by auscultating heart,
which is known as apical pulse, and counting heart
sounds for 1 minute.
• Located over the fifth intercostal
space at the mid clavicular line
• Must use a stethoscope
to auscultate heart rate
• Also called the PMI:
Point of Maximal Impulse
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Respiratory Rate
• Respiratory rate involves
counting number of ventilatory
cycles and inhalation and
exhalation, each minute.
• Men usually breathe diaphragmatically, increasing
movement of abdomen.
• Women tend to be thoracic breathers, noted with
movement of chest.
• Count respiratory rate when patient is unaware to prevent
self-conscious changing of breathing rate or pattern.
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Respiratory Rate
• Note rhythm, depth, and effort of breathing:
• Rhythm is pattern or regularity of breathing and described as
regular or irregular.
• Depth assessed by observing excursion or movement of chest wall.
• Depth described as deep (full lung expansion with full exhalation),
normal, or shallow.
• Normal breathing should be even, quiet, and effortless
when patient is sitting or lying down.
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Blood Pressure
• Blood pressure is force of blood against
arterial walls.
• It reflects relationship between cardiac output
and peripheral resistance.
• Cardiac output is volume of blood ejected
from heart each minute.
• Peripheral resistance is force that opposes
flow of blood through vessels; when arteries
are narrow, peripheral resistance to blood
flow is high, and reflected in elevated blood
pressure.
• Blood pressure is dependent on velocity of
blood, intravascular blood volume, and
elasticity of vessel walls.
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Measurement of
Blood Pressure
• Blood pressure measured in
• millimeters of mercury
(mm Hg).
• Systolic blood pressure is
maximum pressure exerted
on arteries when ventricles
eject blood from heart contracts
• Diastolic blood pressure represents minimum amount of
pressure exerted on vessels when ventricles of heart
relax.
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Recording Blood Pressure
• Blood pressure is recorded with systolic pressure written
on top of diastolic pressure (e.g., 130/76), but it is not a
fraction.
• Pulse pressure is the difference between systolic and
diastolic pressures and normally ranges from 30 mm Hg
to 40 mm Hg.
• Orthostatic blood pressures:
are a series obtained when the
patient is lying, sitting, and then
standing.
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Direct Blood Pressure Measurement
• Direct measurement done by inserting a small catheter
into artery that provides continuous blood pressure
measurements and arterial waveforms.
• Direct measurement done
in critical care settings when
continuous monitoring required.
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Indirect Blood Pressure Measurement:
Auscultation Method
• Indirect measurement in all other settings done by
auscultation with sphygmomanometer and stethoscope or
with noninvasive blood pressure monitor.
• Sphygmomanometer consists of gauge to measure
pressure, a cuff enclosing an inflatable bladder, and bulb
with valve used to inflate and deflate bladder within cuff.
• Stethoscope used to auscultate
blood pressure.
• Listen carefully for Korotkoff sounds.
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Korotcoff Phases
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Mechanism of Blood
Pressure Measurement
• Blood flows freely through artery
until inflated cuff interrupts blood
flow.
• As cuff pressure slowly released,
nurse listens for sounds of blood
pulsating through artery again
• Initial sound is called first Korotkoff
sound, characterized by a clear,
rhythmic thumping that gradually
increases in intensity.
• Fifth Korotkoff sound marks
cessation of sound and indicates
artery completely open.
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Automated Blood Pressure Monitoring
• Noninvasive blood pressure (NIBP) monitor is an electronic
device attached to cuff.
• It senses blood flow vibrations and converts them to electric
impulses transmitted to digital readout.
• Readout indicates blood pressure, mean arterial pressure,
and pulse rate.
• May be programmed to repeat
measurements on a schedule
and to sound alarm if readings
are outside desired limits.
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Physiologic Factors That Affect Blood
Pressure Measurement
• Age: From childhood to adulthood there is gradual rise.
• Gender: After puberty, women usually have a lower blood
pressure than men; however, after menopause, women’s
blood pressure may be higher than men’s.
• Race: Incidence of hypertension is twice as high in black
Americans as in whites. (Cultural)
Weight: Obese patients tend to have higher blood
pressures than non-obese patients.
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Physiologic Factors That Affect Blood
Pressure Measurement
• Diurnal variations: Pressure is lower in early morning and
peaks in late afternoon or early evening.
