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Health Assessment > Ch 5 Vital Signs And General Survey > Flashcards

Ch 5 Vital Signs And General Survey Flashcards

1
Q

What is a general survey

A

A general Survey begins the interview phase otherwise known as beginning of a health assessment

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2
Q

What are you as a nurse doing during the general survey in regards to your patient

A

During a general survey You are “reading your patient “ using all senses and developing an initial impression

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3
Q

What is the definition of vital signs.

what are you Doing when you get a patient’s vital signs (1 main word)

A

 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

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4
Q

What are the six vital signs

A
  1. temperature
  2. pulse
  3. respirations
  4. blood pressure
  5. pain
  6. pulse ox (oxygenation)
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5
Q

What is the umbrella term for CNA’s/ LVN and what is there to know about delegating vital signs to CNA’s

A

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)

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6
Q

As a nurse how do you protect yourself when delegating vitals to Unlicensed assistive personnel

(2 ways)

A

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

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7
Q

What are times when unlicensed personnel can absolutely not get vitals legally and nurses MUST

A
  1. First post op
    • many changes
  2. Patients first blood transfusion
    • in case patient has reaction
  3. Patient just start a new antiarrhythmic drug
    • heart rate (pulse) must be assessed
  4. Patient admitted with asthma attack
    • patient may go into respiratory distress
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8
Q

Why do nurses get patient vitals

A

To help obtain a baseline see overall Health status, patient progress and monitor/evaluate (reactions or responses either or)treatment given to patient

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9
Q

What are the 5 indicators of an urgent situation

A

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
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10
Q

For a patient having extreme anxiety what is important for the nurse not to do

A

Do not leave your patient alone!

Call for help but stay with them and use breathing techniques to bring down the attack

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11
Q

List the order of treatment during an urgent (acute) Assessment and why is it in that order

A 
#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

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12
Q

Who is rapid response and who determines the team

A

Consist of four people determined by the hospital to run emergencies

  1. Doctor
  2. critical care nurse
  3. respiratory therapist
  4. EMT
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13
Q

What does pallor with hypotension indicate

A

Hypovolemic shock

Low blood pressure high heart rate

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14
Q

What are instances you need to call the rapid response team

A

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

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15
Q

Who establishes the guidelines for calling the rapid response team

A

Each facility establishes guidelines within their policy

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16
Q

What is important to remember about a scale when collecting objective data Like weight

A

Calibrate scale to zero
remove shoes
heavy outer garments

Same scale, same time, same clothes

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17
Q

What tape measure is best to use for measuring infants

A

Disposable tape measures that you can use and toss

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18
Q

What kind of environment should be prepared for the patient When collecting objective data

A

A warm relaxing quiet and private environment

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19
Q

What are the steps leading up to the physical assessment (right before you do it )

A
  1. gain a patient’s trust (Address them as they want to be addressed)
  2. wash your hands and clean your stethoscope in front of the patient
  3. explain the purpose of the physical exam and expectations
  4. ask for permission of touch before
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20
Q

What is vital to do before measuring vital signs (5 and 30 minutes)

A

*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

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21
Q

What kind of information are you gathering during the general survey

A

During the general survey (first encounter) you are getting the health history, overall patient appearance, body structure, mobility and behavior (including cognition and speech)

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22
Q

Describe the physical appearances assessed in the general survey

A

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

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23
Q

During the general survey what is assessed under mobility

A

Posture, range of motion, gait

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24
Q

What constitutes your anthropometric measurements

A

Height, weight ( BMI) and vital signs

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25
Q

What is the BMI formula

A

Weight (lbs) / height (inches ^2) then X 703

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26
Q

What is the purpose of measuring vital signs

A

They measure overall health status and body function as well as patient baselines

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27
Q

What is very important to do ALWAYS before completing patient vitals

A

Always assess patient medications first before collecting vitals!

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28
Q

 What determines the frequency of vital measurements

A

It depends on patient condition, treatment and hospital policy (standard of care)

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29
Q

Why and when would a nurse opt to measure only one vital

A

After checking ALL vitals a nurse can choose to only asses one viral at a time based on patient circumstance

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30
Q

When are vitals taken in relation to procedures and what type of procedures

A

Before, during, and after procedures

  • Transfusions
  • dialysis
  • ACE inhibitors
  • diuretics
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31
Q

What do vitals give insight on in relation to procedures

A

Vitals give insights on how the patient is responding to procedures

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32
Q

What is the normal body temperature in Celsius and Fahrenheit

A

Depending on route,

it is 36.5 C (97.7 F) to 37C (98.6 F)

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33
Q

List the temperature routes from least accurate to most accurate

A

Least
- auxiliary (armpit)

  • oral

-* rectal*, temporal, tympanic (CORE TEMPS) hotter than normal range

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34
Q

What is the diurnal cycle also known as and how does it relate to body temperature

A

the diurnal cycle is known as the circadian rhythm (24 hour clock)

it varies body temperature by the time of day

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35
Q

When are the lowest and highest body temperatures in the diurnal cycle

A

Lowest AM 0600

Highest PM 4:00

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36
Q

Where do you regularly use a tympanic thermometer?

