General Inspection and
Measurement of Vital Signs
DSN
Kevin Dobi, MS, APRN
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of Elsevier Inc.
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General inspection begins the moment nurse meets
patient.
Initial impressions guide nurse to areas requiring
further examination:
 Physical appearance
 Hygiene
 Body structure and movement
 Emotional and mental status
 Behavior
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Does patient appear healthy? Any obvious findings
such as tremors or facial drooping? Does patient
appear close to stated age?
Note that patient may appear older or younger than
stated age due to drug and alcohol use, excessive sun
exposure, chronic disease, and endocrine disorders.
Note color and condition of skin. Any variations or
obvious presence of lesions?
Is patient clean and well groomed or disheveled? Any
odors detected?
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Body structure and position:
 Stature and height appropriate for age.
 Nutritional status: Well nourished, cachectic, obese.
 Body symmetry and positioning.
Body movement:
 Note how patient moves.
 Use of assistive devices.
 Are there limitations in range of motion?
 Are there any involuntary movements such as a
tremor or tic?
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Emotional and mental status and behavior:
 Note alertness, facial expressions, tone of voice, and
affect.
 Does patient maintain eye contact as culturally
appropriate?
 Does patient converse appropriately?
 Are facial expressions and body language
appropriate for conversation?
 Is clothing appropriate for weather?
 Is behavior appropriate?
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Baseline indicators of patient’s health status include
measurement of temperature, heart rate, respiratory
rate, blood pressure, oxygen saturation, height, and
weight.
Assessing presence of pain is considered standard
baseline data collected for all patients and included
with assessment of vital signs.
Vital signs, pain assessment, height, and weight are
usually assessed at start of physical exam or integrated
into exam.
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Body temperature is regulated by the hypothalamus:
 Heat gained through processes of metabolism and
exercise.
 Heat lost through radiation, convection, conduction,
and evaporation.
 Expected temperature ranges from 96.4F to 99.1°F
(35.8°C to 37.3°C).
 Average is 98.6°F (37°C).
This is stable core temperature at which cellular
metabolism is most efficient.
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Temperature during menstrual cycle increases 0.5°F to
1.0°F (0.3°C to 0.6°C) at ovulation and remains elevated
until menses cease because of progesterone secretion.
Moderate to vigorous exercise increases temperature.
Normal variations occur throughout the day.
 Diurnal variations of 1°F to 1.5°F occur, with the
lowest temperature in the morning and highest in
the late afternoon.
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Temperature measurement by oral route is safe and
relatively accurate.
Delay at least 10 minutes if patient ingested hot or cold
liquids or smoked.
Electronic thermometer (sheathed): under tongue in
sublingual pocket for 15 to 30 seconds.
 This location receives blood supply from carotid
artery; thus indirectly reflects core temperature.
 Safe for use in school-aged children or confused
adults.
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Tympanic membrane temperature:
 Probe covered with protective sheath, placed in
external ear canal in contact with all sides of canal
for 2 to 3 seconds.
Axillary temperature measurement has questionable
accuracy.
Rectal temperature is used less frequently due to newer
methods.
 Less comfortable, but safe for use in adults.
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Palpation of arterial pulses provides valuable
information about cardiovascular system.
Pulse determines heart rate and rhythm:
 Heart rate is number of times in a minute a pulsation
is felt.
 Rhythm refers to regularity of pulsations or time
between each beat.
Pulses also provide important information on strength
of pulse and perfusion of blood to various parts of the
body.
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To take a pulse, place fingers over artery and feel for
pulsations and rhythm:
 Use finger pads of index and middle fingers; apply
firm pressure over pulse, but not so hard that
pulsation is occluded.
 If rhythm is regular, count number of pulsations for
30 seconds and multiply by 2, or count for 15
seconds and multiply by 4.
 If pulse rhythm is irregular, note any odd rhythm,
and count pulsations for full minute.
 Document irregular pulse when recording vital
signs.
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Radial artery is most frequently used to measure heart
rate because accessible and easily palpated:
 Radial pulse found at radial side of forearm at wrist.
Brachial and carotid arteries are common alternative
sites to assess pulse rate:
 Brachial pulse is located in groove between biceps
and triceps muscles, in bend of elbow.
