Class 1-General Survey, Measurement, Vital Signs Flashcards
What is a general survey?
-looking/inspecting at the general state of health and obvious physical characteristics of the whole person
-how is personal hygiene?
-how do they look from a nutritional standpoint? what is height & weight? BMI?
-are they dressed appropriately for the weather? is clothing clean? cultural norms?
-do they appear their stated age?
-body structure, mobility and behavior
What is a general survey (cont)?
-what is their level of orientation?
-what does their skin look like?
-are they any obvious deformities or asymmetry?
-what does their posture look like?
-what is their speech and language like?
-what is their facial appearance?
-what is their level of mobility?
Speech assessment
-is it clear & understandable?
-Know these terms:
-dysarthria (speech; motor/muscle)
-dysphonia (abnormal voice)
-aphasia (no speech)
-dysphagia (difficulty swallowing)
-dysphasia (difficult speech)
-global aphasia (impairment of all modalities of receptive and expressive language; marked impairments of comprehension of single words, sentences, and conversations, as well as severely limited spoken output)
-expressive aphasia (broca; speak in short but meaningful sentences; eliminate words and & the; can usually understand some speech of others)
-receptive aphasia (wernicke’s; can speak well and use long sentences but what they say may not make sense)
General survey 4 components
- physical appearance
- body structure
- mobility
- behavior
physical appearance
-age
-sex
-level of consciousness
-skin color
-facial features
-overall appearance
body structure
-stature
-nutrition
-symmetry
-posture
-position
-body build, contour
mobility
-gait
-foot placement
-range of motion
-note an involuntary movement
behavior
-facial expression
-mood & affect
-speech
-dress
-personal hygiene
objective data: measurements
Height:
-use wall-mounted device or measuring pole on scale
-align extended headpiece with top of the head
-person should be shoeless, standing straight, looking straight ahead, with feet and shoulders on hard surface
Body mass index:
-body mass index is practical marker of optimal weight for height and an indicator of obesity or protein-calorie malnutrition
objective data: waist circumference
-assesses body fat distribution as indicator of health risk
-excess abdominal fat is an independent risk factor for disease, over and above that of body mass index (BMI)
-waist circumference measured in inches at smallest circumference below rib cage and above iliac crest
-hip circumference measured in inches at largest circumference of buttocks
-note the measurement at end of normal expiration
Abnormalities in body height and proportion
-dwarfism
-hypopituitary dwarfism
-achondroplastic dwarfism
-gigantism versus acromegaly (hyperpituitarism)
-anorexia nervosa versus bulimia nervosa
-endogenous obesity-cushing syndrome (endocrine disorder; steroids can cause)
-marfan syndrome (can have aorta issues)
objective data: vital signs
-include temperature, respiratory rate, pulse, and blood pressure
-data that is trended throughout patient experiences in multiple clinical practice settings
-follow stated facility guidelines for monitoring
-use nursing judgment to warrant additional assessment
Temperature
-what routes are appropriate for assessing temperature?
-what is the age of the person?
-when did the person last exercise?
-did the person drink hot or cold liquids in the last 15 minutes?
-is the person a smoker?
thinking critically when assessing temperature
-local skin temperature, why?
-child?
-menstrual cycle?
-older adult?
-medications taken?
-trends?
-time of day?
-route used to take temp?
-environment temperature?
vital signs: temperature
normal temperature readings:
-oral temperature accurate and convenient
-oral sublingual site has rich blood supply from carotid arteries that quickly responds to changes in inner core temperature
-normal oral temp in a resting person is 37 C (98.6 F) with a range of 35.8-37.3 C (96.4 F to 99.1 F)
-rectal measure 0.4 C to 0.5 C (0.7 F to 1 F) higher
Vital signs: pulse
Pulse: palpable flow felt in the periphery as a result of pressure wave generation from stroke volume
-provides indicator of rate and rhythm of heartbeat as well as local data on condition of artery
Palpation technique
-using pads of the first 3 fingers, palpate radial pulse at flexor aspect of wrist laterally along radius bone until strongest pulsation is felt
-if rhythm is regular, count number of beats in 30 seconds and multiply by 2
-the 30-second interval is most accurate and efficient when heart rates are normal or rapid and when rhythms are regular
-for irregular pulse, count for full minute
-assess pulse for rate, rhythm, force, & elasticity
Pulse descriptors
Use accurate descriptors when documenting pulse:
-site pulse taken, must document site (if not taken at the radial artery)
-force of pulse (graded on a scale of 0-3 in most institutions). terms to describe various numerical results, weak, thready, normal, bounding. 2+ is considered a normal force
-rhythm of pulse is it regular or irregular
Pulse rate parameters
-normal adult rate: 60-100 bpm
-bradycardia: <50 beats per min (less than 40 concerning)
-tachycardia: >95-100 beats per min
ask yourself…
what may be affecting rate, rhythm, and force of pulse?
-fever, meds, anxiety, cardiac history, athlete, activity
When you can’t palpate the pulse
use a doppler; proper technique and documentation
Respirations
Respirations, number of breaths per minute
-1 breath consists of 1 inspiration and 1 expiration
-should be relaxed, regular, automatic, & silent
-respiratory distress is always a 1st level priority
-what is the effort needed to breathe
-what is the respiratory rate, count for 30 seconds or 1 full minute if you suspect abnormally (any sedation count for full minute; do after pulse)
-don’t let the patient know you are counting respirations (do while fingers still on radial pulse)
Think about what situations may affect respirations
-narcotics (reduce)
-head injury (either)
-heart failure with activity intolerance (increase)
-anesthesia (reduce)
-exercise (increase)
-sleep (reduce)
Assessing and describing respiratory effort
-what is the respiratory rate? adult normal rate is 10-20/min
-are there sounds? wheezing, grunting, gurgling
-what is the respiratory effort? is their use of accessory muscles? (retraction in intercostals) neck, abdomen, thorax
-is there a position needed to facilitate breathing? orthopnea (heart failure; hard to breathe laying flat), tripod (bent over, hand on ground/knees), reports of nocturnal dyspnea (wake up & can’t catch their breath-obstructive sleep apnea), sleeping upright in a chair or bed
Pulse Oximetry
-tool used to measure the saturation of oxygen (SpO2) by applying a sensor with a light that measures the relative amount of light absorbed by hemoglobin (how much oxygen in blood)
-compares the ratio of light emitted to the ratio of light absorbed. converts this ratio to a percent
-normal range 97%-99%
-should be part of every shift assessment
-can be monitored continuously or intermittently
**if low first have patient take deep breaths and cough
