(3) GS & VS Flashcards
Identify the units of measure for the following:
a. Blood pressure
b. Pulse
c. Respiration
d. Temperature
e. Height
f. Weight
a. Blood pressure: <120/<80 mmHg
b. Pulse: 60-100 bpm
c. Respiration: 14-20 breaths per min
d. Temperature: 96.4-99.1 average: 98.6
e. Height: inches
f. Weight: lbs
Identify the normal range for adult blood pressures, and HTN:
<120/<80 mmHg
HTN: average of 2 readings on 2 separate occasions > 140/90
List (2) common causes of interference in blood pressure measurements:
- using the wrong-sized cuff; cuff should be appropriate size
- incorrect position and exposure; arm should be at heart level & BARE; if standing, try to support the patient’s arm at mid-chest level
Describe common causes of abnormal blood pressures; what should the patient avoid prior to having BP taken?
Patient should avoid caffeine, exercise, and smoking 30min prior to having BP taken
Identify the normal range of pulse rate; Define tachycardia and bradycardia
60-100 BPM
> 100 tachycardia
< 60 bradycardia
List and describe three (3) common causes of abnormal pulse rates.
- blood pressure
- heart disease
- medication or substances (caffeine, amphetamine, beta-blockers)
Identify normal oral, temporal, axillary, tympanic and rectal temperatures:
- The average normal oral temperature is 98.6°F.
NOT FOR UNCONSCIOUS PATIENTS - Rectal temperature and tympanic temperature is (1°F) higher than an oral temperature.
RECTAL: Good for infants, unconscious, trauma - Axillary temperature and temporal scanner is (1°F) lower than an oral temperature
AXILLARY: least accurate
TEMPORAL: good for children, comparable accuracy to oral
Describe three (3) common causes of abnormal temperatures.
- fever
- many causes including medication - chills
- rising temperature suggest feeling cold, goosebumps, shivering
- falling temperature suggest feeling hot and sweaty (possible menopause)
- recurrent shaking chills suggest more extreme swings in temperature and systemic bacteremia. - night sweats
- occur when fever exaggerates this swing
- occur in TB and malignancy
Identify the normal range for adult respiratory rates:
14-20 breaths per min
What condition is best described? Determine the causes:
Rapid Shallow Breathing
tachypnea
Caused by: salicylate intoxication, restrictive lung disease, pleuritic chest pain, elevate diaphragm
What condition is best described? Determine the causes:
Slow breathing
Bradypnea
Caused by: uremia, drug-induced respiratory depression, increased intracranial pressure
What condition is best described? Determine the cause:
Rapid deep breathing
Hyperpnea
Causes: exercise, high altitude, sepsis, anemia
What is the best condition described? Determine the cause:
Periods of deep breathing alternate with periods of apnea; normal in children and older adults during sleep
Cheyne-Stokes
Caused by: HF, uremia, drugs, brain damage
What is the bet condition described? Determine the cause:
irregular breathing; periods of apnea alternate with regular deep breaths which stop suddenly for short intervals
Ataxic or Biot breathing
Caused by: meningitis, brain damage, respiratory depression
Describe the following abnormal patterns of respiration and causes:
c. Kussmaul’s respiration
compensatory over-breathing due to systemic acidosis; the breathing rate may be fast, normal, or slow.
Causes: DKA (metabolic acidosis)
Describe the test for orthostatic hypotension, ‘Tilt test’, as well as a normal result and positive result:
Determine the causes:
- Measure BP and HR in 2 positions: supine then upright
- After patient is resting supine for 3-10 minutes, measure BP
- Have patient stand up and take BP within 3 minutes
Normal: Slight drop in systolic and rise in diastolic
Positive Orthostatic / Positive test results:
Drop > 20 mmHg systolic
Drop > 10 mmHg diastolic
HR increase > 20 bpm
Caused by medications, blood loss, dehydration, bed rest, autonomic disease
List the (6) ROS for general survey/constitutional symptoms:
- fatigue
- weakness; associated with neuro conditions
- fever/chills
- night sweats
- weight loss or gain
- pain
- List the (8) components of the general survey.
- appearance state of health
-stable or unstable
-acutely sick, chronically ill, not sick - level of consciousness
-awake, alert, responsiveness - signs of discomfort or distress
- skin color and lesions
- dress, grooming, hygiene
-breath/body odor
-condition of teeth and gums - facial expression and eye contact
- posture/gait/motor activity
- height and weight
-Turner syndrome (short)
- Marfan syndrome (tall)
- muscle bulk/slender/stocky/obese/frail
- body symmetric
Identify and interpret the common abnormalities of the general survey: LOC ‘“LOCCS’”
- Lethargic: drowsy, needs verbal and touch stimulation to initiate a response. Will respond appropriately.
- Obtunded: needs repeated stimulation to maintain attention and response. Makes eye contact, speaks slowly
- Confused OR Delirious: disoriented to surroundings, may have impaired judgement, may need cues to respond to commands, restless, agitated, with notable delusion/hallucination
- Comatose: can’t be aroused. No observable response to any external stimuli. No purposeful movement.
- Stuporous: responds only minimally to vigorous stimulation, may only moan as a verbal response.
Identify and interpret the common abnormalities of the general survey: signs of discomfort or distress
- Cardiac or Respiratory Distress
- Diaphoresis
- Labored breathing, wheezing
- Difficulty speaking
- Coughing/choking - Pain
- Wincing
- Clutching painful area - Anxious/Depressed/Flat Affect
- Poor eye contact
- Fidgety / listless
Identify and interpret the common abnormalities of the general survey: skin color and lesions
- Pallor
- Cyanosis
- Jaundice
- Rashes
- Bruises
- Wounds
Identify and interpret the common abnormalities of the general survey: facial expression and eye contact
Eye contact
- Staring – Hyperthyroidism
- Nystagmus – Tumor, ETOH, PCP intoxication
- Averted - Depression
Facial Expression
- Immobile - Parkinson’s
- Smiling
- Flat
- Crying
Identify and interpret the common abnormalities of the general survey: breath and body odors
Breath odors:
- Alcohol
- Fruity -> diabetes
- Ammonia -> CKD
Body odors
- GI bleeds
- Gangrene
- Abscesses
How do you calculate BMI?
703 x (lbs / in^2) = BMI
