General survey and vital signs Flashcards
The general appearance of a patient includes…
Apparent state of health
Level of consciousness
Discomfort or distress
Skin color and lesions
Dress, grooming and personal hygiene
Facial expression
Odors of body and breath
Posture, gait and motor activity
Nociceptive pain + neuropathic pain
Nociceptive: somatic pain
- linked to tissue damage to the skin, MS, or visceral
- sensory nervous system is intact
- acute or chronic
- “dull, pressing, pulling, throbbing”
Neuropathic:
- lesion or ds affecting somatosensory system
- may be independent of inciting injury
- “pins and needles”, shock-like, electric, stabbing, burning
Odors of body and breath
alcohol scent
acetone: diabetes
uremia
liver failure
CI for obtaining BP
lymphedema: swelling
paresis
paralysis
venous catheters
arterial catheters
mastectomy on BP side
dialysis shunts
ID band prohibiting arm use
General Survey:
- Close observation begins at beginning and continues throughout the Hx and PE
-Be specific; use graphic and detailed adjectives to paint a picture of your patient - Avoid general terms such as “well developed” or “in no acute distress”
- Can be a single concise sentence or 2-3 sentences to form a short paragraph
Weight: Things to consider
-Rapid changes in weight = change in fluid not tissue
- Weight gain: nutrition vs. medical causes
- Weight loss: medical vs. psychosocial causes
Loss of ____% or more of usual body weight over a 6-month period = SIGNIFICANT wt loss
5%
What might excess clothing reflect?
Cold intolerance of hypothyroidism
Hide skin rash or needle marks
Mask anorexia
Signal personal lifestyle preferences
Fat distribution:
Generalized fat distribution:
- simple obesity
Truncal fat with relatively thin limbs:
- Cushing syndrome
- metabolic syndrome
What stares should be watched out for?
Hyperthyroidism: bulging eyes
Immobile facies or parkinson
Flat or sad affect of depression
What is the preferred posture for COPD or acute pericarditis?
Leaning forward w/ arms braced (tripod position)
What is the preferred posture for someone with left-sided heart failure?
Sitting upright
BMI: ranges
underweight BMI: <18.5
Normal: 18.5-24.9
overweight BMI: 25-29.9
obese BMI:
- I: 30-34.9
- II: 35-39.9
- Extreme III: >40
What are important things to consider when taking a patients BP?
Back supported and legs uncrossed
Avoid smoking
Caffeine
Exercise for 30 min prior to measurement
Rest 5 minutes prior to measuring BP
Rest the arm on a table a little above the patient’s waist, or support the patient’s arm with your own at his mid-chest level
The width of the inflatable bladder of cuff should be _________ of upper arm circumference. what happens when the cuff is too small/large
40%
If the cuff is too small the BP will read too HIGH
If the cuff is too large the BP will read LOWER
Cuff Size:
Width: 40% of upper arm circumference
Length: 80% of upper arm circumference
Length: ____% of upper arm circumference
80%
Cuff Size:
Width: 40% of upper arm circumference
Length: 80% of upper arm circumference
What is an auscultatory gap associated with? + what is it
Arterial stiffness
Atherosclerotic disease
Auscultatory gap: A silent interval that may be present between the
systolic and diastolic blood pressures; Ex: the sound disappears for a while, then reappears
An unrecognized auscultatory gap may lead to…
Underestimation of systolic pressure or overestimation of diastolic pressure
When does a pressure difference of >10-15 between arms occur?
Subclavian steal syndrome
Supravalvular aortic stenosis
Aortic dissection
How to measure BP:
- Center the inflatable cuff over the brachial artery with the lower border 2.5 cm above the antecubital crease
- Secure the cuff + position the patient’s arm so that it is
slightly flexed at the elbow - With the fingers of your opposite hand, palpate the RADIAL artery and inflate
the cuff until the radial pulse DISSAPEAR - add 30 mm Hg to this pressure
- Deflate the cuff promptly and completely and wait 15-30 seconds
- Place the BELL of the stethoscope lightly over the brachial artery
- Inflate the cuff to the SUM pressure previously determined and deflate slowly
- The point at which you hear the first two consecutive beats is the systolic
pressure - The disappearance point is the diastolic pressure
Deflate the cuff slowly at a rate no faster than ________ mmHg per second
2-3
Taking Blood pressure: how many readings to take on each arm and how long do you wait in between. when do you repeat the reading?
