Ch 09: General Survey, measurements, vital signs Flashcards
study of the whole person that includes observing the patient’s physical appearance, body structure, mobility, and behavior
ex:Observing the patient’s body stature and nutritional status
General Survey
used to measure weight
standardized balance scale
If a sequence of repeated weights is necessary,
then the nurse should attempt to weigh the patient at approximately the same time of day and with the same types of clothing worn each time.
systolic 120-139
diastolic 80-89
prehypertension
systolic 140-159
diastolic 90-99
stage 1 HTN
systolic > 160
diastolic >100
Stage 2 htn
systolic >180
diastolic >120
Hypertensive emergency
newborn’s head measures
32 to 38 cm and is approximately 2 cm larger than the chest circumference. Between 6 months and 2 years, both measurements are approximately the same, and after age 2 years, the chest circumference is greater than the head circumference.
more prominent bony landmarks, decreased body weight (especially in men), a decrease in subcutaneous fat from the face and periphery, and additional fat deposited on the abdomen and hips. Postural changes of kyphosis and slight flexion in the knees and hips also occur.
Changes that occur in the aging person
Rectal temperatures
taken when the other routes are impractical, such as for comatose or confused persons, for those in shock, or for those who cannot close the mouth because of breathing or oxygen tubes, a wired mandible, or other facial dysfunctions.
both the systolic and diastolic pressures increase. (widening pulse pressure)
older adult
hypothalamus regulates heat production
from metabolism, exercise, food digestion, and external factors
hypothalamus heat loss (cold) thru what
through radiation, evaporation of sweat, convection, and conduction
Normal temperature is influenced by?
diurnal cycle, exercise, and age(36.2° C (97.2° F) via the oral route.), menstruation cycle in women
may be a sign of a short-term illness or a chronic illness such as endocrine disease, malignancy, depression, anorexia nervosa, or bulimia.
unexplained weight loss
is commonly found in children and young adults. During the respiratory cycle, the heart rate varies, speeding up at the peak of inspiration and slowing to normal with expiration.
Sinus arrhythmia
the force, or strength, of a pulse,
stroke volume
level of blood pressure is determined by five factors
cardiac output, peripheral vascular resistance, volume of circulating blood, viscosity, and elasticity of the vessel walls
order of infant vs
respiration, pulse, and temperature.
decrease in vital capacity and decreased inspiratory reserve volume. The examiner may notice a shallower inspiratory phase and an increased respiratory rate
Aging
Overgrowth of bone in the face, head, hands, and feet
excessive secretion of growth hormone in adulthood
acromegaly
the patient’s arm span (fingertip to fingertip) should equal the patient’s height
during general survey
arm span that is greater than the person’s height may indicate
Marfan syndrome
falsely low systolic or falsely high diastolic reading may result, which is common in patients with hypertension
auscultatory gap is undetected
the pressure forcing blood into the tissues, averaged over the cardiac cycle
MAP (mean arterial pressure)
taken when the person is hypertensive or is taking antihypertensive medications, when the person reports fainting or syncope, or when volume depletion is suspected. The blood pressure and pulse readings are recorded in the supine, sitting, and standing positions
Orthostatic vital signs
genetic disorder resulting in characteristic deformities;
Achondroplastic dwarfism
caused by a deficiency in growth hormone in childhood and results in a retardation of growth below the third percentile, delayed puberty
Hypopituitary dwarfism
is an inherited connective tissue disorder characterized by a tall, thin stature and other features
Marfan syndrome
BP cuff
The width of the rubber bladder should equal 40% of the circumference of the person’s arm. The length of the bladder should equal 80% of this circumferenc
characterized by weight gain and edema with central trunk and cervical obesity (buffalo hump) and round plethoric face (moon face).
Cushing syndrome is
temperature, respiratory rate, pulse, and blood pressure
adult vs
Shake a glass thermometer down to 35.5° C (96° F) and place it at the base of the tongue in either of the posterior sublingual pockets—not in front of the tongue. Instruct the person to keep his or her lips closed. Leave in place 3 to 4 minutes if the person is afebrile and up to 8 minutes if febrile. (Take other vital signs during this time.) Wait 15 minutes if the person has just taken hot or iced liquids and 2 minutes if he or she has just smoked.
Glass thermometer via oral
advantages of swift and accurate measurement (usually less than 20 to 30 seconds)
electronic thermometer (can be oral or rectum)
is used by sliding the probe across the forehead and behind the ear. The thermometer works by taking multiple readings and providing an average. The reading takes approximately 6 seconds. This approach is well tolerated and is more accurate than TMTs
temporal artery thermometer (TAT)
is a noninvasive, nontraumatic device that is extremely quick and efficient. The probe tip has the shape of an otoscope
senses infrared emissions of the tympanic membrane (eardrum). The tympanic membrane shares the same vascular supply that perfuses the hypothalamus
(TMT)- tympanic membrane thermometer
BP varies
age, sex, race, diurnal rhythm, weight, exercise, emotion, stress
Taking blood pressure reading when person is anxious or angry or has just been active
Falsely high
Faulty arm position
Above level of heart
Falsely low
Below level of heart
Falsely high
Person supports own arm
Falsely high diastolic
Faulty leg position (e.g., person’s legs are crossed)
Falsely high systolic and diastoli
Cuff too narrow for extremity
Falsely high
Cuff wrap is too loose or uneven, or bladder balloons out of wrap
Falsely high
Inflating cuff not high enough
Falsely low systolic
Falsely low systolic
Falsely low diastolic
deflating cuff Too quickly
Falsely low systolic or falsely high diastolic
deflating cuff Too slowly
Falsely high diastolic
Failure to wait 1-2 min before repeating entire reading
Falsely high diastolic
Halting during descent and reinflating cuff to recheck systolic
Falsely high diastolic
