Chapter 10 Flashcards
Introduction
Vision
Hearing
Smell
Components of the General Survey
Physical appearance Mental status Mobility Behavior Lifespan considerations Patient's ability to participate
Physical Appearance
Body shape Build Height and weight Compared to stated age Assessment of function and symmetry
Mental Status
Orientation
Affect: in pain? Hiding?
Anxiety: shaking, crying
Mobility
Posture: Shoulders straight and level
Gait: Walk; Rhythmic
Range of motion
Measuring weight and height
Large discrepancies between stated height and weight and actual measurements may provide clues to patient’s self-image
Lifespan Considerations
Infants
Measure length
Place on standard examination table with legs extended and mark on paper below
Children able to stand on their own at full height should be measured in a standing position.
Children age 2 or 3 may be weighed on upright scale or seated on the infant scale.
Measuring Vital Signs
Obtain baseline data
Detect of monitor a change
Monitor patients at risk for alterations in health
Includes: Temperature, Pulse, Respiratory rate
Blood pressure, Pain, Oxygen saturation
Measuring Body Temperature
Surface temperature unreliable because it fluctuates in response to environmental factors
Relatively constant temperature of body tissues at 37°C or 98.6°F
Factors include: Age, Diurnal variations, Exercise, Hormones, Stress
Ways to measure body temperature
Oral: Most accessible, accurate method Rectal Axillary (armpit) Tympanic (ear) Temporal Artery
Measuring the Pulse Rate
Stroke volume: Amount of blood pumped from heart with each heartbeat
Compliance: Ability of the arteries to contract and expand
Location of the pulse points
Apical (left side): Apex of the heart. 5th intercostal
Peripheral
For example, neck, wrist, or foot
Can be weakened by alterations in patient’s health
Females have higher pulses, hemorrhaging increases pulse
Bradycardia
Pulse of less than 60 beats/min
Tachycardia
Pulse over 100 beats/min
Normal artery feels smooth, straight, and resilient.
Thready or bounding pulses can indicate health alterations.
Oxygen saturation
Measured using a pulse oximeter
In a healthy individual, 97% to 99% considered normal
If 90% or below, investigate
Systolic
Pressure during left ventricular contraction
Diastolic
Pressure during the “resting” period of the heart
Measuring Blood Pressure
Factors that influence BP: Cardiac output Blood volume Peripheral vascular resistance Blood viscosity Vessel compliance Stress Diurnal variations: day and night variations
Assessment of blood pressure
Patient should rest for at least 5 minutes prior, or 20 minutes if engaging in heavy physical activity.
Confirm that blood pressure cuff is appropriate size for patient’s arm
Remove any clothing from patient’s arm
Slightly flex arm and hold it at the level of the heart with the palm upward
Palpate brachial pulse
Place cuff on arm with lower border 1 inch above antecubital area
Palpate radial pulse
Close release valve on pump
Inflate cuff until radial pulse no longer palpable
Place diaphragm of stethoscope over brachial pulse
Pump cuff until sphygmomanometer registers 30 mmHg above palpatory systolic blood pressure
Release valve on cuff carefully
Pain—The Fifth Vital Sign
Subjective and personal experience
Types: Acute, Chronic, Range from severe to mild
