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Health Assessment > Chapter 8: Assessing General Health Status And Vital Signs > Flashcards

Chapter 8: Assessing General Health Status And Vital Signs Flashcards

1
Q

What is the average oral temperature range for an adult?

A

96.6-99.5°F (oral)

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2
Q

What is the average pulse range for an adult?

A

60-100 beats per minute

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3
Q

What is the average blood pressure for an adult?

A

120/80 mmHg

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4
Q

What is the average oxygen saturation range for an adult?

A

95-100%

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5
Q

What is the average respiratory rate for an adult?

A

12-20 breaths per minute

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6
Q

What is the average pain level on a scale from 0-10?

A

0

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7
Q

What factors can alter vital signs?

A

Pain/Illness, stress, talking, chewing gum, anxiety, and movements

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8
Q

What equipment should you gather for a general health survey?

A

Thermometer, sphygmomanometer (blood pressure cuff), stethoscope, watch (second hand), pulse oximeter

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9
Q

What equipment should you gather for a general health survey?

A

Thermometer, sphygmomanometer (blood pressure cuff), stethoscope, watch (second hand), pulse oximeter

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10
Q

What should you do for preparation before assessing a patient?

A

Verify HCP order,
review patient history, previous vital signs,
ensure clean equipment, confirm patient identification (name, DOB, SSN, address, phone number),
hand hygiene,
ensure patient privacy,
and explain the procedure.

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11
Q

What are the methods for taking a temperature?

A

Oral, tympanic, temporal, axillary, and rectum

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12
Q

What is an important age consideration when taking a temperature in older adults?

A

Older adults have a lower core temperature (35-36.4°C or 95-97.5°F)

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13
Q

What is an important age consideration when taking a temperature in older adults?

A

Older adults have a lower core temperature (35-36.4°C or 95-97.5°F)

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14
Q

a shockwave produced by the forceful contraction of the

A

A pulse

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15
Q

How do you assess the radial pulse?

A

check rhythm and amplitude and Count the number of beats per minute

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16
Q

How do you assess pulse rhythm?

A

Assess for equal time between beats; if irregular, assess the apical pulse (auscultation).

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17
Q

How do you assess pulse amplitude?

A

Check for largeness and fullness of pulse, assess bilaterally for equality.

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18
Q

What are the different amplitudes of the pulse?

A

0 = not palpable
1 = weak, thread-like
2= expected, occulde with moderate pressure
3= Strong Difficult to obliterate
4= Very bounding (Finger will bounce) Can’t occulde

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19
Q

What does a 2+ pulse indicate?

A

Expected, occludes with moderate pressure.

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20
Q

What does a 3+ pulse indicate?

A

Strong, difficult to obliterate.

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21
Q

What does a 4+ pulse indicate?

A

Very bounding, the finger will bounce and can’t occlude.

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22
Q

What are factors to consider when assessing a patient’s pulse?

A

Recent activities, stress, activity, stimulants.

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23
Q

What is the respiratory rate range for an adult?

A

12-20 breaths per minute.

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24
Q

How should you begin counting respirations?

A

Begin counting at inhalation, count every subsequent inhalation, assess for 30 seconds x2.

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25
Q

How do you assess respiratory rhythm?

A

Observe pattern, regularity of breathing; if irregular, assess for a full 60 seconds.

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26
Q

How do you assess respiratory depth?

A

Observe excursion (movement of the chest wall), observe for equal bilateral expansion; expected is even, unlabored.

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27
Q

What are abnormal respiratory findings?

A

Shallow or extremely deep respirations, labored or gasping respirations.

28
Q

What does oxygen saturation measure?

A

The percentage of oxygen that is bound to hemoglobin in the blood.

29
Q

What is the average oxygen saturation range?

A

95-100%.

30
Q

The pressure exerted on the walls of the arteries.

A

Blood pressure

31
Q

Pressure on arteries during heart contraction

A

Systolic Blood Pressure(SBP)

32
Q

Normal Systolic Range

A

120 mmHg.

33
Q

Pressure on arteries during heart relaxation

A

Diastolic (DBP)

34
Q

Normal Diastolic Range

A

80 mmHg

35
Q

Heart contraction.

A

Systole

36
Q

Heart relaxation.

A

Diastole

37
Q

Amount of Blood pumped by the heart in one minute, measured in mi/min.

A

Cardiac Output (CO)

38
Q

Amount of Blood pumped by the heart in one minute, measured in mi/min.

A

Cardiac Output (CO)

39
Q

Amount of Blood pumped from the left ventricle during systole. Per beat.

A

Stroke Volume (SV)

40
Q

Stretching of cardiac myocytes before contraction. Increased preload increases diastole.

A

Preload

41
Q

Average arterial pressure during one cardiac cycle.

A

Mean Arterial Pressure (MAP)

42
Q

Average arterial pressure during one cardiac cycle.

A

Mean Arterial Pressure (MAP)

43
Q

2/3 DBP + 1/3 SBP

A

Calculation for Mean
Arterial Pressure.

44
Q

CO - SV x HR

A

Calculation for Cardiac Output.

45
Q

CO - SV x HR

A

Calculation for Cardiac Output.

46
Q

Factors Affecting BP Definition:

A

BP changes require changes in CO or resistance.

47
Q

Resistance in the circulatory system used to create BP.

A

Systemic Vascular Resistance (SVR) & Peripheral Vascular
Resistance (PVR) Definition:

48
Q

Increased resistance =

A

hypertension

49
Q

Decreased Heartrate

A

Dysrhythmia (bradycardia).

50
Q

Decreased PVR/SVR Definition:

A

Vasodilation.

51
Q

Increased heartrate

A

Tachycardia

52
Q

Signs of Decreased PVR/SVR(Resistance)

A

-Lying Down
-Sepsis
-TBI (head injury)
-Systemic inflammatory response syndrome (SIRS)

53
Q

POTS Definition:

A

Postural orthostatic tachycardia syndrome POTS)

54
Q

What determines blood pressure

A

Blood pressure is determined by
cardiac output and arterial resistance.

BP = CO x PVR/SVR

55
Q

What increases blood pressure

A

Anything increasing cardiac output (CO) and/or resistance

56
Q

Prevalence of Hypertension

A

Over 100 million Americans have hypertension.

57
Q

Consequences for Prolonged Hypertension

A

-Leads to vascular damage
-Left ventricular hypertrophy due to increased myocardial workload

58
Q

Normal Blood Pressure Range

A

120/80 mmHg.

59
Q

Pre-Hypertension Blood Pressure

A

SBP 120-129 mmHg & DBP < 80 mmHg

60
Q

Hypertension Stage 1 Blood Pressure

A

SBP 130-139 mmHg or DBP 80-89 mmHg

61
Q

Hypertension Stage 2 Blood Pressure

A

SBP ≥ 140 mmHg or DBP ≥ 90 mmHg

62
Q
  • Blood flow sounds auscultated while taking BP measurement
A

Korotkoff Sounds

63
Q

Korotkoff Sounds Phase 1

A

first sound, repetitive
• Faint tapping, intensifies

64
Q

Korotkoff Sounds Phase 2

A

-swishing, murmur
-Can be intermittent (HTN)
-If miss, underestimate SBP

65
Q

Korotkoff Sounds Phase 3

A

-distinct, crisp sound
-Louder blood flow as reduce pressure

66
Q

Korotkoff Sounds Phase 4

A

muffled blowing
softer

67
Q

What are older adults core temperatures

A

(35-36.4°C or 95-97.5°F)

Health Assessment (2 decks)

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