ASSESSING GENERAL

STATUS
AND VITAL SIGNS
 GENERAL SURVEY
• First part of the physical examination that begins the
moment the nurse meets the client.
• It requires the nurse to use all of her observational
skills while interviewing and interacting with the
client.
• These observations will lead to clues about the
health status of the client. The outcome of the
general survey provides the nurse with an overall
impression of the client’s whole being.
The general survey includes observation of the client’s:

• Physical development and body build

• Gender and sexual development
• Apparent age as compared to reported age
• Skin condition and color
• Dress and hygiene
• Posture and gait
• Level of consciousness
• Behaviors, body movements and affect
• Facial expression
• Speech
• Vital Signs
• The client’s VS (pulse, respirations, blood
pressure, temperature and pain) are the
body’s indicators of health.

• Traditionally, VS have included the client’s

pulse, respirations, BP and temperature. Today
“pain” is considered to be the “fifth VS”.
 OVERALL IMPRESSION OF THE CLIENT
• Forming an overall impression consists of a systematic
examination and recording these general characteristics
and impression of the client.
• Try to observe the client and environment quickly before
interacting with the client.
• When you meet the client for the first time, observe any
significant abnormalities in the client’s skin color, dress,
hygiene, posture and gait, physical development, body
build, apparent age and gender.
• If you observe abnormalities, you may need to perform
an in-depth assessment of the body area that appears to
be affected.
 VITAL SIGNS
• This a common, noninvasive physical assessment procedure
that most clients are accustomed to.
• Provide data that reflect the status of several body systems
including but not limited to the cardiovascular, neurologic,
peripheral vascular, and respiratory systems.
• Measure the client’s temperature first, followed by pulse,
respirations and blood pressure.
• Measuring the temperature puts the client at ease and
causes him/her to remain still for several minutes.
• Pulse, respirations and BP are influenced by anxiety and
activity.
 TEMPERATURE
• For the body to function a cellular level, a core body
temperature between 36.5°C to 37.7 °C orally, must be
maintained.
• Several factors may cause normal variations in the core body
temperature such as strenuous exercise, stress, ovulation can
raise temperature.
• Body temperature is lowest early in the morning (4:00-
6:00AM) and highest late in the evening (8:00pm to midnight).
• Hypothermia (lower than 36.5 °C) may be seen in prolonged
exposure to cold, hypoglycemia, hypothyroidism, or starvation.
• Hyperthermia (higher than 38 °C) may be
seen in viral or bacterial infections,
malignancies, trauma and various blood,
endocrine and immune disorders.
• Convert Fahrenheit (ºF) to Celsius (ºC):
°C = 5/9 x (F – 32 )

• Convert Celsius (ºC): to Fahrenheit (ºF) :

°F = 9/5 x C + 32
 PULSE
• Shock wave produced when the heart contracts and
forcefully pumps blood out of the ventricles into the
aorta.
• It travels along the fibers of the arteries and is
commonly called the arterial or peripheral pulse.
• The body has many arterial pulse sites and one of
them is the radial pulse- gives a good overall picture
of the client’s health status.
• A pulse rate ranging from 60 to 100 beats/min is
normal for adults.
• Tachycardia is a rate greater than 100 beats/min.
May occur with fever, certain medications, stress,
and other abnormal states, such as cardiac
dysrhythmias.

• Bradycardia is a rate less than 60 beats/min. Sitting

or standing for long periods may cause the blood to
pool and decrease the pulse rate. Heart block or
dropped beats can also manifest as bradycardia.

• Perform cardiac auscultation of the apical pulse if

the client exhibits any abnormal findings
Several characteristics should be assessed when measuring
the radial pulse: rate, rhythm, amplitude and contour and
elasticity.