 Carotid pulse is found along medial edge of
sternocleidomastoid muscle in lower third of neck.
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Heart rate can also be assessed by auscultating
heart, which is known as apical pulse, and
counting heart sounds for 1 minute.
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Located over the fifth intercostal space at the mid
clavicular line
Must use a stethoscope to auscultate heart rate
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Respiratory rate involves counting number of
ventilatory cycles and inhalation and exhalation, each
minute.
Men usually breathe diaphragmatically, increasing
movement of abdomen.
Women tend to be thoracic breathers, noted with
movement of chest.
Count respiratory rate when patient is unaware to
prevent self-conscious changing of breathing rate or
pattern.
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Other factors that increase respiratory rate are fever,
anxiety, exercise, and high altitude.
Note rhythm, depth, and effort of breathing:
 Rhythm is pattern or regularity of breathing and
described as regular or irregular.
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Depth assessed by observing excursion or movement of chest
wall.
Depth described as deep (full lung expansion with full
exhalation), normal, or shallow.
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Shallow breathing, small volume of air movement in
and out of lungs, may be difficult to observe.
Observe effort that goes into breathing also.
Normal breathing should be even, quiet, and effortless
when patient is sitting or lying down.
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Blood pressure is force of blood against arterial walls.
 It reflects relationship between cardiac output and
peripheral resistance.
 Cardiac output is volume of blood ejected from heart
each minute.
 Peripheral resistance is force that opposes flow of
blood through vessels; when arteries are narrow,
peripheral resistance to blood flow is high, and
reflected in elevated blood pressure.
 Blood pressure is dependent on velocity of blood,
intravascular blood volume, and elasticity of vessel
walls.
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Blood pressure measured in millimeters of mercury
(mm Hg).
Systolic blood pressure is maximum pressure exerted
on arteries when ventricles eject blood from heart
contracts
Diastolic blood pressure represents minimum amount
of pressure exerted on vessels when ventricles of heart
relax.
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Blood pressure is recorded with systolic pressure
written on top of diastolic pressure (e.g., 130/76), but it
is not a fraction.
Pulse pressure is the difference between systolic and
diastolic pressures and normally ranges from 30 mm
Hg to 40 mm Hg.
Orthostatic blood pressures are a series obtained when
the patient is lying, sitting, and then standing.
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Blood pressure can be measured directly or indirectly.
Direct measurement done by inserting a small catheter
into artery that provides continuous blood pressure
measurements and arterial waveforms.
 Direct measurement done in critical care settings
when continuous monitoring required.
Indirect measurement in all other settings done by
auscultation with sphygmomanometer and stethoscope
or with noninvasive blood pressure monitor.
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Sphygmomanometer consists of gauge to measure
pressure, a cuff enclosing an inflatable bladder, and
bulb with valve used to inflate and deflate bladder
within cuff.
Stethoscope used to auscultate blood pressure.
Listen carefully for Korotkoff sounds.
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Blood flows freely through artery until inflated cuff
interrupts blood flow.
As cuff pressure slowly released, nurse listens for
sounds of blood pulsating through artery again.
Initial sound is called first Korotkoff sound,
characterized by a clear, rhythmic thumping that
gradually increases in intensity.
Pressure reading at which this sound is first heard
indicates systolic pressure.
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Second Korotkoff sound is a swishing sound heard as
cuff continues to deflate.
Third Korotkoff sound is a softer thump than first.
Fourth Korotkoff sound is muffled and low pitched as
cuff is further deflated.
Fifth Korotkoff sound marks cessation of sound and
indicates artery completely open.
Manometer pressure noted at fifth Korotkoff sound is
diastolic pressure.
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Noninvasive blood pressure (NIBP) monitor is an electronic
device attached to cuff.
 Because NIBP monitor is an electronic device, nurse does
not auscultate Korotkoff sounds.
 It senses blood flow vibrations and converts them to
electric impulses transmitted to digital readout.
 Readout indicates blood pressure, mean arterial pressure,
and pulse rate.
 Not capable of determining quality of pulse such as
rhythm or intensity.
 May be programmed to repeat measurements on a
schedule and to sound alarm if readings are outside
desired limits.