When do you not use a tympanic thermometer?

A

Tympanic = ear

Do not use if patient has ear pain

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37
Q

Where do you place oral thermometers

When do you not use oral thermometers

A

You placed oral thermometers in the sublingual pocket

Do not use oral thermometers if it has:

  • seizures
  • patient is confused
  • patient is on oxygen
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38
Q

What type of top does a rectal thermometer have and how do you give a rectal temp

A

A rectal thermometer has a red top

Steps

  1. Don gloves
  2. Lubricate thermometer
  3. Insert 1 inch (2 to 3 cm) making contact with rectal mucosa
  4. Hold until temperature has been read
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39
Q

Who do you not use a rectal thermometer on

A

-newborns
-cardiac patients
• can stimulate vagus nerve and calls bradycardia

  • rectal surgery
  • rectal disease
  • patients with diarrhea
40
Q

What is the temperature converting formula

A

9C = 5F -160

41
Q

What are you document when your documenting Temperature

A

Where temperatures taken, route, equipment, result, time and date

42
Q

Give the definition of a pulse

A

The contraction of the heart causing blood to flow and create a pressure wave

43
Q

What finger should you never use for getting a pulse and why

A

Your thumb because it has its own pulse

44
Q

What do you measure (note) for when you palpate a pulse

A
  • Rate
  • Rhythm
  • Amplitude: post strength
  • elasticity: smooth, resilient
45
Q

What are the three most common abnormal findings in a pulse and give their numerical representation
(Hint: cardias/ stole)

A

Tachycardia: fast +100
Bradycardia: slow below 60 
Asystole: no beat

46
Q

Define these abnormal pulse findings

  1. Sinus arrhythmia
  2. Pulse deficit (when would you assess)
  3. Pulsus alternans
  4. Pulsus bisferiens
A
  1. Irregular heartbeat
  2. Difference in apical pulse and radial when assessing at the same time by different nurses
    • assess when patient is dizzy and has arrhythmias
  3. A regular pulse but alternating strong with weak beats
  4. 2 pulses pause, pair, pause, pair
47
Q

Define Pulse deficit and scenario a pulse deficit could be identified in

A

The difference in apical and radial pulses assessed at the same time by different nurses

Could be assessed patient is dizzy and has arrhythmias

48
Q

 define pulsus alternans and what issue it’s could indicate

A

pulsus alternans is a regular pulse with alternating strong and weak beats

Could indicate ventricular failure

49
Q

Define pulsus bisferiens And issue a could indicate

A

Pulsus bisferiens is two beats (pair), pause, pair, pause

Could indicate aortic valve issues

50
Q

Give all 10 pulse sites on the body

A
  1. Temporal
  2. Carotid
  3. Apical
  4. Brachial
  5. Radial
  6. Ulnar
  7.  Femoral
  8. Popliteal
  9. Dorsal pedis (front)
  10. Posterior tibial (side)
51
Q

What pulse sites are used for emergency assessment in adults

A

Carotid and femoral

52
Q

What pulse sites are used for emergency assessment in children

53
Q

Give the scale for measuring pulse strength

A 
0- Nonpalpable, absent
\+1-weak, thready, barely palpable
\+2-normal
\+3-full, increased
\+4-Bounding
54
Q

What does it mean when a patient has no pedal pulses

A

A medical emergency because there’s no blood circulating to the lower half of the body

55
Q

What do respiration supply and eliminate

A

Respirations supply O2 to the body and vital organs, eliminate CO2

56
Q

What is a normal pulse (heart rate)

A

60 to 100

57
Q

What is considered a full respiration

A

1+1=1

One inspiration and one expiration equals one respiration

58
Q

What is a normal respiratory rate

A

12 to 20 BPM

59
Q

What is eupnea

A

Normal and silent breathing

60
Q

 give the abnormal respiratory findings and their definitions
(hint: -pneas)

A

Dyspnea: difficulty breathing
Tachypnea: rapid breathing
Bradypnea: slow breathing
Apnea: no breathing

61
Q

What do you know when documenting respirations

A

Note depth -deep, normal, or shallow
Note rate- BPM
Note rhythm- regular V irregular
Note scale

62
Q

What are things That can influence respirations

High v low

A

High : exercise, anxiety, pain, smoking, meds, Hyper ventilation

Low: meds, Nuro injuries, hypo ventilation

63
Q

Define oxygen saturation

A

The percentage of hemoglobin bound to oxygen in arteries

64
Q

Give the normal pulse ox

And the normal pulse ox for someone with respiratory issues like COPD and emphysema

A

Normal: 92 to 99%

COPD/emphysema: 85 to 89

65
Q

What is the minimum pulse ox a patient can have before a possible emergency

66
Q

What does a pulse ox of 100% indicate and what causes this

A

Hyperoxemia, when oxygen is given over 2 L / Min

67
Q

What are situations where potential measurement errors of oxygen saturation can happen

