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Beginning the Physical Examination: General Survey and Vital Signs

THE HEALTH HISTORY
I. VITAL SIGNS Factors that affect the bodys heat production 1. Basal Metabolic Rate. It is the rate of energy utilization in the body required to maintain essential activities such as breathing. The younger the erson, the higher the BMR. 2. Muscle Activity. It includes shivering, increases the BMR. 3. Thyroxine Output. Increased thyroxine output increases the rate of cellular metabolism throughout the body, an effect called chemical thermogenesis. 4. Epinephrine, norepinephrine and sympathetic stimulation/stress response. These hormones immediately increase the rate of cellular metabolism in the bidy tissues. 5. Fever. Fever increases the cellular metabolic rate and thus increases the bodys temperature further. Factor affecting Body Temperature 1. Age 2. Diurnal variations (circadian rhythms) 3. Exercise 4. Hormones Figure 1-1 Normal Body Temperature Ranges 5. Stress 6. Environment

The vital signs are body temperature, pulse, respirations and blood pressure. These signs, which should be looked at in total, are checked to monitor the functions of the body. These signs reflect that chances in function that otherwise might not be observed. Monitoring a clients vital signs should not be an automatic or routine procedure; it should be a thoughtful, scientific assessment. Vital signs should be evaluated with reference to the clients present and prior health status, are compared to the clients usual and accepted standards. A. BODY TEMPERATURE Body temperature reflects the balance between the heat produced and the heat loss from the body and is measured in heat units called degrees. There are two kinds of body temperature: core temperature and surface temperature. Core temperature is the temperature of the deep tissues of the body, such as the abdominal cavity and pelvic cavity. It remains relatively constant. The surface temperature is the temperature of the skin, the subcutaneous tissue and fat. It, by contrast, rises and falls in response to the environment.

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A temperature that rises to fever level rapidly following a normal temperature and then returns to normal within a few hours is called a fever spike/spike fever. Two examples of an elevated temperature that is not true: Heat exhaustion. A result of of excessive heat and dehydration. Signs of heat exhaustion include paleness, dizziness, nausea, vomiting, fainting and a moderate increased temperature. Heat stroke. Persons experiencing heat stroke generally have been exercising in hot weather, have warm, flushes skin, and often do not sweat, Then usually have a temperature of 106 degree F or higher and may be delirious, unconscious or having seizures. Hypothermia is a core body temperature below the lower limit of normal. The three physiologic mechanisms of hypothermia are (a) excessive heat loss, (b) inadequate heat production to counteract heat loss and (c) impaired hypothalamic thermoregulation. Figure 1-2 Terms used to describe alterations in body temperature (oral measurements) and ranges in Celsius (centigrade) and Fahrenheit scales

Heat is lost from the body through radiation, conduction, convection and vaporization. Radiation is the transfer of heat from the surface of one object to the surface of another without contact between two objects, mostly in the form of infrared rays. Conduction is the transfer of heat from one molecule to a molecule of lower temperature. Convection is the dispersion of heat by air currents. The body usually has a small amount of warm air adjacent to it. Vaporization is continuous evaporation of moisture from the respiratory tract and from the mucosa of the mouth and from the skin.

Alterations in Body Temperaute Pyrexia and Hypothermia A body temperature above the usual range is called pyrexia, hyperthermia or fever. A very high fever, such as 41 degree C is called hyperpyrexia. Client who has a fever is referred to as febrile; the one who does not is afebrile.

Four Common Types of Fevers; intermittent, remittent, relapsing and constant Intermittent fever. The body temperature alternates at regular intervals between periods of fever and periods of normal or subnormal temperatures. Remittent fever. With a cold or influenza, a wide range of temperature fluctuations, occurs over 24-hour period, all of which above normal. Relapsing fever. Short febrile periods of a few days are interspersed with periods of 1 to2 days of normal temperature. Constant fever. The body temperature fluctuates minimally but always remains above normal.

