General Assessment/Vitals Flashcards
What level of consciousness?
the state of arousability, behavior, and response to stimuli (verbal –> touch –> pain)
What should u document in LOC?
Eye opening
Verbal responses
Motor responses
What are the 3 categories of nutritional status?
Well nourished
Undernourished
Overnourished
What is well nurished?
Appearance suggesting caloric intake over expenditure that allows for preservation of subcutaneous tissues and muscle mass.
What is undernurished?
Appearance of having overall caloric expenditure greater than intake presented by a body habitus which is underweight
What is overnurished?
Appearance of having overall caloric intake greater than that of expenditure with increased:
“Appears younger than the stated age” implies what?
overall higher state of health than others in the same age group
“Appears stated age” implies what?
state of health equal to that of others in the same age group
“Appears older than the stated age” implies what?
implies a lower state of health than, and past or present morbidity greater than, those of others in the same age group
What are the 3 types of distress a pt can encounter?
pain, respiratory, or emotional/psychological
What is somatic pain?
Such as seen with musculoskeletal conditions or trauma
Charactersitics of somatic pain?
Often described as sharp or stabbing (sympathetic)
Usually well-localized
Demonstration of protective guarding or hesitancy in movement of the area
Movement may appear stiff, slow, and purposeful in an attempt to avoid triggering the pain
Facial grimacing
Charactersitics of acute visceral pain?
Results in diffuse peritonitis
Movement exacerbates the pain resulting in the patient attempting to remain still
Respirations are shallow in avoidance of moving the diaphragm
Abdomen is often guarded by the upper extremities
Contracture of abdominal muscles results in rigidity
Signs of resp distress in adult?
increase in respiratory rate open-mouth breathing exaggerated chest wall motion use of accessory muscles intercostal retractions cyanosis
Signs of resp distress in infant?
increased rate
exaggerated chest wall motion and accessory muscle use
intercostal retractions
cyanosis - look for perioral involvement
nasal flaring - newborns are obligate nose breathers
Position of comfort - tripoding
Signs of emotional pain?
Expressions of anxiety and depression Facial expressions sadness anguish tearfulness crying Nervousness, apprehension, muted responses, and even hysteria
What are some colors of a pt’s skin?
diffuse pallor – anemia
cyanosis – hypooxygenation
jaundice – hyperbilirubinemia
erythema - polycythemia, infection, drug reaction, or carbon monoxide poisoning
What does hygine mean?
Can be a reflection of the overall health of the patient
May equate to self-neglect in more than grooming
May be signs of medical conditions or an inability to care for oneself
this
is so stupid
How many cm are in an inch?
2.54
How many lbs are in a kg?
2.2 (what i learned is an ez conversion is take the pt’s weight in lbs, say 180 lbs, divide it by 2, so 90, and then subtract that by the first #, so 90-9 = 81kg)
What is the BMI conversion in metric?
BMI = weight in kg ÷ (height in m)2
What is the BMI conversion in english coversion?
weight in lb ÷ (height in inches)2 x 703
Healthy BMI?
18.5-24.9
overweight BMI?
25-30
obese class I BMI?
30-35
obese class II BMI?
35-40
obese class III BMI?
> 40
What are the 5 components to vitals?
Temperature Pulse Respirations Blood pressure Pain
Temperature calc for degrees F?
F = C x 9/5 + 32
Temperature calc for degrees C?
C = (f-32) x 5/9
Butt temperatures are 1 degree higher or lower than oral?
higher
Armpit temperatures are 1 degree higher or lower than oral?
lower
What is pyrexia?
Elevated body temperature most commonly associated with inflammation and infection resulting in an elevation of the body’s temperature set point
What is hyperthermia?
Elevation of body temperature not caused by fever but rather the inability of the body to dissipate heat
Certain medications, drugs, and heat stroke
What is hypothermia?
refers to lower than normal body temperature
most commonly as a result of environmental exposure
What are the 3 things to assess for on a pulse?
Rate
Rhythm
Character
Normal HR?
60-100
Normal RR?
12-20 bpm
What is apneustic breathing?
inspiration longer than expiration
What is obstructive breathing?
expiration longer than inspiration
Asthma, COPD
What is restrictive breathing?
shallow inspirations, become rapid with exertion
Restrictive lung diseases
What is hypernea?
rapid, deep inspirations
What is Kussmaul breathing?
deep gasping respirations such as found in diabetic acidosis
What is sighing?
deep inspirations with the breathing pattern
normal variant if occasional
What is cheyne-stokes?
increasing then decreasing amplitude of respiration with periods of apnea. depression of the frontal lobe
What is ataxic breahting?
irregular, unpredictable pattern with periods of apnea. meningitis, increased intracranial pressure
What is the systolic measurement of the BP?
the pressure of the blood on the arterial wall at the peak of left ventricular contraction
What is the distolic measurement of the BP?
the resting pressure on the arterial wall, occurring during ventricular relaxation.
What is the preHTN bp?
120-140
What is the HTN stage 1 BP?
140-160
What is the HTN stage 2 BP?
> 160
definition of orthostatic hypoTN?
a drop in blood pressure of 20 mmHg or the rise of pulse by 20 beats per minute from supine to standing
What is pain?
My brain for doing these flashcards right now.
