Ch 5 Vital Signs And General Survey Flashcards
What is a general survey
A general Survey begins the interview phase otherwise known as beginning of a health assessment
What are you as a nurse doing during the general survey in regards to your patient
During a general survey You are “reading your patient “ using all senses and developing an initial impression
What is the definition of vital signs.
what are you Doing when you get a patient’s vital signs (1 main word)
 vital signs are indicators of patient physiological status, progress, and response to things such as meds
When getting a patient’s vitals you are creating their baselines of how patient currently is
What are the six vital signs
- temperature
- pulse
- respirations
- blood pressure
- pain
- pulse ox (oxygenation)
What is the umbrella term for CNA’s/ LVN and what is there to know about delegating vital signs to CNA’s
CNA‘s are otherwise known as unlicensed assistive personnel
Though vital signs are commonly delegated to unlicensed assistive personnel, Nurses need to know what circumstances to not assign others to do vitals because the nurse is ultimately responsible for the vitals of a patient (legally)
As a nurse how do you protect yourself when delegating vitals to Unlicensed assistive personnel
(2 ways)
With a pt at risk of A hypertensive emergency:
- You either tell the CNA please report if systolic above 140 diastolic above 110
Or
- go ask the CNA
What are times when unlicensed personnel can absolutely not get vitals legally and nurses MUST
- First post op
- many changes
- Patients first blood transfusion
- in case patient has reaction
- Patient just start a new antiarrhythmic drug
- heart rate (pulse) must be assessed
- Patient admitted with asthma attack
- patient may go into respiratory distress
Why do nurses get patient vitals
To help obtain a baseline see overall Health status, patient progress and monitor/evaluate (reactions or responses either or)treatment given to patient
What are the 5 indicators of an urgent situation
PAC ‘EM and go
P-ALLOR (pale)
A-CUTE DISTRESS (shock, resp distress)
-must be immediately treated
C-YANOSIS (lack of O2)
‘
E-XTREME ANXIETY (anxiety attack)
M-ENTAL STATUS CHANGE
-from A& O x3 to disoriented (lethargy)
out of the blue
For a patient having extreme anxiety what is important for the nurse not to do
Do not leave your patient alone!
Call for help but stay with them and use breathing techniques to bring down the attack
List the order of treatment during an urgent (acute) Assessment and why is it in that order
#1 call rapid response #2 continue with assessment
It’s in this order so we’re treating the patient rapid response is actively on their way
Who is rapid response and who determines the team
Consist of four people determined by the hospital to run emergencies
- Doctor
- critical care nurse
- respiratory therapist
- EMT
What does pallor with hypotension indicate
Hypovolemic shock
Low blood pressure high heart rate
What are instances you need to call the rapid response team
Rapid response team is called during an acute emergency situation
An acute change in mental status
Stridor
-respiratory distress (gasp)
Respirations below 10 above 32 BPM
Increased effort to breathe
-use of accessory muscles
New onset chest pain
Agitation
- hypoxia, delirium
Restlessness
Temperature below 35C(95F) above 39.5C( 103F)
Pulse below 55 BPM above 120 BPM
Blood pressure: systolic below 100 mmHg above 170 mmHg
pulse ox below 92%
- 85 if COPD/ emphysema
Who establishes the guidelines for calling the rapid response team
Each facility establishes guidelines within their policy
What is important to remember about a scale when collecting objective data Like weight
Calibrate scale to zero
remove shoes
heavy outer garments
Same scale, same time, same clothes
What tape measure is best to use for measuring infants
Disposable tape measures that you can use and toss
What kind of environment should be prepared for the patient When collecting objective data
A warm relaxing quiet and private environment
What are the steps leading up to the physical assessment (right before you do it )
- gain a patient’s trust (Address them as they want to be addressed)
- wash your hands and clean your stethoscope in front of the patient
- explain the purpose of the physical exam and expectations
- ask for permission of touch before
What is vital to do before measuring vital signs (5 and 30 minutes)
*Have a patient rest for at least five minutes
- Ask if they have eaten drink or smoke in the last 30 minutes
- if so you cannot take vitals
Remove constrictive clothing around the arm
-BP
Patient can sit or stand
What kind of information are you gathering during the general survey
During the general survey (first encounter) you are getting the health history, overall patient appearance, body structure, mobility and behavior (including cognition and speech)
Describe the physical appearances assessed in the general survey
Overall appearance
Hygiene, dress
-any B.O, Tobacco, urine, stool, alcohol
Is there a dress appropriate to the environment and clean
Skin color, body surface, development
- their symmetry and same tone of skin
- White, red, blue, yellow
Behavior and facial expressions
-are they cooperative? Flat affact, too eelated, any tremors or tics
Level of consciousness and speech
- A&O x3 , confused; is speech clear rapid slurring
During the general survey what is assessed under mobility
Posture, range of motion, gait
What constitutes your anthropometric measurements
Height, weight ( BMI) and vital signs
What is the BMI formula
Weight (lbs) / height (inches ^2) then X 703
What is the purpose of measuring vital signs
They measure overall health status and body function as well as patient baselines
What is very important to do ALWAYS before completing patient vitals
Always assess patient medications first before collecting vitals!
 What determines the frequency of vital measurements
It depends on patient condition, treatment and hospital policy (standard of care)
Why and when would a nurse opt to measure only one vital
After checking ALL vitals a nurse can choose to only asses one viral at a time based on patient circumstance
When are vitals taken in relation to procedures and what type of procedures
Before, during, and after procedures
- Transfusions
- dialysis
- ACE inhibitors
- diuretics
What do vitals give insight on in relation to procedures
Vitals give insights on how the patient is responding to procedures
What is the normal body temperature in Celsius and Fahrenheit
Depending on route,
it is 36.5 C (97.7 F) to 37C (98.6 F)
List the temperature routes from least accurate to most accurate
Least
- auxiliary (armpit)
- oral
-* rectal*, temporal, tympanic (CORE TEMPS) hotter than normal range
What is the diurnal cycle also known as and how does it relate to body temperature
the diurnal cycle is known as the circadian rhythm (24 hour clock)
it varies body temperature by the time of day
When are the lowest and highest body temperatures in the diurnal cycle
Lowest AM 0600
Highest PM 4:00
Where do you regularly use a tympanic thermometer?
When do you not use a tympanic thermometer?
Tympanic = ear
Do not use if patient has ear pain
Where do you place oral thermometers
When do you not use oral thermometers
You placed oral thermometers in the sublingual pocket
Do not use oral thermometers if it has:
- seizures
- patient is confused
- patient is on oxygen
What type of top does a rectal thermometer have and how do you give a rectal temp
A rectal thermometer has a red top
Steps
- Don gloves
- Lubricate thermometer
- Insert 1 inch (2 to 3 cm) making contact with rectal mucosa
- Hold until temperature has been read
