General survey, measurement, vital signs Flashcards
What is a general survey?
Looking/inspecting at the general state of health and obvious physical characteristics of a person
ex. How is personal hygiene? How do they look from a nutritional standpoint? What is height and weight? BMI? Are they addressed appropriately for the weather? Is clothing clean? Cultural norms? Do they appear their stated age?
Dysarthria
Difficult or unclear articulation of speech that is otherwise linguistically normal.
Dysphonia
Difficulty in speaking due to a physical disorder of the mouth, tongue, throat, or vocal cords.
Aphasia
a disorder that affects how you communicate; affects language expression and comprehension.
What are the 4 components of the general survey?
- Physical appearance
- Body structure
- mobility
- Behavior
What do we assess for physical appearance
age
sex
LOC
skin color
facial features
what do we assess for body structure
Stature
nutrition
symmetry
posture
position
body build, contour
what do we assess for mobility
Gait and ROM
What do we assess for behavior
Facial expression
mood and affect
speech
dress
person hygiene
What is the normal temperature range?
35.8-37.5 C
96.4-99.1 F
If the person has recently drank hot or cold liquids in the last 15 minutes, how long should you wait to assess temperature?
20-25 minutes
If the person has recently smoked, how long should you wait to assess temperature?
30 minutes
What is pulse?
A pressure wave created by stroke volume when the heart is pumping
What is stroke volume?
Amount of blood pumped by the left ventricle (during each systolic contraction)
What is the normal stroke volume in adults?
70 mL
Apical pulse should always be
taken for 1 minute.
When is it okay to take peripheral pulse for 30 seconds?
If the pulse has a regular rhythm. If it is irregular, take it for 1 minute.
What should be included when documenting pulse?
site pulse is taken ( if not taken at the radial artery)
Force of pulse (0-3)
If pulse is regular or irregular
What is the scale for force of pulse?
0 no pulse present
1+ weak, thready
2+ normal
3+ bounding
*some may go on 4+ scale
Normal pulse rate
60-100/beats per minute
Bradycardia
<50/beats per minute
Tachycardia
> 95-100/beats per minute
What can effect pulse rate, rhythm and force?
Fever
meds
anxiety
cardiac history
athlete
activity
What do you do when you cannot palpate the pulse?
Use a doppler.
How to accurately document doppler pulse findings
Doppler signal present, and rate.
*When we use a doppler, we are checking for perfusion into the extremities.
What does 1 breath consist of?
1 inspiration and 1 expiration.
should be relaxed, regular, automatic and silent
How long do you count respirations when they are regular? Irregular?
Regular: 30 seconds
Irregular: 1 full minute
Respiratory distress is considered what type of priority?
1st priority
What is the regular range for respirations?
12-20 breaths (fundamentals)
16-20 (assessment)
How do you not let the patient know you’re counting respirations?
When palpating pulse, keep fingers on the artery and count respirations for 30 seconds (if regular)
What situations affect respirations?
Narcotics (decrease)
Head injury (decrease commonly)
Heart Failure with activity intolerance ( increase)
Anesthesia (increase)
Sleep (decrease)
Anxiety (increase)
What is pulse oximetry
A tool used to measure the saturation of oxygen by applying a sensor with a light that measures the relative amount of light absorbed by hemoglobin.
Compares ratio and spits out a percentage.
What is the normal range for oxygen saturation (SpO2)
97-99%
85-92 is seen with pulmonary disease
*Anything under 85 is abnormal!
What could affect oxygen saturation?
Anemia (decreased blood cells)
Lung Disease
Heart disease
Inadequate O2 given or method of delivery (check tubing, placement, etc)
What is blood pressure?
Blood pushing against the vessel wall.
Systolic pressure
maximum pressure felt on the artery wall during left ventricular contraction
Diastolic pressure
Resting blood pressure is pressure against the vessel wall between contractions (when heart is resting)
Which lasts longer? Diastole or systole?
Diastole (refilling)
What is pulse pressure?
Pulse pressure is the difference between systolic and diastolic blood pressure.
systolic-diastolic
what affects blood pressure?
Age (increase w/ age)
Race (African Americans have increased BP)
Weight (increased weight, decreased BP control)
Emotions (Stress, anxiety)
Sex (increase in females v. males)
Exercise
Stress
Medication
What physiologic factors control blood pressure?
Cardiac output (recorded in L)
Peripheral vascular disease ( tighter tubes, increased pressure)
volume of circulating blood
viscosity (thickness)
Elasticity of vessel walls (decreased elasticity as increased in age)
Normal blood pressure range
<120/80
Hypertension range
120-129/<80
lifestyle modification should be implemented
Orthostatic hypotension
Drop in a systolic B/P >20mmHg
Increase in pulse >20 beats/min when changing to a standing position
Who is at most risk for orthostatic hypotension
The elderly due to vascular changes with aging.
How to assess orthostatic hypotension
Lying-sitting-standing position changes
Take B/P and pulse 2-3 minutes after position change.
Normal difference from supine to standing should be <10mmHg
common causes of orthostatic hypotension
Fluid loss
Aging and related vascular changes
Bedrest (decreased amount of circulation)
Changes in blood pressure medication
Where can blood pressure be measured?
Upper arm/brachial artery most common site
lower arm/radial artery
lower leg/tibial artery
Upper leg/popliteal artery
How many mmHg above the pulse cessation point should the examiner go?
20-30 mmHg
How many mmHg should the bulb be released?
a gradual, even 2 mmHg
What sound does Korotkoff I signify?
First sound heard is the systolic number.
What sound does Korotkoff V signify?
When the first sound heard becomes silent. The diastolic pressure