• Emotions: Anxiety, anger, or stress may increase blood
pressure. (White Coat Syndrome)
• Pain: Acute pain may increase blood pressure.
• Personal habits: Caffeine or smoking within 30 minutes
before measurement may increase reading.
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Oxygen Saturation
• Measurement of oxygen saturation
is included with vital signs in
many settings:
• Oxygen saturation is measured by a pulse oximeter—a device that
estimates oxygen saturation of hemoglobin in blood.
• Probe is taped or clipped to patient’s fingertip, toe, earlobe, or
nose; oxygen saturation appears as a digital readout within 10 to
15 seconds after oximeter is placed.
• Oxygen saturation levels lower than 90% are considered abnormal
and require further evaluation.
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Pain
• Routine assessment of patient’s pain or comfort level is
standard practice in all health care settings and often
assessed with vital sign measurement.
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Weight
• Measure weight using a balance scale by
asking patient to stand on platform while large
and small weights are balanced.
• Adjust smaller weight to balance scale reading
weight to nearest quarter pound.
• Body weight or mass is influenced by a number
of factors, including genetics, dietary intake,
exercise, and fluid volume.
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Height
• Ask patient to stand on scale without
wearing shoes; lower height attachment
until horizontal headpiece touches top
of patient’s head.
• Vertical measuring scale can measure in inches or
centimeters
• Adult height attained by age 18 to 20 years.
• Height is influenced by genetics and dietary intake;
measured on a platform scale with a height attachment
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Special Age-Related Variations:
Infants and Children
• Measurement of height (recumbent length), weight, and
head and chest circumferences are important indicators of
growth.
• Data are plotted on growth charts
to assess growth patterns of infant
and child and to compare growth to
infants and children of same age
and gender.
• Same process for general
inspection and vital signs
measurement among infants
and children is followed as
previously described.
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Special Age-Related Variations:
Older Adults
• Measurement of height, weight, and vital signs in older
adults is generally the same as previously described.
• Techniques and equipment may
vary depending on medical
conditions, and patient mobility/ability
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Question 1
The nurse is working in a primary care clinic. She walks
into the room, and the general inspection begins. What is
not part of the general inspection?
A.
B.
C.
D.
Patient’s facial expressions are consistent with
verbalized emotions.
Patient is wearing clothes that are normally worn by
whites.
Patient is staring down at the floor through most of the
interview.
Patient’s gait is strong and symmetrical.
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Question 2
The nurse collects patient data through assessment of vital
signs. Many nurses will delegate the performance of temperature
data collection to unlicensed assistive personnel. As the nurse
talks to the assistant, the nurse knows to teach that:
Tympanic thermometers touch the tympanic membrane.
Axillary temperatures are taken with the red probe on the
electronic thermometer.
C. Axillary temperatures are usually most accurate because of
the local blood supply.
D. Rectal thermometers are placed 2.8 cm to 3.5 cm into the
rectum.
A.
B.
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Question 3
A woman in labor suffers from preeclampsia. Nurses in the
labor and delivery unit need to assess her blood pressure.
The nurse explains to the patient that:
Using a cuff that is too narrow will give a reading that is
inaccurate and high.
B. Deflating the cuff too quickly will make the reading inaccurate
and high.
C. Deflating the cuff 5 mm Hg per second will make the reading
inaccurate and high.
D. Waiting 3 minutes before repeating the blood pressure
measurement will result in a false-high blood pressure
measurement.
A.
CHAPTER 6
Pain Assessment
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What is Pain?
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Anatomy & Physiology of Pain
• Physiology of pain involves
journey:
• Transduction from site of
stimulation of peripheral
receptors to spinal cord.
• Transmission up spinal
cord.
• Perception at cerebral
cortex.
• Modulation back down
spinal cord.
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A&P of Pain: Step One
• The pain process begins with response of nociceptors to
noxious stimuli.
• Nociceptors are primary sensory
nerves located in:
•
•
•
•
•
Tendons
Muscles
Subcutaneous tissue
Epidermis
Skeletal muscles
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A&P of Pain: Step Two
Sensory peripheral nerves are stimulated.
• Large A-Delta fibers – associated with sharp, pricking, acute,
well localized pain of short duration.
• Small C fibers – associated with dull, aching, throbbing, or
burning sensations.
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A&P of Pain:
Step Three
• Thalamus receives impulses
from spinothalamic tract:
• Impulses travel to parietal lobe in
cerebral cortex and to limbic
system.