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Factors Affecting the Pulse Age Gender Exercise Fever Medications Hypovolemia Stress Position changes Pathology

B. PULSE The pulse is a wave of blood created by contraction of the left ventricle of the heart. Generally, the pulse wave represents the stroke volume output or the amount of blood that enters the anteries with each ventricular contraction. Cardiac output is the volume of the blood pumped into the arteries by the heart and equals the result of the stroke volume (SV) times the heart rate (HR) per minute. A peripheral pulse is a pulse located away from the heart, for example, in the foot or wrist. The apical pulse in contrast, is a central pulse; that is, it is located at the apex of the heart, also referred to as the point of maximal impulse (PMI).

Pulse Sites Temporal Used when radial pulse is not accessible Carotid used during cardiac arrest/shock in adults. Used to determine circulation to the brain Apical Routinely used for infants and children up to 3 years of age. Used to determine discrepancies with radial pulse. Used in conjunction with some medications Brachial Used to measure blood pressure. Used during cardiac arrest for infants.

Figure 1-3 Illustration of the different pulse sites

Radial Readily accessible

Femoral Used in cases of cardiac arrest/shcok. Used to determine circulation to a leg. Popliteal Used to circulation to the lower leg. determine

Posterior tibial Used to determine circulation to the foot. Pedal (dorsalis pedis) Used to determine circulation to the foot.

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D. BLOOD PRESSURE Arterial blood pressure is the pressure exerted by the flows through the arteries. blood moves in waves, there pressure measures. a measure of blood as if it Because the are two blood

C. RESPIRATIONS Respiration is the act of breathing. Inhalation or inspiration refers to the intake of air into the lungs. Exhalation or expiration refers to breathing out or the movement of gases from the lungs to the atmosphere. Ventilation is also used to refer to the movement of air in and out of the lungs. Before assessing a clients respirations, a nurse should be aware of the following: The clients normal breathing pattern

The systolic pressure is the pressure of the blood as a result of contraction of the ventricles, that is, the pressure of the height of the blood wave. The diastolic pressure is the pressure when the ventricles are at rest. Diastolic pressure then is the lower pressure. The difference between the diastolic and systolic pressure is called pulse pressure. Hypertension is a blood pressure that is persistently above normal. A single elevated blood pressure reading indicates the need for reassessment. Hypotension is a blood pressure that is below normal, that is, a systolic reading consistently between 85 and 110 mm Hg in an adult whose normal pressure is higher than this.

The influence of the clients health problems on respirations Any medications or therapies that might affect respirations The relationship of the clients respirations to cardiovascular function Breathing that is normal in rate and depth is called eupnea. Abnormally slow respirations are referred to as bradypnea and abnormally fast respirations are called tachypnea or polypnea. Apnea is the absence of breathing.

II. Table 1-1 Variations Respirations by Age PULSE AGE AVERAGE (AND RANGES) Newborn 130 (80180) 1 year 120 (80140) 5-8 years 100 (75120) 10 years 70 (50-90) Teen 75 (50-90) Adult 80 (60100) Older 70 (60adult 100) in Pulse and

GENERAL SURVEY

Health assessment usually begins with a general survey that involves clients: General appearance Mental health status

RESPIRATIONS AVERAGE (AND RANGES) 35 (30-80) 30 (20-40) 20 (15-25) 19 (15-25) 18 (15-20) 16 (12-20) 16 (15-20)

Measurement of vital signs including height and weight General appearance and mental status of an individual must be assessed in relation to: Culture Educational Level Socioeconomic status Current circumstances Age, sex, race

Physical Examination

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Reports of discharge, presence of a lump or sore, or change in color, size, and shape of an genital organ Changes in urinary function Need for Papanicolaou test Request for birth control

Physical examination of the female genitals and reproductive tract and the male genitals is part of a routine physical examination in some agencies. Nursing history data indicating the need for physical examination include the following: Suspicion of infertility, pregnancy, or an STI