General Survey

Question 1

General survey

Answer 1

-starts when you walk in room
-changes in weight- rapid (fluid) or gradual (tissue)
-fatigue- loss of energy
-weakness- loss of muscle power
-fever, chills, night sweats- travel, meds

Question 2

2 parts of general survery

Answer 2

-1. general appearance
-2. height and weight

Question 3

general appearance

Answer 3

-apparent state of health
-LOC
-signs of distress
-skin color/lesions
-hygiene
-facial expression
-smell
-posture, gait, motor

Question 4

heigh and weight

Answer 4

-weight distribution
-BMI
-symmetry
-deformity

Question 5

BMI

Answer 5

-lbs x 700 / heigh (inches)
-underweight <18.5
-normal - 18.5-24.9
-overweight- 25-29.9
-obesity 1 - 30-34.9
-obesity 2- 35-39.9
-extreme obesity 3- >40

Question 6

vital signs

Answer 6

-bp- avoid smoking/drinking caffeine 30 min before, pt rests 5 mins before, no clothing, brachial artery at heart level, rest arm
-hr
-rr
-temp

Question 7

bp cuff size

Answer 7

-width- 40% of upper arm circumference
-length- 80% of upper arm circumference

Question 8

bp reading

Answer 8

-no ETOH or caffeine 30 mins before
-room is quiet and warm
-5 mins after rest
-palpate brachial artery @ heart level
-rest arm on table or support
-2.5cm above antecubital crease
-+30 after radial pulse disappears
-point when you heart 1st 2 consecutive beats is systolic
-use BELL
-take 2 readings 1 min apart and average the readings
-measure both arms
-repeat addition BP if difference between first 2 is > 5

Question 9

hypertension classification

Answer 9

-normal- <120/<80
-prehypertension- 120-139/80-89
-stage 1 HTN- 140-159/90-99
-stage 2 HTN- >160/>100

Question 10

orthostatic blood pressure

Answer 10

-measure BP and HR with pt supine -> wait 3 mins -> pt stands up -> repeat
-normal- systolic BP drops slightly or remains, diastolic BP rises slightly
-orthostasis- systolic BP drops > 20 or diastolic BP drops > 10 within 3 mins of standing
-can be seen with mod-severe blood loss, drugs, prolonged bed rest

Question 11

HR

Answer 11

-radial pulse
-if normal count 30 and x 2
-if abnormal confirm with EKG

Question 12

respiratory rate

Answer 12

-12-20 WNL
-count for 60 seconds
-rhythm, depth, effort

Question 13

temp

Answer 13

-pyrexia -fever
-hyperpyrexia- > 41.1 (106)
-hypothermia- < 35 (95)
-oral- 98.6F/37C -> 96.4-99.1
-axillary 1F < oral
-rectal- gold standard- 1F > oral
-tympanic- 1.4F > oral
-temp is lowest early morning and highest afternoon/evening
-tympanic is the hottest
-unit of measurement MUST be documented

Question 14

acute vs chronic pain

Answer 14

-acute- < 3-6 months
-chronic- >3-6 months or > 1 month after acute injury/illness -> not assoc with cancer/other medical conditions
-can be at intervals

Question 15

wong baker facies scale

Answer 15

-0-10 scale

Question 16

comprehensive vs focused pt assessment

Answer 16

-comprehensive- new pts. structured, thorough, baseline, health promotion*, full body
-focused- established pts, routine fu, problem

Question 17

HPI

Answer 17

-CC
-story
-oldcart
-thought and feelings about illness
-*****uses ROS for pertinent + and -

Question 18

Dual Process Theory of Decision
Making

Answer 18

-system 1- FAST, effortless, quick
-system 2- SLOW, logical

Question 19

illness scripts

Answer 19

-symptoms align with disease symptoms you learned
-textbook guidelines

Question 20

fever

Answer 20

> 100.4

Question 21

temp tools

Answer 21

-red- rectal -> short thick
-blue- oral -> long slender
-keep in mouth 3-4 mins
-digital
-tympanic - variable*
-mercury glass- gold standard
-galinstan- non toxic
-temporal- heat energy

Question 22

bp cuff types

Answer 22

-aneroid- basic one
-mercury
-automatic digital

Question 23

stadiometer

Answer 23

-height