Class 1-General Survey, Measurement, Vital Signs

Question 1

What is a general survey?

Answer 1

-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

Question 2

What is a general survey (cont)?

Answer 2

-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?

Question 3

Speech assessment

Answer 3

-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)

Question 4

General survey 4 components

Answer 4

1. physical appearance
2. body structure
3. mobility
4. behavior

Question 5

physical appearance

Answer 5

-age
-sex
-level of consciousness
-skin color
-facial features
-overall appearance

Question 6

body structure

Answer 6

-stature
-nutrition
-symmetry
-posture
-position
-body build, contour

Question 7

mobility

Answer 7

-gait
-foot placement
-range of motion
-note an involuntary movement

Question 8

behavior

Answer 8

-facial expression
-mood & affect
-speech
-dress
-personal hygiene

Question 9

objective data: measurements

Answer 9

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

Question 10

objective data: waist circumference

Answer 10

-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

Question 11

Abnormalities in body height and proportion

Answer 11

-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)

Question 12

objective data: vital signs

Answer 12

-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

Question 13

Temperature

Answer 13

-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?

Question 14

thinking critically when assessing temperature

Answer 14

-local skin temperature, why?
-child?
-menstrual cycle?
-older adult?
-medications taken?
-trends?
-time of day?
-route used to take temp?
-environment temperature?

Question 15

vital signs: temperature

Answer 15

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

Question 16

Vital signs: pulse

Answer 16

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

Question 17

Palpation technique

Answer 17

-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

Question 18

Pulse descriptors

Answer 18

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

Question 19

Pulse rate parameters

Answer 19

-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

Question 20

When you can’t palpate the pulse

Answer 20

use a doppler; proper technique and documentation

Question 21

Respirations

Answer 21

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)

Question 22

Think about what situations may affect respirations

Answer 22

-narcotics (reduce)
-head injury (either)
-heart failure with activity intolerance (increase)
-anesthesia (reduce)
-exercise (increase)
-sleep (reduce)

Question 23

Assessing and describing respiratory effort

Answer 23

-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

Question 24

Pulse Oximetry

Answer 24

-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

Question 25

What situation could be affecting oxygen saturation?

Answer 25

-anemia (not enough cells to deliver oxygen)
-lung disease
-heart disease
-inadequate oxygen given or method of delivery

Question 26

Vital signs: blood pressure

Answer 26

Blood pressure is force of blood pushing against side of its container, vessel wall
-strength of push changes with event in cardiac cycle
-systolic pressure: maximum pressure felt on artery during left ventricular contraction, or systole
-diastolic pressure: elastic recoil, or resting, pressure that blood exerts constantly between each contraction
-pulse pressure: difference between systolic & diastolic
^^reflects stroke volume
-mean arterial pressure (MAP): pressure forcing blood into tissues, averaged over cardiac cycle (average arterial pressure; perfusion)

Question 27

Influences on blood pressure

Answer 27

-age
-race
-weight
-emotions
-sex
-exercise
-stress (pain, social, financial, emotions)
-medication (steroids)

Question 28

Orthostatic hypotension

Answer 28

-drop in systolic BP >20 mmHg and/or drop in diastolic BP >10 mmHg
-increase risk in elderly due to vascular changes with aging
-caused by: hypovolemia, drugs, autonomic, miscellaneous
-to take: lying, sitting, standing..1-3 mins between pressures

Question 29

What are some common causes of orthostatic changes in B/P?

Answer 29

-fluid loss
-aging & related vascular changes
-bedrest
-changes in blood pressure medications

Question 30

Where can blood pressure be measured?

Answer 30

-upper arm/brachial artery-most common site
-lower arm/radial artery
-lower leg/tibial artery site
-upper leg/popliteal artery site
-B/P can be auscultated or palpated depending on the situation

Question 31

Measuring blood pressure

Answer 31

blood pressure measured with stethoscope and aneroid sphygomanometer
-aneroid gauge subject to drift and must be recalibrated at least once each year and must rest at zero
-cuff is inflatable bladder inside a cloth cover
-width of rubber bladder should equal 40% of circumference of person’s arm; length of bladder should equal 80% of this circumference

Question 32

The procedure: arm pressure (1 of 2)

Answer 32

person may be sitting or lying, with bare arm supported at heart level
-palpate brachial artery; with cuff deflated, center it about 2.5 cm (1 in) above brachial artery and wrap it evenly
-now palpate brachial or radial artery
-inflate cuff until artery pulsation obliterated and then 20 to 30 mm Hg beyond
-this will avoid missing an auscultatory gap, when korotkoff sounds disappear during auscultation
-deflate cuff quickly and completely; wait 15 to 30 seconds before reinflating so blood trapped in veins can dissipate

Question 33

The procedure: arm pressure (2 of 2)

Answer 33

-place bell of stethoscope over site of brachial artery, making a light but airtight seal
-diaphragm endpiece usually adequate, but bell designed to pick up low-pitched sounds of blood pressure reading
-rapidly inflate cuff to maxim inflation level you determined
-then deflate the cuff slowly and evenly, about 2 mmHg per heartbeat
-note points at which you hear first appearance of sound, muffling of sound, and final disappearance of sound

Question 34

common errors with blood pressure assessment

Answer 34

-arm placement
-patients holds arm up
-legs are crossed
-examiner eyes not level with manometer or meniscus
-incorrect cuff size (too small and/or too large)
-failure to palpate for level of inflation
-deflate too fast or too slow
-stopping during descent and then reinflating
-failure to wait 1-2 minutes between readings
-subconscious bias
-diminished hearing ability of examiner
-defective equipment
-number preferences

Question 35

Correct technique for BP measurement

Answer 35

-cuff placement related to location of brachial pulse and correct cuff size
-proper cuff inflation and pulse palpation before taking BP, release and wait 30 seconds
-correct arm position and examiner position
-proper stethoscope placement over artery, using bell of stethoscope
-proper stethoscope placement in ears/removing loud extraneous sounds
-proper inflation to determined parameter 20-30 mmHg above pulse cessation point
-proper release of bulb gradual, even 2 mmHg release pattern
-Ability to identify Korotkoff sounds:
-korotkoff I (systolic number) first clear audible tapping sound
-korotkoff V is silence, diastolic pressure is the number at which the last audible sound is heard before silence

Question 36

Blood pressure factors

Answer 36

Level of bp determined by 5 factors
1. Cardiac output
2. Peripheral vascular resistance
3. Volume of circulating blood
4. Viscosity
5. Elasticity of vessel walls

Question 37

Cardiac output

Answer 37

Increases in CO leads to increase in BP whereas decrease in CO leads to decrease in bp

Question 38

Peripheral vascular resistance

Answer 38

Increased resistance (vasoconstriction) leads to increase in bp whereas decrease in resistance (vasodilation) leads to decrease in bp

Question 39

Volume of circulating blood

Answer 39

Fluid retention leads to increased bp whereas hemorrhages leads to decreased bp

Question 40

Viscosity

Answer 40

Increase associated with increase in bp

Question 41

Elasticity of vessel walls

Answer 41

Increasing rigidity associated with increase in bp (overtime vasodilation, Htn, diabetes)