Amplitude can be quantified as follows:

• 0 absent
• 1+ weak, diminished (easy to obliterate)
• 2+ Normal (Obliterate with moderate pressure)
• 3+ Bounding (unable to obliterate or requires firm pressure)

Note: If abnormalities are noted during assessment of the

radial pulse, perform further assessment.
 RESPIRATIONS
• Respiratory Rate and character are additional clues to the
client’s overall health status.
• Observe respirations without alerting the client by watching
chest movement before removing the stethoscope after you
have completed counting the apical beat.
• Notable characteristics of respiration are rate, rhythm and
depth.
• Between 12 and 20 breaths/min is normal.
• Tachypnea – more than 24 breaths/min
• Bradypnea – less than 10 breaths/ min
 BLOOD PRESSURE
• BP reflects the pressure exerted on the walls of the arteries.
• This pressure varies with the cardiac cycle, reaching a high
point with systole and a low point with diastole.
• A measurement of the pressure of the blood in the arteries
when the ventricles are contracted (systolic BP) and when
the ventricles are relaxed (diastolic BP).
• BP is expressed as the ratio of the systolic pressure over the
diastolic pressure. It is affected by several factors such as
cardiac output, distensibility of the arteries, blood volume,
blood velocity, blood viscosity.
• A client’s BP will normally vary throughout the day
due to external influences that include time of day,
caffeine or nicotine intake, exercise, emotions, pain
and temperature.
• Difference between systolic and diastolic pressure is
termed the pulse pressure. Normal pulse pressure is
30 to 50 mmHg
• Blood pressure may also vary depending on the
positions of the body and of the arm.
 PAIN
• Pain screening is very important in developing a
comprehensive plan of care for the client. It is
essential to assess pain at the initial assessment.
• When pain is present, identify location,
intensity, quality, duration, and alleviating or
aggravating factors to the client.
• Pain intensity measurement tools may be used.
Pain quality may be described as “dull”, “sharp”,
“radiating”, or “throbbing”
• Pain is a combination of
physiologic phenomena
but with psychosocial
aspects that influence
perception of the pain.
 CLASSIFICATION OF PAIN (DURATION AND
ETIOLOGY)

• Acute Pain: usually associated with a recent injury

• Chronic nonmalignant pain: usually associated with a specific

cause or injury and described as a constant pain that persists
for more than 6 months

• Cancer pain: often due to the compression of peripheral

nerves or meninges or from the damage to these structures
following surgery, chemotherapy, radiation, or tumor growth
and infiltration
PAIN LOCATION CLASSIFICATIONS INCLUDE:

• Cutaneous pain (skin or subcutaneous tissue)

• Visceral pain (abdominal cavity, thorax, cranium)
• Deep somatic pain (ligaments, tendons, bones, blood
vessels, nerves)
• Radiating pain - perceived both at the source and
extending to other tissues
• Referred pain - perceived in body areas away from the
pain source.
• Phantom pain -can be perceived in nerves left by a
missing, amputated, or paralyzed body part.
• Neuropathic pain causes an abnormal
processing of pain messages and results from
past damage to peripheral or central nerves
due to sustained neurochemical levels, but
exact mechanisms for the perception of
neuropathic pain are unclear.
• Intractable pain is defined by its high
resistance to pain relief.
Pain Assessment Tools
• There are many assessment tool, some of which are specific to
special types of pain. The main issues in choosing the tool are
its reliability and its validity. Moreover, the tool must be clear
and, therefore, easily understood by the client.
• There are many pain assessment scales, such as:
– Visual Analog Scale (VAS)
– Numeric Rating Scale (NRS)
– Numeric Pain Intensity Scale (NPI)
– Verbal Descriptor Scale
– Simple Descriptive Pain Intensity Scale
– Graphic Rating Scale
– Verbal Rating Scale
– Faces Pain Scales
 MEASURE TEMPERATURE
TYMPANIC TEMPERATURE
• To measure tympanic temperature, place the
probe very gently at the opening of the ear canal
for 2–3 seconds until the temperature appears in
the digital display.
• Normal tympanic temperature range is 36.7-
38.3°C. The tympanic membrane temperature is
normally about 0.8 °C than oral temperature.
• It is also a good device for measuring core body
temperature because the tympanic membrane is
supplied by a tributary of the artery (internal
carotid) that supplies the hypothalamus (the
body’s thermoregulatory center).
ORAL TEMPERATURE
• Use an electronic thermometer with a
disposable protective probe cover. Then
place the thermometer under the
client’s tongue to the right or left of the
frenulum deep in the posterior
sublingual pocket.
• Ask the client to close his or her lips
around the probe. Hold the probe until
you hear a beep.
• Remove the probe and dispose of its
cover by pressing the release button.
• Oral temperature is
• Electronic thermometers give a digital
reading in about 2 mns
AXILLARY TEMPERATURE
• Hold the glass or electronic
thermometer under the axilla
firmly by having the client hold
the arm down and across the
chest.
• The axillary temperature is 0.5°C
lower than the oral temperature.
Normal axillary temperature
range is 35.4–37.0 °C
TEMPORAL ARTERIAL TEMPERATURE
• Remove the protective cap from the
thermometer. Place the thermometer over
the client’s forehead and while holding and
pressing the scan button, gently stroke the
thermometer across the client’s forehead
over the temporal artery to a point directly
behind the ear.
• You will hear beeping and a red light will
blink to indicate a measurement is taking
place. Release the scan button and remove
the thermometer from the forehead.
• Read the temperature on the display. The
temporal artery temperature is
approximately 0.4°C (0.8°F) higher than oral.
Normal temporal artery temperature range
is 36.3–37.9°C.
RECTAL TEMPERATURE
• Cover the glass thermometer with a
disposable, sterile sheath, and lubricate
the thermometer.
• Wear gloves, and insert thermometer 1
inch into rectum.
• Hold a glass thermometer in place for 3
minutes; hold an electronic
thermometer in place until the
temperature appears in the display
window.
• The rectal temperature is between 0.4°C
and 0.5°C higher than the normal oral
temperature. Normal rectal temperature
range is 36.3–37.9°C.
 MEASURE PULSE RATE
RADIAL PULSE

