General Survey and Vital Signs Flashcards
1
Q
patient’s general appearance
A
- posture and position of patient
- gait/ambulation
- gross assessment of nutritional status
- body habitus
- estimation of psychological status
- apparent state of health (healthy, chronically ill, frail)
- level of consciousness (awake, alert, responsive, lethargic, obtunded (hear you but respond slowly, confused))
- height and build (short, tall, slender, stocky, lanky)
- weight (cachectic, emaciated, slender, obese, morbidly obese)
- dress, grooming, personal hygiene
- facial expression (eye contact, level of attention, facial expression, affect)
2
Q
signs of cardiac distress
A
clutching chest, diaphoretic (sweating heavily)
3
Q
body odors and breath
A
- fruity odor of diabetes
- scent of alcohol, cigarettes, marijuana
- body odors (homeless, nursing home, cancer)
4
Q
Antalgic gait
A
Due to pain
5
Q
6 primary vital signs
A
- BMI, height, weight
- blood pressure
- heart rate (pulse)
- respiratory rate
- temperature
- pain
- pulse oximetry (oxygen saturation)
- last menstrual period (LMP)
6
Q
how to measure height and weight
A
without shoes or heavy clothing
7
Q
body mass index
A
- more accurate than height/weight charts
- estimated measure of body fat
- BMI = weight (kg) / height (m2) (target range between 19-25) (>25 = overweight, >30 = obese, <17 = underweight)
8
Q
medical implications of obesity
A
- diabetes, metabolic syndrome
- hypertension
- vascular disease
- osteoarthritis
9
Q
possible causes of low BMI
A
- eating disorders
- cancer
- wasting syndrome
- hyperthyroidism
10
Q
BMI >25 or <17
A
- indications for nutritional assessment, referral or counseling
- counseling/education geared at optimal weight and nutrition
11
Q
blood pressure
A
- window into the CV system
- provides pressure readings of heart during contraction (systomle) and relaxation (diastole)
12
Q
how to take blood pressure (patient position and setting)
A
- patient seated and relaxed at least 5 min, feet on floor
- no smoking, caffeine 30 min prior
- arm resting with antecubital crease at heart level, free of clothing, and supported
13
Q
blood pressure (cuff and cuff placement)
A
- spyhgmomanometer
- center of inflatable baldder at 2.5 cm above the antecubital crease in line with brachial artery
- cuff should be tight around arm (use appropriate cuff size)
- width of bladder 40% of upper arm circumference
- length of bladder 80% upper arm circumference
14
Q
blood pressure (inflating the cuff)
A
- estimate systolic pressure by palpation
- deflate and wait
- apply bell of stethoscope over brachial artery
- inflate cuff to 30 mmHg above pressure at which radial pulse disappeared on estimation check
- slowly deflate at rate of 2-3mmHg/sec
- listen closely until 10-20mmHg below where sounds disappear
15
Q
Blood pressure sounds
A
- Korotkoff sounds (low pitch heard when checking BP, 1st sound is SBP, last sound is DBP)
- Auscultatory gap (silent interval that may be present between systolic and diastolic pressures, associated with atherosclerosis) ; sometimes noticed when taking manual blood pressure and can be misinterpreted leading to underestimations of systolic BP and overestimation of diastolic BP
16
Q
Repeating blood pressure reading
A
- wait at least 2 minutes to repeat BP if needed to confirm findings and average your readings (if >5mmHg difference, check agin before averaging readings)
- BP should be taken both arms at least once (pressure differences 5-10mmHg btw arms is ok, pressure differences >10-15mmHg suggests cardiac or arterial problem on lower pressure side)
17
Q
Blood pressure readings and their meanings
A
- normal (SBP <120mmHg, DBP <80mmHg)
- Prehypertensive (SBP 120-139, DBP 80-89)
- Hypertension Stage 1 (SBP 140-159, DBP 90-99)
- Hypertension Stage 2 (SBP >160, DBP >100)
18
Q
orthostatic (postural) hypotension
A
-measure BP and HR supine, seated, standing
wait 2-3 mins between positions
Positive if drop in SBP > or = 22mmHg, drop in DBP > or =10mmHg, increase in HR > 10bpm, or dizziness
19
Q
Pulsus paradoxus
A
SBP drop >10mmHg upon inspiration
20
Q
Heart rate and rhythm
A
- measured as beats per minute
- 4 components to pulse (rate, rhythm, amplitude, contour)
- -amplitude = how far it rises