A 
Nail polish
 cold hands 
anemic
 excess movement
 CO2 on patient
68
Q

Define blood pressure and Give the normal blood pressure

A

 blood pressure is a force exerted by blood flow against arterial walls

Normal: 120/80

69
Q

What is systolic blood pressure and Diastolic blood pressure in relation to the left ventricle

A

Systolic: left ventricular contraction maximum pressure

Diastolic left ventricular relaxation, minimum pressure

  • Present all times in artery
  • most important number
70
Q

 peripheral vascular resistance

Atherosclerosis v arteriosclerosis

A

Atherosclerosis: hardening, narrowing

Arterial sclerosis: thick and stiff arteries

71
Q

What happens ifvessel wall elasticity decreases

A

Blood pressure increases

72
Q

What factors influence blood pressure

And how does it affect blood pressure

A

Age, gender, ethnicity weight diurnal cycle all increase blood pressure with age by decreasing blood vessel elasticity

73
Q

How should the patient’s arm be positioned to avoid incorrect readings when taking your blood pressure and what are correct leg placements

A

Arm should be at heart level and legs should not be crossed 

74
Q

Why should you wait to take a blood pressure when a patient is exhibiting fear and pain

A

Fear and pain can increase blood pressure

75
Q

Is it relevant if a patient smokes before having their blood pressure taken

A

Yes, ensuring the patient hasn’t smoked before blood pressure is vital because it causes Vasoconstriction increasing blood pressure

76
Q

Give the numerical value for hyper tension and hypo tension

A

Hyper tension:  Greater than 140/90 (Stage one)

Hypotension: 90/60

77
Q

How do you ensure you have the correct size of blood pressure cuff for your patient

A

The bladder of the cuff should cover 80% circumference of the patient’s arm

40% length of blood pressure cuff cover 40% length of patient arm

78
Q

What happens if you have an inappropriate size blood pressure cuff

Two big (loose) and too tight (small)

A

Incorrect size = incorrect reading

Too big = low reading
Too small = high reading

79
Q

When taking a blood pressure cuff what are instances you would not use a certain arm

A
  • mastectomy on same side (lymphedema)
  • dialysis fistula/graft
  • Iv
  • cast
  • edema
80
Q

What variation range of blood pressure is allowed between the right and left arm

A

A 5 to 10 mmHg is a normal BP variation

81
Q

If you’re not taking a blood pressure on an arm where else can you take it and what would the systolic look like what would the diastolic look like ?

A

You can take a blood pressure from the popliteal artery

The systolic can range 10mmHg above arm systolic but if it’s over 10 you must report and the diastolic would remain the same

82
Q

If you need to retake a blood pressure how long should you wait (this goes for examining orthostatic hypotension as well)

A

Wait one or two minutes

83
Q

What is orthostatic hypotension and what are the positions

What is a parameters to classify orthostatic hypotension in relation to mmHg

A

Orthostatic hypotension is a drop in blood pressure when changing positions causing a HIGH FALL RISK

Laying (supine), sitting, standing

systolic drop of 15 mmHg
Diastolic drop of 10mmHg

84
Q

What is pulse pressure and what is a normal pulse pressure

A

The difference between the systolic and diastolic

Normal: 40mmHg

85
Q

What is mean arterial pressure MAP

A

The average pressure in a patient’s artery during a cardiac cycle

86
Q

What temperature is classified as hypothermia what temperature is classified as hyperthermia

F and C

A

Hypothermia: 35C (95F)

Hyper thermia: 38.3C (101F)

87
Q

What can we do as primary prevention to prevent hypertension (modifiable a non-modifiable)

A

Prevent and educate on:

MODIFIABLE

  • Weight loss( diet/exercise)
  • stop smoking
  • decrease alcohol intake
  • less stress

NON MODIFIABLE
-genetics

88
Q

What are lifespan considerations for older adults as far as height and weight

A

What are adults will have a decrease in height and weight

89
Q

How will vitals be affected by the lifespan considerations of an older adult

A
  1. Temp
    • might have an infection but not display fever because of a lower body temperature which is normal in older adults
  2. pulse
  3. Respirations
    • BOTH; affected by polypharmacy
  4. Pulse ox
    - affected by disease
  5. BP
    - elevated because of narrow vessels and decreased elasticity
90
Q

Who should you drape as you go because they are sensitive to temperature during physical assessment

A

Infants, young kids and the older population

91
Q

What is the best possible way to communicate with someone who does not speak English and why

A

Speak in patients native language to avoid miscommunication

92
Q

How do Mexican Americans see nurses v doctors

A

Nurses are warm and doctors are just focus on business

93
Q

In southeast Asian cultures what does “Krun” mean

A

”krun” describes a wide range of symptoms or diseases

94
Q

What is a fact about Africans Americans related to high blood pressure

A

African Americans are 40% more likely to have her blood pressure than whites

95
Q

What is a fact about US Hispanics in relation to being obese

A

US Hispanics have a higher percentage of being obese whites

96
Q

What kind of death is high in Hispanics

A

Premature death is high in Hispanics

97
Q

How do you develop a nursing diagnosis

A

P- roblem
E- tology ( causes) R/T
S- S&s (AEB)

Health Assessment (20 decks)

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