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Clinical Assessment > General Survey and Vital Signs > Flashcards

General Survey and Vital Signs Flashcards

1
Q

Order of Basic Exam Technique (unless otherwise specified)

A
  1. Inspection (synonymous with Assessment)
  2. Palpation
  3. Percussion
  4. Auscultation
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2
Q

Basic Exam Techniques

A

Perform a thorough, accurate exam

  • Develop a routine sequence, usually head to toe order
  • Examine from right-hand side
  • Speak to pt during the PE - let them know what you are doing & why
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3
Q

General Survey

A

-Overall impression of the patient based on clinical observation = objective findings

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4
Q

Components of General Survey

A
  • Apparent state of health
  • Level of consciousness
  • Signs of distress
  • Dress, grooming & personal hygiene
  • Facial expression
  • Breath & body odors
  • Posture, gait & motor activity
  • Body habitus
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5
Q

Apparent State of Health

A

Fit, frail, healthy, appearing, WD/WN, robust

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6
Q

Level of Consciousness

A

Alert, oriented, confused, drowsy, sleepy, responsive

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7
Q

Signs of Distress

A

Labored breathing, seems anxious, positio (exam table, chair), pallor, sitting comfortably, tripoding, curled up on table

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8
Q

Grooming and Hygiene

A

Condition of clothes/shoes, personal cleanliness

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9
Q

Facial Expression

A

Appropriate to conversation, eye contact, flat affect

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10
Q

Breathe/Body Odors

A

Alcohol, fruity/sweet, tobacco, halitosis

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11
Q

Posture, Gait, and Motor Activity

A

Invountary Movements, tremors, fidgets, non-movement, limps, uneven gait, gait intact

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12
Q

Body Habitus

A

Morbidly obese, overweight, emaciated, muscular

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13
Q

General Survey

A
  • Objective
  • Clinical observation
  • Physical signs= PE
  • Clinician’s impression of patient
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14
Q

General ROS

A
  • Subjective
  • Patient based history
  • Symptom based information obtained through question/answers
  • weight change
  • fatigue
  • Weakness
  • Fever/Chills, night sweats
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15
Q

Weight Gain Causes

A
  • tissue vs. body fluids
  • tissue–> fat; takes months
  • body fluids –> edema, hours/days
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16
Q

Weight Loss Causes

A
  • Decreased intake of food (anorexia, dysphagia, vomiting, insufficient food supply, eating disorder, need dental work)
  • increased caloric intake (hyperthyroid, malignancy, eating disorders, malabsorption)
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17
Q

Fatigue

A
  • relatively non-specific complaint
  • a sense of weariness of loss of energy
  • consider context of symptom (response to hard work/stress/grief or unrelated to specific factor)
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18
Q

Weakness

A
  • not synonymous with fatigue
  • denotes a demonstrated loss of muscle strength
  • localized to a neuro-anatomic pattern (suggests a disorder of nervous system or muscles)
  • Need MSS, CNS & Psych ROS
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19
Q

Fever/Chills, Night Sweats

A
  • Ask pt to clarify what they mean by having a fever (subjective vs. pt used thermometer)
  • Has the pt. noted excessive sweating or felt chilly & cold? (+ response: is it night time or throughout day)
  • Distinguish between subjective chilliness verses a shaking chill
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20
Q

Vital Signs

A

BP, Pulse, Respiration, Temperature, Height, Weight

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21
Q

BP

A
  • Patients should avoid exercise, smoking, caffeine before BP reading
  • Width of inflatable cuff = 40% of upper arm circumference
  • Length = 80% of upper arm circumference
  • Support pt’s arm so brachial artery at heart level
  • pt should be sitting, legs uncrossed
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22
Q

How long do you wait if you need to repeat BP?

A

Wait 2 minutes for same arm or use other arm

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23
Q

Normal Blood Pressure

A

Systolic: 90-119
Diastolic: 60-79

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24
Q

Pre-Hypertension

A

Systolic: 120-139
Diastolic: 80-90

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25
Q

Hypertension Stage 1

A

Systolic: 140-159
Diastolic: 90-99

26
Q

Hypertension Stage 2

A

Systolic: 160+
Diastolic: 100+

27
Q

White Coat Hypertension

A
  • Systolic BP may go up because of anxiety/nervousness

- may want to recheck at the end of visit

28
Q

Masked Hypertension

A
  • Ambulatory is elevated

- Fine clinically

29
Q

Hypertensive Urgency/Emergency

A

diastolic BP above 150

30
Q

Coarctation of the Aorta

A
  • narrowing of the aorta

- need to check for this when someone is diagnosed with hypertension

31
Q

Orthostatic (Postural) Hypotension

A
  • Measure BP in 3 positions for pt on HTN medication or with a history of fainting, postural dizziness, possible depletion of BV
  • Wait 1-5 minutes between sitting and standing
  • Fall in Systolic Pressure is 20mm Hg or more from supine or sitting to standing
32
Q