• When impulses reach parietal
lobe, patient feels pain.
• Although journey takes a fraction
of a second, no pain is perceived
until parietal lobe is stimulated.
• Stimulation of limbic system
generates emotional response to
pain:
• Crying
• Anger
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A&P of Pain: Step Four

Pain journey ends when body produces substances to reduce pain perception:



Release of substances that inhibit transmission of noxious stimuli and produce analgesia:





As sensory nerve fibers travel to brainstem, they stimulate nerves that inhibit nociceptor stimuli.
Descending fibers start in brainstem and travel down the dorsal horn of the spinal cord.
Endogenous opioids, e.g., endorphins and enkephalins
Serotonin (5HT)
Norepinephrine (NE)
Gamma-aminobutyric acid (GABA)
These substances occupy the receptors sites, which prevent A and C nerve fibers from
opening “the gate.”
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Types of Pain
• Pain is categorized in several ways, but clear distinctions
among types may not be possible.
• Acute pain has recent onset and results from tissue
damage, is usually self-limiting, and ends when tissue
heals.
• May cause physiologic signs associated with pain.
• Persistent (chronic) pain may be intermittent or
continuous pain lasting more than 6 months.
• Clinical manifestations of chronic pain are not those of physiologic
stress because patient adapts to pain, but often reports symptoms
of irritability, depression, withdrawal, or insomnia.
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Types of Pain
• Nociceptive pain:
• Arises from somatic structures
such as bone, joint, or muscle.
• Results from activation of normal
neural systems.
• Neuropathic pain:
• Occurs because of abnormal
processing of sensory input.
• Referred pain:
• Pain felt in a location away from the injury.
• Often visceral pain, as many abdominal organs have no pain receptors.
• Phantom pain:
• Pain felt in an amputated extremity.
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Pain Threshold and Tolerance
• Concepts of pain threshold and pain
tolerance affect patient’s pain
experience.
• Pain threshold is point at which a
stimulus is perceived as pain.
• This threshold does not vary
significantly among people or
in same person over time.
• Pain tolerance is duration or intensity of pain a person will
endure before outwardly responding.
• Pain tolerance decreases with repeated exposure to pain, fatigue, anger,
boredom, and sleep deprivation.
• Tolerance increases after alcohol consumption, medications, hypnosis,
warmth, distracting activities, and strong faith-related beliefs.
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Cognitive & Cultural Influences on Pain
 Perception of and response to pain is influenced by
cognitive and cultural factors:
 Patient’s previous experiences with pain and current
physical and mental status affect pain perception and
response.
 Cognitive factors:
 Attention people give to the pain.
 Expectation or anticipation of pain.
 Appraisal or expression of pain.
 Cultural factors:
 Cultural influences may affect how pain is communicated.
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Effects of Pain and Treatment
• Pain:
• Increases catabolic demands
• Poor wound healing
• Weakness
• Muscle break down
• May reduce mobility. (↑ risk of thromboembolic event)
• May affect respiratory status
• Shallow breathing
• Tachypnea
• May affect cardiac status
• Tachycardia
• Hypertension
• May Impair sleep.
• May contribute to loss of appetite.
• May contribute to depression and/or anxiety
• Narcotics change elimination pattern.
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Pain Assessment
• Pain relief is primary responsibility of all health care
providers.
• Assessing patient’s pain is first step in achieving goal of
pain relief.
• Pain assessment and management often referred to as
fifth vital sign.
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Standards for Pain Assessment
• The Joint Commission standards assert that patients have
a right to appropriate assessment and management of
pain, including the following:
• Pain is assessed in all patients.
• Initial assessment and regular reassessment of pain, taking into
account personal, cultural, spiritual, and ethnic beliefs.
• Education of all relevant providers in pain assessment and
management.
• Education of patients and families regarding roles in managing pain
and potential limitations and side effects of pain treatments.
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Health History:
Present Health Status
• Do you have any chronic illnesses? If so, do they cause
you pain?
• Describe
• Do you take any medications?
• What, and how often?
• Do they relieve your pain?
• Are you allergic to any medications?
• What kind of allergic reaction occurs from these medications?
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Problem-Based History
• Pain is a complex, multidimensional, subjective
experience
• Collect data from patients using a symptom analysis
applying the mnemonic OLD CARTS
• O = Onset
• L = Location
• D = Duration
• C = Characteristics
• A = Aggravating factors
• R = Related symptoms
• T = Treatment by the patient
• S = Severity
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Beliefs about Pain
• Do you communicate your pain verbally or nonverbally?