• Use the pads of your two middle fingers

and lightly palpate the radial artery on
the lateral aspect of the client’s wrist.
• Count the number of beats you feel for
30 seconds if the pulse rhythm is
regular. Multiply by two to get the rate.
Count for a full minute if the rhythm is
irregular. Then, verify by taking an apical
pulse as well.
• A pulse rate ranging from 60 to 100
beats/min is normal for adults.
• Evaluate PULSE RHYTHM.
– Palpate the pulse with the tips of the first two fingers
feeling for each beat. Evaluate beats for regularity (equal
length of time between each beat) or irregularity (unequal
length of time between beats).
– Perform auscultation of the apical pulse if the client
exhibits irregular intervals between beats.
– When describing irregular beats, indicate whether they
are regular irregular or irregular irregular. Regular rhythm
is present when there is an equal amount of time
between beats. An irregular rhythm may be regularly
irregular or irregularly irregular. A regularly irregular pulse
would be one that follows a pattern of variation while an
irregularly irregular pulse follows no pattern.
• Assess pulse AMPLITUDE AND CONTOUR.
– Pulsation is equally strong in both wrists. Upstroke is
smooth and rapid with a more gradual downstroke.
– A bounding or weak and thready pulse is not normal.
Delayed upstroke is also abnormal. Follow up on
abnormal amplitude and contour findings by palpating
the carotid arteries, which provides the best
assessment of amplitude and contour.