Positive Response for Orthostatic Hypotension

A
  • Fall in Systolic Pressure is 20mm Hg or more from supine or sitting to standing
  • Fall in Diastolic pressure is 10mm Hg or more
33
Q

Special Considerations for BP

A
  • Coarctation of the aorta
  • Orthostatic (Postural) Hypotension
  • Very obese, very thin, weak Korotkoff sounds
34
Q

Pulse

A
  • rate (bpm), rhythm (pattern), amplitude (strength, bounding), and contour (speed of upstroke)
  • Sites: Radial, carotid, brachial (infants)
35
Q

Pulse Rate

A

Fast (>100, tachycardia), Normal (60-100), slow (<60, bradycardia)

36
Q

Rhythm of Pulse

A
  • Regular

- Regularly irregular or irregularly irregular (evaluate by auscultation)

37
Q

Respiration

A

-Observe signs of respiratory alteration
-Count while patient is distracted and not talking
-Observe one complete respiratory cycle
-Regular- count for 30 sec x 2
Irregular- count for full minute

38
Q

Patterns of Respiration

A

Bradypnea, Tachypnea, hyperventilation, obstructive breathing, Cheyne-Stokes, Ataxac (Biot’s) breating

39
Q

Bradypnea

A

abnormally slow breathing rate

40
Q

Tachypnea

A

rapid and shallow breathing

41
Q

Hyperventilation (hyperpnea)

A

rapid and deep breathing

42
Q

Obstructive breathing

A

prolonged expiration (such as COPD, Asthma attack)

43
Q

Cheyne-Stokes

A

deep alternating breathing with apneic

-take slow or rapid deep breaths and then stop

44
Q

Ataxic (Biot’s) breathing

A
  • unpredictable and irregular

- no real pattern

45
Q

Normal Oral Temperature

A
  • 37 C or 98.6 F

- lower in arm and higher in PM

46
Q

Normal Rectal Temperature

A

higher by 0.4-0.5C (0.7.-0.9F)

47
Q

Normal Axillary Temperature

A

lower than oral by 1 degree, less accurate

48
Q

Normal Tympanic Temperature

A

higher by 0.8°C (1.4°F)

49
Q

refers to extreme elevations in temperature, above 41.1° C (106°F)

A

Hyperpyrexia

50
Q

refers to an abnormally low temperature, below 35°C (95°F) rectally

A

Hypothermia

51
Q

What are two terms that mean elevated temperature?

A

Hyperpyrexia and Hypothermia

52
Q

Pulse Oximetry

A
  • Indirect measurement of oxygen saturation
  • % of hemoglobin in the oxyhemoglobin configuration
  • Normal range = 95 to 100%
  • Does not determine: metabolism of oxygen or amount of oxygen used
53
Q

Pulse Oximetry Normal

A

95-100%

54
Q

Healthy Lifestyles Motivational Interview

A

Optimal weight & nutrition (Obesity in the population; Variables to promote and/or evaluate)
Nicotine cessation
Dealing w/pain

55
Q

Assess Healthy Lifestyle (5 R’s)

A 
Relevance change or cessation
Risks 
Rewards
Roadblocks
Repetition
56
Q

Assessing readiness to change to Healthy Lifestyle

A
  • Ask about use, exercise, foods
  • Advise (Be clear about why a change is in pt best interests)
  • Assess (w/readiness for change)
  • Assist (Develop realistic & attainable plan)
  • Arrange (Follow up visit to review pt success or reassess readiness cessation/change)
57
Q

5 A’s

A

Ask, Advise, Assess, Assist, Arrange

58
Q

Types of Pain

A

Nociceptive (somatic)
Neuropathic
Central sensitization
Psychogenic & idiopathic

59
Q

Normal Pulse for Adults

A

60-100 bpm

60
Q

Normal Respiratory Rate

A

14-20 breathes per minute

Clinical Assessment (11 decks)

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