• Be aware of cultural influences of pain:
•
•
•
•
Overt pain expression
Stoicism
Silence
Smiling
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Health History:
Description of Pain
• Location:
• Where is your pain? Point to location(s).
• Quality:
• Describe what the pain feels like.
• Quantity:
• How would you describe intensity, strength, or severity of the pain
on a scale of 0 to 10, with 0 being no pain and 10 being most
intense pain possible?
• At what point on this scale of 0 to 10 do you usually take
medication for your pain?
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Problem-Based Health History:
Onset of Pain
• Onset:
• When does the pain occur?
• During activity?
• Before or after eating?
• Does the pain occur suddenly or gradually?
• What do you think is causing your pain?
• Why do you think the pain started when it did?
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Problem-Based Health History:
Location and Duration of Pain
• Location:
• Where do you feel pain?
• Can you point to the location(s)?
• Duration:
• How long do you feel the pain?
• Is it constant or intermittent?
• How often does it occur?
• How long does it last?
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Problem-Based Health History:
• Characteristics: Can you describe
what the pain feels like?
• Aggravating factors:
• What makes the pain worse?
• Related symptoms:
• What other symptoms do you have during pain?
• Palpitations
• Shortness of breath
• Sweating
• Rapid or irregular heartbeat
• Nausea or vomiting
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Self-Treatment by Patient
• Treatment: Have you tried to relieve the pain?
• How effective have these measures been?
• What medications did you take, and in what amounts?
• Have you considered alternative methods?
• Massage
• Mind-body medicine
• Lifestyle changes
• How much pain are you expecting?
• Cultural beliefs may affect expectations.
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Severity of Pain
• How would you describe your pain?
• On a scale of 0 to 10, with 0 being no pain and 10 being the worst
pain possible, describe:
• Intensity
• Strength
• Severity
• At which point on this 0 to 10 scale do you usually want to
take your pain medicine?
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Response to Pain
• How do you react to pain?
• How do you express your pain?
• What do you fear most about the pain?
• What problems does your pain cause you?
• Does your pain have any particular meaning to you?
• Spiritual
• Psychological
• Do you have any concerns about taking pain relief?
• Has the pain affected your quality of life?
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Pain Reassessment
• After taking the medication, how would rate your pain
now?
• 30 minutes after parenteral administration.
• 60 minutes after oral administration.
• Assessing those who cannot communicate:
• Attempt self-report.
• Search for potential causes of pain.
• Observe for behavioral changes.
• Question caregivers about patient’s usual response to pain.
• Attempt analgesic trial and observe behavior.
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Examination
• Observe patient for posture and behavior that helps
relieve pain.
• Observe facial expressions.
• Listen for sounds made by patient.
• Inspect skin for color, temperature, moisture.
• Measure blood pressure and pulse.
• Assess respiratory rate and pattern.
• Observe pupillary size and reaction to light.
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Age-Related Variations:
Infants and Children
• Nurses find different responses to
pain depending on age of patient.
• Neonate responses to pain are
global, evidenced by increased
heart rate, hypertension, pallor,
sweating, and decreased
oxygenation saturation.
• Young children have difficulty
understanding pain but have a
basic ability to describe pain and
location.
• School-age children better
understand pain
and are able to describe pain
location.
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Age-Related Variations:
Older Adults
• Although transmission and perception of
pain may have slowed down in older person,
pain is felt no differently than by any other adult.
• Many older adults have a lifetime of experience in coping
with pain, but pain is not an expected part of aging.
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Question 1
Initiation of intravenous access can be a painful experience
for the patient. As the needle is inserted into skin, the
patient is calm. However, when the needle pierces the vein,
the patient pulls the hand away. The time that the person
endured the pain before outwardly responding is known as:
Pain tolerance.
Pain intolerance.
C. Pain perception.
D. Pain threshold.
A.
B.
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Question 2
Assessment of circulation, motion, and sensation is done
every 8 hours in a patient recovering from a laminectomy 3
days after surgery. The patient had the surgery for
consistent low back pain. Now on day 3, the patient has a
burning sensation on the lateral edge of the right foot. This
is best described as:
Cellulitis.
B. Nociceptive pain.
C. Fasciitis.
D. Neuropathic pain.
A.