• Palpate arterial ELASTICITY

– Artery feels straight, resilient, and springy.
– Artery feels rigid is an abnormal finding . The older client’s
artery may feel more rigid, hard, and bent.
 MEASURE RESPIRATIONS
• Observe the client’s chest rise and fall with each breath.
Count respirations for 30 seconds and multiply by 2.
• If you place the client’s arm across the chest while palpating
the pulse, you can also count respirations. Do this by
keeping your fingers on the client’s pulse even after you have
finished taking it.
• Observe respiratory rhythm
– Rhythm is regular (if irregular, count for 1 full minute).
• Observe respiratory depth.
– There is equal bilateral chest expansion of 1 to 2 inches.
– Unequal, shallow, or extremely deep chest and labored
or gasping breaths are abnormal.
 MEASURE BLOOD PRESSURE
• Measure on dominant arm first. Take blood pressure in both
arms when recording it for the first time. Take subsequent
readings in arm with highest measurement.
• Systolic pressure is ˂ 120 mmHg, Diastolic pressure is ˂ 80 mmHg.
A pressure difference of 10 mmHg between arms is normal.
• Advise client to avoid nicotine and caffeine for 30 minutes prior
to measurement. Ask client to empty bladder before evaluating
and avoid talking to the client while taking the reading. Each of
these prevents elevating blood pressure prior to/during reading.
• If the client takes antihypertensive medications or has a history
of fainting or dizziness, assess for possible orthostatic
hypotension.
• Before measuring the blood pressure, consider the
following behavioral and environmental conditions that
can affect the reading:
– Room temperature too hot or cold
– Recent exercise
– Alcohol intake
– Nicotine use
– Muscle tension
– Bladder distention
– Background noise
– Talking (either client or nurse)
– Arm position
1. Assemble your equipment so that the
sphygmomanometer, stethoscope, and your pen and
recording sheet
2. Assist the client into a comfortable, quiet,
restful position for 5 to 10 minutes. Client
may lie down or sit.
3. Remove client’s clothing from the arm and
palpate the pulsations of the brachial
artery. (If the client’s sleeve can be pushed
up to make room for the cuff, make sure
that the clothing is not so constrictive that it
would alter a correct pressure reading.
4. Place the blood pressure cuff so that the
midline of the bladder is over the arterial
pulsation, and wrap the appropriate-sized
cuff smoothly and snugly around the upper
arm, 1 inch above the antecubital area so
that there is enough room to place the bell
of the stethoscope.
• A cuff that is too small may give a false or abnormally high BP
reading
5. Support the client’s arm slightly flexed at heart level with the
palm up.
6. Put the earpieces of the stethoscope in your ears, then palpate
the brachial pulse again and place the stethoscope. Position the
gauge on the manometer at eye level.
7. Adjust the screw above the bulb to tighten the valve on the air
pump, and make sure that the tubing is not kinked or obstructed.
8. Inflate the cuff by pumping the bulb to about 30 mmHg above the
point at which the radial pulse disappears. This will help you
avoid missing auscultatory gap.
9. Deflate the cuff slowly—about 2 mm per second—by turning the
valve in the opposite direction while listening for the first
Korotkoff’s sound.
10. Read the point, closest to an even number, on the gauge at
which you hear the first faint but clear sound. Record this number
as the systolic BP. This is the phase 1 of Korotkoff’s sound.
11. Next, note the point, closest to an even number, on the
gauge at which the sound becomes muffled (phase IV of
Korotkoff’s sounds). Finally, note the point at which the sound
subsides completely (phase V of Korotkoff’s sounds). When
both a change in sounds and a cessation of the sounds are
heard, record the numbers at which you hear phase I, IV, and
V sounds. Otherwise, record the first and last sounds.

12. Deflate the cuff at least another 10 mmHg to make sure you
hear no more sounds. Then deflate completely and remove.

13 Record the readings

• Orthostatic hypotension may be related to a decreased
baroreceptor sensitivity, fluid volume deficit (e.g.,
dehydration), or certain medications (i.e., diuretics,
antihypertensives).
• Symptoms of orthostatic hypotension include dizziness,
lightheadedness, and falling. Further evaluation and referral
to the client’s primary care provider are necessary.
• Assess the pulse pressure, which is the difference between
the systolic and diastolic blood pressure levels. Record
findings in mmHg. For example, if the blood pressure was
120/80, then the pulse pressure would be 120 minus 80 or 40
mmHg.
– Pulse pressure is 30 to 50 mmHg. Higher or lower may
indicate cardiovascular disease.
– Widening of the pulse pressure is seen with aging due to
less elastic peripheral arteries.
 ASSESSING PAIN
• Observe comfort level.
– Client assumes a relatively relaxed posture without excessive
position shifting. Facial expression is alert and pleasant.
– Facial expression indicates discomfort (grimacing, frowning).
Client may brace or hold a body part that is painful.
Breathing pattern indicates distress (e.g., shortness of breath,
shallow, rapid breathing).
• Ask the client if he or she has any pain.
– No subjective report of pain.
– Explore any subjective report of pain using the mnemonic
COLDSPA.
 PULSE , RESPIRATION & BLOOD PRESSURE
HR RR BP (Systole) BP
Beats/min Breaths/min mmHg (Diastole)
mmHg
Range Average Range Average
Newborn 100-160 140 30-60 50 73-92 62-65
0-1 month
Infant 80-140 120 30-50 40 80-100 53-67
Above 1 mo – 12
mos
Toddler 75-120 100 25-40 30 80-100 56-68
Above 1 yr – 3 yrs
Pre-School Age 75-120 100 22-40 30 90-110 55-70
Above 3 yrs – 5 yrs
School-Age 70-110 100 20-30 25 90-120 60-76
Above 5 yrs – 13
yrs

Adolescent 60-100 80 16-22 20 100-130 63-83

Above 13 yrs – 18
yrs
Adult 60-100 80 12-20 20 113-136 65-84
Above 18 yrs