Chapter 9: General Survey, Measurement, Vital Signs Flashcards
Physical appearance consist of?
Age, Sex, level of consciousness, skin color, facial features, overall appearance.
Age findings?
The person appears his or her stated age. Appearance older than stated age, as with chronic illness or chronic alcoholism.
Sex findings?
Sexual development should be appropriate for sex and age. If the individual is transgender note the stage of transformation. Note delayed or precocious puberty.
Level of consciousness findings?
The person should be alert and oriented to person place time and situation. Attends to and responds appropriately to questions. No confuse drowsy lethargic.
Skin color findings?
Skin color tone is even, pigmentation varying with genetic background; skin is intact with no obvious lesions. Make note of tattoos and piercings and a stage of healing. Note pallor, cyanosis, jaundice, erythema, And any lesions.
Facial features findings?
Facial features are symmetric with movement. Note if immobile, Mask like, asymmetric, or drooping.
Overall appearance findings?
No signs of acute distress are present. Cardiac or respiratory signs include diaphoresis, clutching the chest, shortness of breath, wheezing. Pain indicated by facial grimace or holding body part.
Body structure includes what?
Stature, nutrition, symmetry, posture, position , Body build and contour, obvious physical deformities.
Stature findings?
The height appears within normal range for age, genetic heritage. Note if excessively short or tall.
Nutrition findings?
The weight appears within normal range for height and body build; body fat distribution is even. Note if cachectic, emaciated. No simple obesity, with even fat distribution. note centripetal obesity, truncal, fat concentrated in face, neck, Trunk, with extremities, as in Cushing syndrome.
Symmetry findings?
Body parts look equal bilaterally and are in relative proportion to each other. Note unilateral atrophy or hypertrophy. Note asymmetrical location of a body part.
Posture findings?
The person stands comfortably erect as appropriate for age. Note video of the normal “plumb line” through anterior ear, hip, shoulder, patella, ankle. Exceptions are the standing Toddler, who has a normally protuberant abdomen, toddler lordosis, and the aging person, who may be stooped with kyphosis.
Position findings?
The person sits comfortably with arms relaxed at sides and head turned to examiner. Note if tripod - leaning forward with arms braced on chair arms; occurs with chronic pulmonary disease. Note if sit straight up and resists lying down example heart failure. Note if curled up in fetal position, example acute abdominal pain.
Body build, contour findings?
Proportions are:
1. Arm span (fingertip to fingertip) equals height.
2. Body length from Crown to pubis equal to length from pubis to sole.
Note elongated arm span for example Marfan syndrome, hypogonadism.
Obvious physical deformities findings?
Note any congenital or acquired defects. For example, missing extremities or digits; webbed digits; shortened limb.
Mobility consists of what?
Gait and range of motion.
Gait findings?
Feet approximately shoulder width apart; foot placement is accurate; walk is smooth and even, and person can maintain balance without assistance. Associated movements such as symmetric arm swing are present. No exceptionally wide base, staggering and stumbling. Note shuffling, dragging, nonfunctional leg. Note limping with injury. Note propulsion, Difficulty stopping.
Range of motion findings?
Note full mobility for each joint and that movement is deliberate, accurate, smooth, and coordinated. Note involuntary movement. Note limited joint range of motion. Note paralysis, absence of movement. No jerky, uncoordinated movement. Note tics, tremors, seizures.
Behavior consists of what?
Facial expression, mood and affect, speech, speech pattern, dress, and personal hygiene.
Facial expression findings?
The person maintains eye contact (If culturally appropriate); expressions are appropriate to the situation.
Mood and affect findings?
The person is comfortable in cooperative with the examiner and interacts pleasant.
Speech findings?
Articulation is clear and understandable. Note Dysarthria and dysphasia, Speech defect, monotone, garbled speech.
Speech pattern findings?
The stream of the talking is fluent, with an even pace. The person conveys ideas clearly.Word choice is appropriate for culture and education. Communicates in prevailing language easily by himself or herself or with an interpreter
Dress findings?
