15.8: Summary
15.1 Performing a General Survey
During the nurse’s interactions with a patient, the nurse must be prepared to obtain vital data, assess the patient’s status, and communicate openly with the patient. The patient’s appearance, behavior, age, gender, culture, growth, and development will be rapidly assessed when meeting the patient. From these initial observations, the nurse should be able to ascertain if the patient requires immediate intervention or will need the help of additional health care by being able to distinguish between normal and abnormal findings. The cognitive status will also need to be addressed, and any abnormalities found in cognition will require further investigation. Vital signs, height, and weight will be gathered during the initial encounter, providing objective data used to determine the patient’s current condition. To obtain this data, the nurse will need to be prepared. This preparation includes gathering appropriate instruments and refining the nurse’s skills using eyes, ears, and touch. Throughout the nurse’s various interactions with the patient, information will be exchanged, both verbally and nonverbally. An astute nurse will listen carefully to what the patient says and follow up as appropriate. The combination of these aspects in a generalized survey provides a thorough baseline for the patient’s status.
15.2 Common Types of Anthropometric Measurements
The anthropometric measurements of height, weight, and BMI guide patient treatment plans allowing the nurse to personalize the patient’s plan of care. Obtaining these measurements requires that nurses utilize the proper equipment. Standing scales and bariatric scales measure weight in ambulatory patients, whereas bed scales and sling scales are used in those with physical limitations. Although the ideal method for obtaining the height is using the stadiometer that requires the patient to stand upright, the demi-span aids in calculating the height for those unable to stand. The BMI is calculated from the height and weight data of a patient and is used to classify those results as either underweight, healthy weight, overweight, obese, or severely obese. This categorization provides data to help guide the patient’s plan of care.
15.3 Vital Signs
Vital signs provide a snapshot of health for the patient and are routinely assessed to monitor a patient’s progression. The nurse must make sure the right equipment and right methods are used to obtain accurate results. Even understanding the patient’s history can affect the method and equipment needed for vital signs. Vital sign monitoring occurs at routine intervals depending on the status of the patient, but the nurse can always assess these outside of these prescribed times, as nursing judgment dictates. Because vital signs are measured routinely on a patient, the nurse must be able to quickly validate and document these results. An abnormal vital sign or one outside of the patient’s trends requires further investigation. Once the vital signs are obtained and validated, they must be documented to facilitate communication with the entire healthcare team.
15.4 Temperature
In conclusion, the simple task of obtaining a patient’s temperature provides needed health information for the patient, which is why it is considered a vital sign. The ideal body temperature is 98.6°F (37°C), but small fluctuations are normal. The environment can hasten heat loss or heat gain through the mechanisms of heat transfer, which are conduction, convection, radiation, and evaporation. An infection, inflammation, malignancy, or autoimmune condition may be responsible for the development of a fever. Obtaining a patient’s temperature may be done through a variety of methods, depending on the patient, situation, and availability of equipment. Temperature abnormalities, outside the normal range, can indicate the presence of infection, exposure to harsh environment, or the need for further investigation.
15.5 Heart Rate
The pulse must be palpated as part of obtaining vital signs. The pulse provides valuable information about the circulatory system because it mimics the heart rate and illustrates the perfusion of the extremities. The radial pulse is the preferred site in most patients because of its peripheral and convenient location. In infants, auscultation of the apical pulse should be used to determine the heart rate, rather than the radial pulse. When a nurse is palpating the pulse, the rate, rhythm, and volume of the blood should be assessed and documented. Pulse abnormalities may be indicative of metabolic changes, cardiac complications, vascular conditions, or even activity levels.
15.6 Respiration
Assessing respirations is another component of the obtainment of vital signs and illustrates the efficiency of the respiratory system. When the nurse is preparing to obtain respirations, the normal range for the patient’s age and the patient’s trends should be known. To complete this assessment, the nurse should assess the respiratory effort by determining the respiratory rate, rhythm, and depth. Any difficulty breathing should be documented and communicated to the provider. The nurse should also be prepared to obtain the oxygen saturation of the blood via the pulse oximeter. This piece of equipment shows not only the oxygen saturation but also the pulse rate. Abnormalities identified in the respiratory assessment may be due to acid-base imbalances, pulmonary complications, neurological issues, and increased metabolism.
15.7 Blood Pressure
Blood pressure is the final vital sign obtained during the vital sign collection since it is often the most uncomfortable due to the squeezing. This measurement provides critical information on the cardiovascular system and takes specific equipment to obtain. An appropriately sized blood pressure cuff or sphygmomanometer, a stethoscope, and a trained nurse are all needed to obtain an accurate blood pressure reading. Once the blood pressure cuff is in place, the nurse assesses the location of the pulse, places the stethoscope over the pulse, and inflates the cuff. As the cuff slowly deflates, the nurse listens carefully for the origin and disappearance of the Korotkoff sounds to determine the systolic and diastolic results, being careful not to be confused by the auscultatory gap. Once the results are obtained, the nurse determines the pulse pressure and verifies the results, comparing them to both the normal ranges for the patient’s age and the individual trends. Abnormalities may be due to a host of issues such as abnormalities in the heart’s contraction, the diameter of the blood vessels, and the amount of circulating blood.