Chapter 10

Copyright © 2014 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

 Physical Appearance  Body Structure
◦ Age ◦ Stature
◦ Sex ◦ Nutrition
◦ Level of Consciousness ◦ Symmetry
◦ Skin Colour ◦ Posture
◦ Facial Features ◦ Position
◦ Body Build and Contour

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 Mobility  Behaviour
◦ Gait ◦ Facial Expression
◦ Range of Motion ◦ Mood and Affect
◦ Speech
◦ Dress
◦ Personal Hygiene

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 Weight
◦ Balance scale
◦ Recommended range for height
 Note: When measures of weight will be repeated, time
of day and amount of clothing should be the same
each time.
 Height
◦ Use a wall-mounted device or the measuring pole on
the balance scale. Align the extended headpiece with
the top of the head. The patient should be shoeless,
standing straight with gentle traction under the jaw,
and looking straight ahead. Feet, shoulders, and
buttocks should be in contact with the pole or the wall.

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 BMI Calculation:
 World Health Organization (WHO, 2011):
 <16.0: Severe thinness
 16.0–16.99: Moderate Thinness
 17.0–18.5: Mild Thinness
 <18.5: Underweight
 18.5–24.9 Normal weight
 25.0–29.9: Overweight
 30.0–34.9: Obesity (Class 1)
 35–39.9: Obesity (Class 2)
 ≥40: Extreme obesity (Class 3)

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 Hip-Waist Ratio = Apple versus Pear:
◦ Indicates your probable health risks. People with
more weight around the waist, face more health risks
than people who carry more weight around their hips.
◦ At risk for cardiovascular and metabolic disorders:
◦ Women
 Waist > 35 inches
 Waist-to-hip ratio > 0.8
◦ Men
◦ Waist > 40 inches
◦ Waist-to-hip ratio > 1.0

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 The normal oral temperature in a resting patient ranges from
35.8°C to 37.3°C (mean of 37°C).
 The normal temperature is influenced by:
 Diurnal Cycle: A cycle of 1° to 1.5°C (1°F to 1.5°F), with the trough
occurring in the early morning hours and the peak occurring in
late afternoon to early evening.
 Menstruation Cycle: 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 the infant and young child
due to less effective heat control mechanisms. In older adults,
temperature is usually lower than in other age groups, with a
mean of 36.2°C (97.2°F).

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 Abnormal Findings:
1. Hyperthermia, or fever, is caused by pyrogens secreted by
toxic bacteria during infections or from tissue breakdown
such as that following myocardial infarction, trauma, surgery,
or malignancy. Neurological disorders (e.g., a cerebral
vascular accident, cerebral edema, brain trauma, tumour, or
surgery) also can reset the brain's thermostat at a higher
level, resulting in heat production and conservation.
2. Hypothermia is usually due to accidental, prolonged exposure
to cold. It also may be purposefully induced to lower the
body's oxygen requirements during heart or peripheral
vascular surgery, neurosurgery, amputation, or
gastrointestinal hemorrhage.

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 Stroke Volume: With every beat, the
heart pumps an amount of blood—the
stroke volume—into the aorta. This is
about 70 ml in the adult. The force flares
the arterial walls and generates a
pressure wave, which is felt in the
periphery as the pulse.
 Technique of Measurement: Using the
pads of your first three fingers, palpate
the radial pulse at the flexor aspect of
the wrist laterally along the radius bone.
Push until you feel the strongest
pulsation. If the rhythm is regular, count
the number of beats in 30 seconds and
multiply by 2. The 30-second interval is
the most accurate and efficient when
heart rates are normal or rapid and when
rhythms are regular. However, if the
rhythm is irregular, count for a full
minute.

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◦ 1. Rate
 Normal rate for age group
 Average adult = 60 to 100 beats per minute
 Bradycardia
 Tachycardia
◦ 2. Rhythm
 Sinus Arrhythmia
◦ 3. Force
 3+ = Full, bounding (pulse denotes an increased stroke volume, as
with anxiety, exercise, and some abnormal conditions)
 2+ = Normal
 1+ = Weak, thready (decreased stroke volume - hemorrhagic
shock)
 0 = Absent
◦ 4. Elasticity
◦ With normal elasticity, the artery feels springy, straight, resilient.

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 Normally, a person's breathing is relaxed,
regular, automatic, and silent. Because most
people are unaware of their breathing, do not
mention that you will be counting the
respirations, because sudden awareness may
alter the normal pattern. Instead, maintain
your position of counting the radial pulse and
unobtrusively count the respirations. Count
for 30 seconds or for a full minute if you
suspect an abnormality. Avoid the 15-second
interval. The result can vary by a factor of + or
−4, which is significant with such a small
number.
 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.
 Normal for an adult is 10-20 breaths per
minute.

