Chapter 9: General Survey Measurements and Vital Signs

Question 1

What is a general survey?

Answer 1

a study of the whole person

it covers general health state and any obvious physical characteristics

Question 2

Describe a general survey encounter:

Answer 2

What leaves an immediate impression? Does person stand promptly as his or her name is called and walk easily to meet you?
Or does person look sick, rising slowly or with effort, with shoulders slumped and eyes without luster or downcast?
Is hospitalized patient conversing with visitors, involved in reading or television, or lying perfectly still?
Even as you introduce yourself and shake hands, you collect data
Does person fully extend the arm, shake your hand firmly, make eye contact, or smile? Are palms dry or wet and clammy?
As you proceed through health history, measurements, and vital signs, note following points that will add up to general survey.
Consider these four areas: physical appearance, body structure, mobility, and behavior

Question 3

What objective data is taken on the physical appearance?

Answer 3

Age: person appears his or her stated age
Sex: sexual development appropriate for gender and age
Level of consciousness: person alert and oriented, attends to your questions and responds appropriately
Skin color: color tone even, pigmentation varying with genetic background, skin intact with no obvious lesion
Facial features: symmetric with movement
No signs of acute distress present

Question 4

What objective data is taken on body structure?

Answer 4

Stature: height appears within normal range for age, genetic heritage
Nutrition: weight appears within normal range for height and body build; body fat distribution even
Symmetry: body parts look equal bilaterally and are in relative proportion
Posture: person stands comfortably erect as appropriate for age
Exceptions
Standing toddler who has a normally protuberant abdomen (toddler lordosis)
Aging person who may be stooped with kyphosis
Position: person sits comfortably in chair or on bed or examining table, arms relaxed at sides, head turned to examiner
Body build, contour: proportions are correct
Arm span (fingertip to fingertip) equals height
Body length from crown to pubis roughly equal to length from pubis to sole
Obvious physical deformities: note any congenital or acquired defects

Question 5

What objective data is taken for mobility?

Answer 5

Gait: normally, base is as wide as shoulder width
Foot placement: accurate; walk smooth, even, and well-balanced; and associated movements, such as symmetric arm swing, are present
Range of motion: note full mobility for each joint, and that movement is deliberate, accurate, smooth, and coordinated
No involuntary movement

Question 6

What objective data is taken on the behavior?

Answer 6

Facial expression: person maintains eye contact (unless a cultural taboo exists), expressions appropriate to situation (e.g., thoughtful, serious, or smiling)
Note expressions both while face is at rest and while person is talking
Mood and affect: person comfortable and cooperative with examiner and interacts pleasantly
Speech: articulation (ability to form words) clear and understandable
Stream of talking is fluent, with an even pace
Conveys ideas clearly
Word choice appropriate to culture and education
Person communicates in prevailing language easily by himself or herself or with interpreter
Dress: appropriate to climate, looks clean and fits body, and is appropriate to person’s culture and age group; for example, normally:
Amish women wear clothing from nineteenth century
Indian women may wear saris
Culturally determined dress should not be labeled as bizarre by Western standards or by adult expectations
Personal hygiene: person appears clean and groomed appropriately for his or her age, occupation, and socioeconomic group

Question 7

What objective data is taken on measurements and weight?

Answer 7

Use a standardized balance or electronic standing scale
Inapproximately same time of day and same type of clothing worn each time
Record weight in kilograms and pounds
Show person how his or her weight matches up to recommended range for height
Compare person’s current weight with previous visit
Recent weight loss may be explained by successful dieting
Weight gain usually reflects overabundant caloric intake, unhealthy eating habits, and sedentary lifestyle
Instruct person to remove his or her shoes and heavy outer clothing before standing on scale
When sequence of repeated weights is necessary, aim for
Height
Use wall-mounted device or measuring pole on scale
Align extended headpiece with top of head
Person should be shoeless, standing straight, looking straight ahead, with feet and shoulders on hard surface
Body mass index
Body mass index is practical marker of optimal weight for height and an indicator of obesity or protein-calorie malnutrition

Question 8

What objective data is taken on waist circumference?

Answer 8

Assesses body fat distribution as indicator of health risk
Excess abdominal fat is an independent risk factor for disease, over and above that of body mass index (BMI)
Waist circumference measured in inches at smallest circumference below rib cage and above iliac crest
Hip circumference measured in inches at largest circumference of buttocks
Note the measurement at end of normal expiration

Question 9

What is normal temperature influenced by?

