General Survey: Ch. 9 Flashcards
When is the general survey done?
During the interview
6 observations to note for Physical Appearance during the general survey?
- Age: pt. looks stated age (older appearance could mean chronic illness)
- Sex: sexual development is app. for age. Note transgender & what stage
- Skin: even tone, color, app. for genetic background, intact, tattoo & piercing
- Facial Features: symmetrical w/ movement
- Level of Consciousnesses (LOC): place, time, situation
- Overall appearance: no acute distress
characteristics of Centripetal Obesity
Obesity concentrated in the face, neck & trunk. Thin extremities.
what is Cachexia
Wasting
3 observations to note when assessing Mobility
- Gait: feet shoulder width, symmetrical arm swing, smooth walk, even, maintain balance
- ROM: mobility of joints, deliberate, accurate, smooth, coordinated
- No involuntary movement
7 observations to note when assessing Body Structure
- Stature: height
- Nutrition: weight
- Symmetry: body equal bilaterally, normal proportions
- Posture: plum line through ear, shoulder, hip, knee, ankle
- Position: sits comfortably
- Body Build, Contour: arm span = height, crown to pubis = pubis to sole of feet
- Obviously physical deformities: congenital, acquired defect (amputation)
Lordosis
Excessive inward curve of lumbar vertebrae
Kyphosis
Humpback appearance common in the very old and in those with osteoporosis.
6 observations to note for Behavior
- Facial Expression: app. eye contact, app. expression
- Mood & Affect: pt. is comfortable & cooperative
- Speech: articulation
- Speech pattern: fluent w/ even pace, conveys ideas clearly, communicates easily on their own or through an interpreter
- Dress: app. for weather
- Personal hygiene: clean, groomed
What would nurse obtain during a general survey?
PBBM
Begins when you first meet the patient, observation of general health state and any obvious physical characteristics. It is an introduction for the physical examination that will follow.
(objective data)
Physical appearance
Behavior
Body structure
Mobility
what do you do to measure Height
Shoe-less
Children <2y use measuring board
what do you do to measure Weight
Record in kg (1 kg = 2.2 lbs)
Shoe-less & remove heavy outer clothing
Infants use platform scale
what is BMI? what are its drawbacks?
Indicates healthy weight for height
Useful in obesity risk assessment
Drawbacks: muscle weighs more than fat
how do you take Body Measurements for an adult & an infant
Taken in cm
- Adult
head: around temporal & occiptal
waist: just above illiac crest (risk for DM: >40” in men & >35” in women)
-Infant
head: around temporal & occiptal (32 to 38 cm)
chest: around nipple line
newborn’s head is about 2cm larger than chest, Between 6mo. and 2y head and chest should be equal
Hypopituitary Dwarfism
Deficiency in growth hormone in childhood results in retardation of growth.
Delayed puberty, hypothyroidism, and adrenal insufficiency
Gigantism
Excessive secretion of growth hormone by the anterior pituitary.
Overgrowth of the entire body.
When this occurs during childhood before closure of bone epiphyses, it causes increased height, as well as increased weight and delayed sexual development.
Acromegaly (Hyperpituitarism)
Excessive secretion of growth hormone in adulthood after normal completion of body growth.
Overgrowth of bone in face, head, hands, and feet but no change in height.
Internal organs also enlarge, and metabolic disorders (e.g., diabetes mellitus) may be present
Achondroplastic Dwarfism
A genetic disorder in converting cartilage to bone.
Normal trunk size, short arms and legs, and short stature.
It is characterized by a relatively large head with frontal bossing; midface hypoplasia (small); and often thoracic kyphosis, prominent lumbar lordosis, and abdominal protrusion.
The mean adult height in men is about 131.5 cm (4 ft 4 in) and in women about 125 cm (4 ft 1 in).
Amenorrhea (uh-men-o-REE-uh)
The absence of menstruation — one or more missed menstrual periods
Endogenous Obesity—Cushing Syndrome
adrenal cortex secretes excess cortisol.
Weight gain and edema
central trunk and cervical obesity, round, plethoric face, muscle wasting; weakness; thin arms and legs; reduced height; and thin, fragile skin with purple abdominal striae, bruising, and acne.
Marfan Syndrome
Inherited connective tissue disorder is characterized by tall, thin stature
arachnodactyly (long, thin fingers), hyperextensible joints
arm span > height, pubis to sole > crown to pubis
sternal deformity (note pectus excavatum), high-arched narrow palate, narrow face, and pes planus (flat feet).
Early morbidity and mortality occur s aa result of cardiovascular complications