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 Influences on blood pressure:
 Age: Normally, a gradual rise occurs through childhood and
into the adult years.
 Gender: Before puberty, no difference exists between males
and females. After puberty, females usually show a lower BP
reading than do male counterparts. After menopause, BP in
females is higher than in male counterparts.
 Ethnocultural Background: In Canada, adults of African
descent usually have a higher BP than do Euro-Canadians of
the same age. The incidence of hypertension is twice as high
in this group; reasons for the difference are not fully
understood, but it appears to be due to genetics and
environmental factors.

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 Diurnal Rhythm: A daily cycle of a peak
and a trough occurs: the BP climbs to a
high in late afternoon or early evening
and then declines to an early morning
low.
 Weight: BP is higher in obese persons
than in persons of normal weight of the
same age (including adolescents).
 Exercise: Increasing activity yields a
proportionate increase in BP. Within 5
minutes of terminating the exercise, the
BP normally returns to baseline.
 Emotions: The BP momentarily rises
with fear, anger, and pain as a result of
stimulation of the sympathetic nervous
system.
 Stress: The BP is elevated in persons
feeling continual tension because of
lifestyle, occupational stress, or life
problems.
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 Common errors in blood pressure
measurement
◦ Orthostatic (or postural) hypotension, which is a
drop in the systolic pressure of more than 20 mm
Hg or pulse in creases 20 bpm or more with
standing.
 What would you do if your client with history of
hypertension was recently prescribed a new anti-
hypertensive medication and then states they feel dizzy
at certain times. How should you evaluate the blood
pressure?

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 An automated vital signs monitor is in frequent use in hospital
or clinic settings, especially when frequent monitoring is
required. The BP mode is non-invasive and fast and has
automatic measurement intervals and a bright numerical
display. As with manual BP machines, accuracy depends on
cuff selection and placement and on calibration of the
equipment.
 The electronic BP monitor cannot sense vibrations of low BP or
rapidly irregular pulses, as in atrial fibrillation. Do not use it if
the patient's systolic BP is less than 90 mm Hg or if the patient
has conditions such as shivering, tremors, or seizures.
 Note: If the numerical display does not correspond to the
clinical presentation of the patient, always validate your
findings with a manual sphygmomanometer and your
stethoscope. Don’t be passive in your nursing care!

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 The pulse oximeter is a noninvasive
method to assess arterial oxygen
saturation (SpO2). A sensor attached to the
person's finger or earlobe has a diode that
emits light and a detector that measures
the relative amount of light absorbed by
oxyhemoglobin (HbO2) and unoxygenated
(reduced) hemoglobin (Hb). Because it
only measures light absorption of
pulsatile flow, the result is arterial oxygen
saturation. A healthy person with no lung
disease and no anemia normally has an
SpO2 of 97 to 98%.
 Select the appropriate pulse oximeter
probe. The finger probe is spring loaded
and feels like a clothespin attached to the
finger but does not hurt. At lower oxygen
saturations, the earlobe probe is more
accurate and is less affected by peripheral
vasoconstriction.
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 Chapter 10 Review
General Survey, Measurement and Vital Signs

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a. Palpating
b. Interviewing
c. Inspecting
d. Auscultating

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a. Always
b. Test deep tendon reflexes
c. Never
d. Assess pain in the kidneys

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a. Ethnicity, sex, age and socioeconomic status
b. Physical appearance, sex, ethnicity and affect
c. Dress, affect, non-verbal behaviour and mobility
d. Physical appearance, body structure, mobility and
behaviour

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a. Varied, depending upon the height if the person
b. Equal to the length of the arm
c. As wide as the shoulder width
d. Half of the height of the client

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a. Count for 15 seconds if pulse is regular
b. Begin counting with 0; count for 30 seconds
c. Count for 30 seconds, and multiply by 2 for all cases
d. Count for 1 full minute; begin counting with 0

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a. Behaviour
b. Body structure
c. Mobility
d. Physical appearance

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 Jarvis, C. (2014). General Survey,
Measurement and Vital Signs. In A. J. Browne,
J. MacDonald-Jenkins & M. Luctkar-Flude
(Eds.). Physical examination and health
assessment (2nd Canadian Ed.) (p. 151-181).
Toronto, ON: Saunders Elsevier Canada.
 Images used with permission from Elsevier.

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