CH 9 & 10: General Survey, Measurement, & Vital Signs Flashcards

1
Q

What is a general survey?

A

Inspecting general state of health and obvious physical characteristics of the whole person

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2
Q

General survey component 1?

A

Physical appearance:
Age
Sex
Level of consciousness/alertness
Skin color
Facial features
Overall appearance

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3
Q

General survey component 2?

A

Body structure:
Stature
Nutrition
Symmetry
Posture
Position
Body build & contour

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4
Q

General survey component 3?

A

Mobility:
Gait
Foot placement
Range of motion
Note involuntary movements

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5
Q

General survey component 4?

A

Behavior:
Facial expression
Mood and affect
Speech
Dress
Personal hygiene

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6
Q

Speech terminology?

A

Dysarthria: slurred speech
Dysphonia: abnormal voice (hoarseness)
Aphasia: cannot understand or express speech
Dysphagia: difficulty swallowing
Dysphasia: difficulty speaking
Global aphasia: impaired receptive and expressive language
Expressive aphasia: (Broca’s) difficulty producing speech
Receptive aphasia: (Wernicke’s) speech does not make sense

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7
Q

Measurements?

A

Height
Body Mass Index
Waist circumference

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8
Q

Abnormalities in body height and proportion?

A

Dwarfism:
Hypopituitary- short stature, delayed dentition, delayed skeletal maturation
Achondroplasia- bone growth disorder, genetic mutation in arms and legs
Gigantism- hyper secretion of GH before long bone epiphysis fusion, characterized by tall stature
Acromegaly- GH hyper secretion after fusion of epiphysis, leads to large extremities and characteristic facies
Hyperpituitarism- excessive pituitary gland secretion
Anorexia Nervosa- eating disorder caused by obsession of weight, distorted body image
Bulimia Nervosa- eating disorder characterized by binging and purging
Cushing’s Syndrome- extended exposure to high cortisol levels (fatty deposits around face and weight gain in midsection)
Marfan Syndrome- inherited connective tissue disorder (tall and thin)

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9
Q

Convert F to C?

A

(F-32)5/9=C
ex.
F= 97.6
(97.6-32)= 65.6
65.6
5= 328
328/9= 36.4
C= 36.4
Convenient equivalents:
104F = 40C
98.6F = 37C
95F = 35C

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10
Q

Oral temperature?

A

Accurate and convenient (sublingual site blood supply from carotid arteries, quick response to inner core temp changes)
Blue tipped probe
Normal: 35.8 C - 37.3 C
Smoking: increases for 30 mins
Cold liquids: decreases for 10-15 mins
Hot liquids: affects for 35 mins
When respiratory rate increases, temperature decreases: tachypnea

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11
Q

Rectal temperature?

A

Most accurate, as close to core temp as possible
(generally subtract 1 degree)
Red tipped probe
Procedure: pt on left lateral decubitus (on side). Gloves, probe cover, and lube, insert 2 to 3 cm (1in)
Normal: 0.4 - 0.5 C higher

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12
Q

When not to give rectal?

A

Heart problems- stimulates vagus nerve and drops HR
Kids
Low WBC- neutropenic
Decrease platelets

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13
Q

Tympanic membrane temperature? (TMT)

A

Senses infrared emissions of tympanic membrane (eardrum), accurate for core temp bc shares vascular supply with hypothalamus
Cerumen may lower temp

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14
Q

Temporal artery temperature? (TAT)

A

Slide probe across forehead and behind ear, average of multiple infrared readings- questionable reliability and likely not as accurate

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15
Q

Surface temperatures?

A

Oral, axilla (add 1 degree), skin surface

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16
Q

Pulse rate parameters?

A

Normal adult: 60 - 100 bpm
Bradycardia: less than 50 bpm
Tachycardia: greater than 95-100 bpm

17
Q

Pulse descriptors?

A

Location
Force scale-
0: Absent
1+: Weak, thready
2+: Normal
3+: Bounding
Rhythm: regular even tempo

18
Q

Pulse effectors?

A

Fever, meds, anxiety, cardiac history, athlete, etc

19
Q

Respirations?

A

Normal: 10 or 12 - 20 per minute
*respiratory distress always 1st level priority

20
Q

Respiration descriptors?

A

Relaxed/regular/automatic
Sounds? wheezing, gurgling, etc
Effect? use of accessory muscles? (neck, abdomen, thorax)
Position

21
Q

Respiratory effectors?

A

Narcotics, head injury, heart failure, anesthesia, exercise, sleep

22
Q

Pulse oximetry?

A

Measures oxygen saturation
Normal: 97-99%
*always check hemoglobin to assess blood/bleeding

23
Q

Pulse ox effectors?

A

Anemia (not enough blood cells to transfer oxygen), heart disease, lung disease, inadequate O2

24
Q

Blood pressure?

A

Normal: less than 120/80
Systolic: max pressure on artery during left ventricular contraction (systole)
Diastolic: elastic recoil or resting pressure that blood exerts between contractions (diastole)
Pulse pressure: difference between systolic and diastolic (reflects stroke volume)
Mean arterial pressure (MAP): pressure forcing blood into tissues, average of cardiac cycle (can cause stroke or bleeding issues if too high)

25
BP influencers?
Age, race, weight, sex, exercise, medication (steroids), pain, social/financial/emotional stress
26
Blood pressure factors?
Cardiac output (how much blood your heart can squeeze out) : increase CO = increased BP Peripheral vascular resistance (vessels themselves): increased resistance (vasoconstriction) = increased BP Volume of circulating blood: fluid retention = increased BP, hemorrhages = decreased BP Viscosity (blood thickness): increase = increased BP Elasticity of vessel walls: increased rigidity = increased BP *hypertension and diabetes silent killers over time*
27
BP parameters?
Normal: lower than 120/80 Elevated: 120-129 AND less than 80 Hypertension stage 1 (will definitely start treating if showing other symptoms/factors): 130-139 OR 80-89 Hypertension stage 2: 140+ OR 90+ Hypertensive crisis: higher than 180 AND/OR higher than 120 200+: stroke or heart attack *lower sodium in diet for elevated levels
28
Korotkoff sounds?
Phase I: soft, clear tapping- systolic pressure Auscultatory Gap: silence for 30-40 mmHg Phase II: swooshing/softer murmur following tapping Phase III: crisp, high pitched knocking Phase IV: abrupt, low pitched murmur Phase V: silence- diastolic pressure
29
What is orthostatic hypotension?
Drop in BP while rising from a seating or reclined position Drop in systolic BP by >20 mmHg and/or diastolic >10 mmHg
30
How to measure orthostatic hypotension?
Patient lies down for 5 minutes- measure BP and pulse rate Have patient sit up/stand, repeat BP after 1 minute and 3 minutes
31
OH common causes?
Fluid loss, aging, bedrest, changes in BP meds
32
Where can you measure BP?
Upper arm/brachial artery: most common Lower arm/radial artery Upper leg/popliteal artery Lower leg/tibial artery
33
Common BP assessment errors?
Arm placement Patient holds up arm Legs crossed Examiner not eye level Patient conversing Incorrect cuff size Failure to palpate for inflation level Deflate too fast or too slow