Answer 9

Diurnal cycle of 1° F to 1.5° F, with trough occurring in early morning hours and peak occurring in late afternoon to early evening
Menstruation cycle in women: progesterone secretion, occurring with ovulation at midcycle, causes a 0.5° F to 1.0° F rise in temperature that continues until menses
Exercise: moderate to hard exercise increases body temperature
Age: wider normal variations occur in infant and young child due to less effective heat control mechanisms; in older adults, temperature usually lower than in other age groups, with a mean of 36.2° C (97.2° F)

Question 10

What are the differences among the temperature sites?

Answer 10

Oral temperature accurate and convenient
Oral sublingual site has rich blood supply from carotid arteries that quickly responds to changes in inner core temperature
Normal oral temperature in a resting person is 37° C (98.6° F), with a range of 35.8° C to 37.3° C (96.4° F to 99.1° F)
Rectal measures 0.4° C to 0.5° C (0.7° F to 1° F) higher

Question 11

What is stroke volume?

Answer 11

amount of blood every heart beat pumps into aorta (about 70ml in adult)

Question 12

What part of the hand is used to palpate radial pulse?

Answer 12

pads of the first three fingers

Question 13

What traits are assessed with pulse?

Answer 13

rate
rhythm
force
elasticity

Question 14

What are the variances in pulse?

Answer 14

Rate normally varies with age and is more rapid in infancy and childhood and moderate during adult and older years
Rate also varies with gender; after puberty, females have slightly faster rate than males
In adult, a heart rate less than 60 bpm is bradycardia
This occurs normally in well-trained athletes whose heart muscle develops along with skeletal muscles
Stronger, more efficient heart muscle pushes out a larger stroke volume with each beat, thus requiring fewer beats per minute to maintain a stable cardiac output
A more rapid heart rate, over 100 bpm, is tachycardia
Occurs normally with anxiety or with increased exercise to match body’s demand for increased metabolism

Question 15

What is sinus arrhythmia?

Answer 15

one irregularity commonly found in children and young adults
Here heart rate varies with respiratory cycle, speeding up at peak of inspiration and slowing to normal with expiration
Inspiration momentarily causes a decreased stroke volume from left side of heart
To compensate, heart rate increases
If any other irregularities are felt, auscultate heart sounds for a more complete assessment

Question 16

How is the strength of pulse rated?

Answer 16

Force of pulse is strength of heart’s stroke volume
Weak, thready pulse reflects a decreased stroke volume (e.g., as occurs with hemorrhagic shock)
Full, bounding pulse denotes increased stroke volume, as with anxiety, exercise, and some abnormal conditions
Pulse force recorded using three-point scale
3+ Full, bounding
2+ Normal
1+ Weak, thready
0 Absent

Question 17

How do you take respirations accurately?

Answer 17

Because most people are unaware of their breathing, do not mention that you will be counting respirations, because sudden awareness may alter normal pattern
Instead, maintain your position of counting radial pulse and unobtrusively count respirations
Count for 30 seconds or a full minute if you suspect an abnormality
Avoid 15-second interval; the result can vary by a factor of + or −4, which is significant with small number
Also, a fairly constant ratio of pulse rate to respiratory rate exists, which is about 4:1
Normally, both pulse and respiratory rates rise as a response to exercise or anxiety

Question 18

What is blood pressure?

Answer 18

force of blood pushing against side of its container/vessel wall

Question 19

What is systolic pressure?

Answer 19

maximum pressure felt on artery during left ventricular contraction or systole

Question 20

What is diastolic pressure?

Answer 20

elastic recoil/resting pressure that blood exerts constantly between each contraction

Question 21

What is pulse pressure?

Answer 21

difference between systolic and diastolic: reflects stroke volume

Question 22

What is mean arterial pressure (MAP)?

Answer 22

pressure forcing blood into tissues, averaged over cardiac cycle

Question 23

What are the differences seen in blood pressure?

Answer 23

Average BP in young adult is 120/80 mm Hg; varies normally with many factors:
Age: gradual rise through childhood and into adult years
Gender: after puberty, females show a lower BP than males; after menopause, females higher than males
Race: African American adult’s BP usually higher than White person’s of same age
The incidence of hypertension is twice as high in African Americans as in Whites; reasons for difference not understood fully but appear to be due to genetic heritage and environmental factors

Question 24

What are the 5 factors that blood pressure is determined by?

Answer 24

1. ) cardiac output
2. ) peripheral vascular resistance
3. )Volume of circulating blood
4. ) Viscosity
5. ) elasticity of vessel walls

Question 25

How does cardiac output contribute to determining BP?

Answer 25

if heart pumps more blood into blood vessels, pressure on container walls increases

Question 26

How does peripheral vascular resistance contribute to determining blood pressure?