Take 2 reading that are 1 minute apart + avg your readings
Repeat additional BP if difference between the first two readings is >5 mmHG
Repeat if BP is elevated and verify in the contralateral arm
Orthostatic BP:
1) take BP and HR with them supine and wait 3 min
2) take BP and HR with pt standing
Diagnostic: systolic drops by 20 or diastolic drops by 10 in 3 minutes
Causes:
- mod-severe blood loss,
-drugs
- prolonged bed rest
Heart Rate
- RADIAL pulse is commonly used to measure the heart rate
- Use the pads of the index and middle fingers
Normal rate (60–90 bpm) + regular rhythm:
- count the rate for 30 seconds and multiple by 2.
If the rate is fast or slow and/or the rhythm is irregular:
- count for a full 60 seconds.
- Abnormal HR should be confirmed with EKG
Respiratory rate:
Observe rate, rhythm, depth, and effort of breathing
Normal rate: ~20 breaths/minute (12-20)
- Count for 60 seconds
Abnormal rate:
- Under 12 or over 25 breaths/min
Observe rhythm: regular vs irregular
Observe depth: shallow vs gasping
Observe effort: normal vs labored
Acute Pain:
Typically lasts < 3-6 months
Common with trauma, acute illness, and surgery
Protective function
Resolves as injured tissue heals
Chronic Pain:
Not associated with cancer or other medical conditions that persists > 3- 6 months OR
Lasts > 1 month after an acute injury or illness
Recurring at intervals of months or years
Types of pain
Nociceptive or somatic:
- related to tissue damage
Neuropathic :
– resulting from direct trauma to the peripheral or central nervous system
Psychogenic :
– relates to factors that influence the patient’s report of pain
- Psychiatric conditions
- Personality and coping style
- Cultural norms
- Social support systems
Idiopathic :
– no identifiable etiology
What increases systolic and diastolic blood pressure?
Acute caffeine use
Acute nicotine use or exposure
Bladder distention
Cold exposure
Paretic arm
White coat effect
Insufficient rest period
Legs crossed at knees
Unsupported arm
Arm lower than heart level
Talking during movement
Incorrect smaller cuff size
What decreases systolic and diastolic blood pressure?
Acute meal ingestion
Acute alcohol ingestion
Incorrect larger cuff size
fatigue vs weakness
Weakness:
- loss of muscle power
- associated with neuropathy and myopathy
fatigue:
- sense of weariness or loss of energy
- “I don’t feel like getting up in the morning”…
- common symptom of depression and anxiety; infections; endocrine etc
Recurrent shaking chills what does it suggest
suggest more extreme swings in temperature and systemic bacteremia.
Edema from extravascular fluid retention: what conditions
heart failure
nephrotic syndrome
liver failure
venous stasis.
Temperature body
- lowest in the early morning and highest in the afternoon and evening
- Women have a wider range of normal temperature than men
Axillary temperatures:
- take 5-10 minutes to register
- less accurate
Tympanic:
- can be more variable than oral or rectal temperatures
Oral:
- generally lower than core body and rectal
Rectal:
- 0.5 degrees C warmer than oral temp
- glass rectal: Gold standard
Three scale of assessing pain
Visual Analog Scale (VAS)
Numeric Rating Scale (NRS),
Wong-Baker FACES® Pain Rating Scale
VAS
- horizontal line with verbal descriptive anchors at each end to express the extremes of pain.
- Patients mark the point on the line that best corresponds to their symptom severity
Body temperature: scale of hypothermia, pyrexia and hyperpyrexia
Hypothermia: 95 F, 35 C
Fever/pyrexia: elevated body temperature
hyperpyrexia: 41.1 C, 106 F
coolest in morning and warmest temp in afternoon (~1 C change during day)