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Number of patient-related factors affect blood pressure
and should be kept in mind when interpreting blood
pressure measurements.
Age: From childhood to adulthood there is gradual
rise.
Gender: After puberty, women usually have a lower
blood pressure than men; however, after menopause,
women’s blood pressure may be higher than men’s.
Race: Incidence of hypertension is twice as high in
black Americans as in whites. (Cultural)
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Diurnal variations: Pressure is lower in early morning
and peaks in late afternoon or early evening.
Emotions: Anxiety, anger, or stress may increase blood
pressure.
Pain: Acute pain may increase blood pressure.
Personal habits: Caffeine or smoking within 30 minutes
before measurement may increase reading.
Weight: Obese patients tend to have higher blood
pressures than nonobese patients.
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Accuracy of blood pressure measurement is
significantly affected by nurse’s technique.
Research indicates that many health care providers
demonstrate incorrect technique or lack of knowledge
associated with blood pressure measurement .
Incorrect technique can result in false-low or false-high
measurements.
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Measurement of oxygen saturation is included with
vital signs in many settings:
 Oxygen saturation is measured by a pulse
oximeter—a device that estimates oxygen saturation
of hemoglobin in blood.
 Probe is taped or clipped to patient’s fingertip, toe,
earlobe, or nose; oxygen saturation appears as a
digital readout within 10 to 15 seconds after
oximeter is placed.
 Oxygen saturation levels lower than 90% are
considered abnormal and require further evaluation.
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Routine assessment of patient’s pain or comfort level is
standard practice in all health care settings and often
assessed with vital sign measurement.
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Body weight or mass is influenced by a number of
factors, including genetics, dietary intake, exercise, and
fluid volume.
Genetics influence height and body size, including
bone structure, muscle mass, and gender.
Body weight is important for nutritional assessment, to
determine changes in weight over time, and to
calculate medication dosage.
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Unintentional weight change may be significant
finding.
Unexplained weight loss may be one indication of
suspected malignancy or disease process.
Measure weight using a balance scale by asking patient
to stand on platform while large and small weights are
balanced.
Adjust smaller weight to balance scale reading weight
to nearest quarter pound.
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Height is influenced by genetics and dietary intake;
measured on a platform scale with a height attachment.
Ask patient to stand on scale without wearing shoes;
lower height attachment until horizontal headpiece
touches top of patient’s head.
Vertical measuring scale can measure in inches or
centimeters.
Adult height attained by age 18 to 20 years.
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Measurement of height (recumbent length), weight,
and head and chest circumferences are important
indicators of growth.
Data are plotted on growth charts to assess growth
patterns of infant and child and to compare growth to
infants and children of same age and gender.
Same process for general inspection and vital signs
measurement among infants and children is followed
as previously described.
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Measurement of height, weight, and vital signs in older
adults is same as previously described.
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The nurse is working in a primary care clinic. She walks
into the room, and the general inspection begins. What is
not part of the general inspection?
A.
B.
C.
D.
Patient’s facial expressions are consistent with
verbalized emotions.
Patient is wearing clothes that are normally worn by
whites.
Patient is staring down at the floor through most of the
interview.
Patient’s gait is strong and symmetrical.
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The nurse collects patient data through assessment of vital signs.
Many nurses will delegate the performance of temperature data
collection to unlicensed assistive personnel. As the nurse talks to
the assistant, the nurse knows to teach that:
Tympanic thermometers touch the tympanic membrane.
Axillary temperatures are taken with the red probe on the
electronic thermometer.
C. Axillary temperatures are usually most accurate because of
the local blood supply.
D. Rectal thermometers are placed 2.8 cm to 3.5 cm into the
rectum.
A.
B.
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A woman in labor suffers from preeclampsia. Nurses in the
labor and delivery unit need to assess her blood pressure.
The nurse explains to the patient that:
Using a cuff that is too narrow will give a reading that is
inaccurate and high.
B. Deflating the cuff too quickly will make the reading
inaccurate and high.
C. Deflating the cuff 5 mm Hg per second will make the reading
inaccurate and high.
D. Waiting 3 minutes before repeating the blood pressure
measurement will result in a false-high blood pressure
measurement.
A.
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