Answer 26

opposition to blood flow through arteries, when vessels become smaller or constricted pressure needed to push becomes greater

Question 27

How does the volume of circulating blood contribute to determining blood pressure?

Answer 27

refers to how tightly blood is packed into arteries; increasing contents in vessels increases pressure

Question 28

How does viscosity contribute to determining blood pressure?

Answer 28

“thickness of blood determined by its formed elements, blood cells; when contents thicker, pressure increases

Question 29

How does the elasticity of vessel walls contribute to determining blood pressure?

Answer 29

when vessels are stiff and rigid pressure needed to push increases

Question 30

In what situations do we take serial measurements of pulse and blood pressure?

Answer 30

You suspect volume depletion
Person is known to have hypertension or taking antihypertensive medications
Person reports fainting or syncope
Position changed from supine to standing, normally slight decrease (less than 10 mm Hg) in systolic pressure may occur

Question 31

What is taken into account about weight with the aging adult?

Answer 31

Weight: appears sharper in contour with more prominent bony landmarks than younger adult
Weight decreases during 80s and 90s; this factor more evident in males, because of greater muscle shrinkage
Distribution of fat also changes during 80s and 90s; even with good nutrition, subcutaneous fat lost from face and periphery (especially the forearms), whereas additional fat deposited on abdomen and hips

Question 32

What is taken into account with height of the aging adult?

Answer 32

Height: by 80s and 90s, many people are shorter than they were in their 70s
Results from shortening in spinal column, thinning of vertebral disks, shortening of individual vertebrae, and postural changes of kyphosis and slight flexion in knees and hips
Because long bones do not shorten with age, overall body proportion looks different: shorter trunk with relatively long extremities

Question 33

What happens to the aging adult in regards to temperature?

Answer 33

changes in body’s temperature regulatory mechanism leave aging person less likely to have fever but at greater risk for hypothermia
Temperature is less reliable index of older person’s true health state; sweat gland activity is also diminished

Question 34

What happens to the aging adult in regards to pulse?

Answer 34

normal range of heart rate is 60 to 100 bpm, but rhythm may be slightly irregular
Radial artery may feel stiff, rigid, and tortuous in older person, although does not necessarily imply vascular disease in heart or brain
Increasingly rigid arterial wall needs faster upstroke of blood, so pulse is actually easier to palpate

Question 35

What is taken into account with the aging adult in regards to respirations?

Answer 35

aging causes decrease in vital capacity and decreased inspiratory reserve volume
You may note shallower inspiratory phase and an increased respiratory rate

Question 36

What is taken into account with the aging adult in regards to blood pressure?

Answer 36

aorta and major arteries tend to harden with age
As heart pumps against a stiffer aorta, systolic pressure increases, leading to widened pulse pressure
In many older people, both systolic and diastolic pressures increase, making it difficult to distinguish normal aging values from abnormal hypertension

Question 37

What is the pulse oximeter?

Answer 37

a noninvasive method to assess arterial oxygen saturation (SpO2)
Sensor attached to person’s finger or earlobe has diode that emits light and detector measures relative amount of light absorbed by oxyhemoglobin (HbO2) and unoxygenated (reduced) hemoglobin (Hgb)
Compares ratio of light emitted to light absorbed and converts this ratio to percentage of oxygen saturation
Because it only measures light absorption of pulsatile flow, result arterial oxygen saturation

Question 38

What is the SPO2 of a healthy person with no lung disease and no anemia?

Answer 38

97% to 98%

Question 39

Is the finger probe or the earlobe probe more accurate?

Answer 39

Select appropriate pulse oximeter probe
Finger probe spring loaded and feels like clothespin attached to finger but does not hurt
At lower oxygen saturations, earlobe probe more accurate and less affected by peripheral vasoconstriction

Question 40

What are the doppler techniques?

Answer 40

In many situations, pulse and BP measurement enhanced by using an electronic device, Doppler ultrasonic flow meter
Technique works by a principle that sound varies in pitch in relation to distance between sound source and listener: pitch is higher when distance is small, and pitch lowers as distance increases
In this case, sound source is blood pumping through artery in rhythmic manner
Handheld transducer picks up changes in sound frequency as blood flows and ebbs, and it amplifies them

Question 41

What are abnormal findings in body height and proportion?

Answer 41

Hypopituitary dwarfism
Gigantism
Acromegaly (hyperpituitarism)
Achondroplastic dwarfism
Anorexia nervosa
Marfan syndrome
Endogenous obesity: Cushing syndrome