General Survey; Measurement; Routine Vital Signs Flashcards
What are the components of physical appearance? (There are 5)
Age - appears stated
Sex - development appropriate for age and gender
Level of consciousness - alert and oriented (x3), attending and responsive
Skin colour - even tone, pigmentation, intact skin with no obvious lesions
Facial features - symmetrical with movement; no acute signs of distress
What are the components of the general survey?
Physical appearance
Body structure
Mobility
Behaviour
What are the components of body structure? (There are 6)
Stature - height normal range for age and genetic heritage
Nutrition - weight within normal range for height and body build, even distribution of body fat
Symmetry - body parts equal bilaterally and in relative proportion to each other
Posture- standing comfortably erect appropriate for age, “plumb line” (anterior ear, shoulder, hip, patella, and ankle)
Position - sitting comfortably, arms relaxed, head turned to examiner
Body build/contour - normal proportions (arm span equals height), body length from crown to pubis approximately equal to length from pubis to sole, obvious physical deformities, congenital or acquired defects
What are the components of mobility? (There are 2)
Gait - normal, base width equal to shoulder width, accurate foot placement, smooth, even, well-balanced, presence of associated movements (symmetrical arm swing)
Range of motion - full mobility in each joint, deliberate, accurate, smooth, coordinated movement
What are the components of behaviour? (There are 5)
Facial expression - maintaining eye contact, expression appropriate to situation
Mood and affect - comfortable and cooperative, interacting pleasantly
Speech - clear and understandable articulation, fluent, even pace, convey ideas clearly, word choice appropriate
Dress - clothing appropriate to climate and season, clean and fits body, appropriate for culture and age
Personal hygiene - clean and groomed appropriately for patients age, occupation and socioeconomic group
What are the components of measurement? (There are 4)
Weight - standardized balance or electronic scale (remove shoes and heavy clothing)
Height - use wall-mounted device or measuring pole on balance scale (feet, shoulders, and buttocks should be in contact with pole or wall)
Body mass index - practical marker of optimal weight for height
BMI = weight (kg)/height2(m)
Waist-to-hip ratio - reflects body fat distribution (waist circ/height circ)
What are the vital signs?
Temperature
Pulse
Respiration
Blood pressure
How do you measure temperature?
Can measure orally, rectally, axillary, or temporally
Oral temp - accurate and convenient, oral sublingual site has a rich blood supply from the carotid artery
What is the normal range for temperature?
36-38 degrees Celsius
How do you measure pulse?
Radial - measure rate and rhythm of heart, palpate for 30 seconds then multiply by 2 (unless irregular, then count full 60 seconds)
What is the normal pulse range?
60 - 100 beats per minute
How do you measure respirations?
Rate - normally relaxed, regular, automatic and silent; count breaths for 30 seconds, then multiply by 2 (unless irregular, then count the full 60 seconds)
Oxygen saturation - use digital machine - should be 92-100% saturation on room air
What is the normal respiration rate?
12-20 breaths per minute
How do you measure blood pressure?
Arm - measure with stethoscope and blood pressure cuff
1 step or 2 step
Palpate radial or brachial artery while inflating cuff; once pulse disappears, pump an additional 200-300 mmHg, slowly release, listening with stethoscope for Korotkoffs sounds (phases 1-5) to determine BP. Phase 1 is systolic, phase 5 is diastolic.
What is systolic pressure?
The maximum pressure felt on the artery during left ventricle contraction