- -contour = how fast it rises and falls (or how slowly)
21
Q
Measuring heart rate
A
- locate radial pulse
- palpate with pads of middle and index fingers
- count beats for 15 secs and multiply by 4 (if irregular or very fast or slow, count for 60 secs)
- note rhythm, contour and amplitude of pulse (regular or irregular, strong, bounding, weak, thready)
22
Q
Heart Rate ranges
A
- Normal 60-100 bpm
- bradycardia <60 bpm
- tachycardia >100 bpm
23
Q
small weak pulse (low pulse pressure) indications
A
heart failure, hypovolemia, vascular disease
24
Q
irregularly irregular pulse indication
A
indicates atrial fibrillation
25
respiratory rate
-measured as breaths per minute
26
measuring respirations
- count the number of breaths in 1 minute
- visual inspection (watch the patient breathe quietly)
- auscultation (over trachea when examining other area)
27
normal respiration rate
14-20 breaths/min (expiration should be longer than inspiration but not by a lot, and should be regular)
28
cheyne-stokes breathing
periods of deep breathing alternate with apnea
29
kussmaul breathing
- "air hunger"
| - rapid deep breathing due to metabolic acidosis
30
ataxic (biot's) breathing
unpredictable irregularity in breathing
31
obstructive breathing
prolonged expiration due to narrowed airways
32
temperature
- measures core body temperature
- not always necessary to check temp
- normal range (oral 96-99F, 35-37C)
- average (98.6F, 37C)
- lower in AM, higher in PM
33
rectal temperature
slightly higher than oral (closest to core temp, indicated in babies, unconscious or uncooperative pts in respiratory distress)
34
glass thermometer
- for checking oral or rectal temperature
- can be affected by anything recently in the mouth
- shake thermometer, insert under tongue, wait 3-5 minutes and read; reinsert 1 minute and read again
35
digital (electronic) thermometer
- for checking oral, rectal, or tympanic temperature depending on which machine is used
- use disposable cover, insert under tongue
- wait to readout, about 10 seconds
36
fever (pyrexia)
>100.5F (38C)
| -abnormal, elevated core body temperature
37
hyperpyrexia
>106F (41C)
38
hypothermia
<95F (35C)
39
causes of fever
infection, trauma, cancer, drug reactions, etc.
40
causes of hypothermia
exposure to cold, paralysis, starvation, etc.
41
pain
- newest vital sign
- should be included whenever a patient complains of pain
- scale of 0-10 or can use symbols for children or patients who do not understand number scale
- 0 = no pain
- 10 = most severe pain
42
oxygen saturation
- indicated in patients with respiratory complains or problems
- pulse oximeter machine required (measures O2 saturation in capillaries, false negatives and positives)
- normal is >95% saturation on room air (may be less for patients with COPD)
- always note if patient is on room air or supplemental oxygen
43
general survey and vital signs
- introduce self, state name and title
- wash hands
- assess patient's level of consciousness, posture, movements, grooming and hygiene, manner, affect, apparent state of health
- check height and weight, and calculate BMI
- check temperature
- check BP bilaterally in seated position
- check respiratory rate
- check heart rate
44
Tripod posture
Due to COPD
45
Involuntary movements
Could be due to Parkinson’s
46
signs of respiratory distress
labored breathing, sitting forward, using intercostal muscles for respiration
47
signs of pain
wincing, writhing, rigid, protecting painful area
48
signs of anxiety and depression
fidgeting, sweaty palms, poor eye contact, appears disheveled
49
large bounding pulse (high pulse pressure) indications:
fever, anemia, hyperthyroidism, exercise, fear/anxiety
50
pulsus alternans
pulse alternates in amplitude from beat to beat, but rhythm is regular
51
bisferiens pulse
increased arterial pulse with double systolic peak
52
bigeminal pulse
normal beat alternates with premature contraction, varying in amplitude
53
bradypnea
<14 breaths per minute
54
tachypnea
rapid shallow breathing
55
hyperpnea (hyperventilation)
rapid deep breathing
56
4 components of breathing
rate, depth, rhythm, effort
57
axillary temperature
slightly lower than oral (less accurate)
58
tympanic temperature
slightly higher than oral