Clothing is appropriate to the climate, looks clean and fits the body, And is appropriate to the culture and age group of the person. Culturally determined dress should not be labeled as inappropriate by Western standards or adult expectation.
Personal hygiene findings?
The person appears clean and groomed appropriately for his or her age, Occupation, socioeconomic group. hair is groomed and brushed. Make up is appropriate for age and Culture.
What measurements should you include in the general survey?
Weight, height, body mass index, and waist circumference.
What is a BMI?
It is a practical marker of optimal healthy weight for height and an indicator of obesity or malnutrition. It provides a more accurate measurement of total body fat compared with the measure of a body weight alone. Healthy BMI is a level of 19 or greater to less then 25.
Vital signs consist of what?
Temperature, pulse, blood pressure, respirations, and pain.
How does the body maintain a steady temperature?
Through a thermostat, or feedback mechanism, regulated in the hypothalamus of the brain. The thermostat balances heat production with heat loss.
What is the average normal oral temperature in a resting person? And what is the range of a normal oral temperature?
Normal oral temperature in the resting person is 37°C or 98.6°F. The normal range of oral temperature is 35.8° to 37.3°C or 96.4° to 99.1°F.
What is the normal rectal temperature measures?
0.4° to 0.5°C or 0.7° to 1°F.
Normal temperatures influenced by what?
A diurnal cycle of 1° to 1.5°F, with the trough occurring in the early morning hours and the peak occurring in late afternoon to early evening.
The menstruation cycle in women. Progesterone secretion, Occurring with ovulation at midcycle, causes a 0.5° to 1°F rise in temperature that continues until menses.
Exercise. Moderate to hard exercise increases body temperature.
Age. Wider normal variations occur in the infant and young child because of less effective heat control mechanisms. In older adults temperature is usually lower than the other age groups, with a mean of 36.2°C or 97.2°F via the oral route.rectal temperatures remain 0.5°C higher than oral temperatures in older adults.
What is the most convenient and accurate site temperature?
The oral temperature. In the sublingual pocket there is a rich blood supply from the carotid arteries that quickly responds to changes in the inner core temperature.
Where should you place a glass or electronic thermometer while taking an oral temperature?
Place it at the base of the tongue in either of the posterior sublingual pockets. Do not placed in front of the tongue.
How long should you leave a glass thermometer in the person’s mouth?
3 to 4 minutes if the person is afebrile and up to eight minutes if febrile.
How long should you wait to take an oral temperature if a person has just drank or smoked?
Wait 15 minutes if the person has just taken a hot or iced liquid and 2 minutes if he or she has just smoked.
What is the most accurate temperature route?
A rectal temperature is the most accurate route, and the result is as close to core temperature as possible without using more invasive measures.
How do you take a rectal temperature?
Wear gloves and insert a lubricated rectal probe on the electronic thermometer only 2 to 3 cm or 1 inch into the adult rectum, directed toward the umbilicus.
What is hyperthermia?
The fever, caused by pyrogen secreted by toxic bacteria during infections or from tissue breakdown such as that following myocardial infarction, trauma,surgery, or malignancy. Neurologic disorders can also reset the thermostat of the brain at a higher level, resulting in heat production and conservation.
What is hypothermia?
It is usually caused by accidental, prolonged exposure to cold. It also may be purposefully induced to lower the body’s oxygen requirements during heat or peripheral vascular surgery or neurosurgery, amputation, postcardiac arrest, or gastrointestinal hemorrhage.
What is the tympanic membrane temperature?
A TMT senses infrared emissions of the tympanic membrane (eardrum). The tympanic membrane shares the same vascular supply that perfuses the hypothalamus.
How do you describe a pulse?
By noting it’s rate, rhythm, and force.
What is a stroke volume?
When the heart pumps blood into the aorta. About 70 mL in the adult.
What creates the pulse?
After the stroke volume the force flares the arterial walls and generates a pressure wave, which is felt in the periphery as the pulse.
What is traditional resting heart rate limits?
60 to 100 bpm.
