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Nurse Assessment > General survey, measurement, vital signs > Flashcards

General survey, measurement, vital signs Flashcards

1
Q

What is a general survey?

A

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?

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2
Q

Dysarthria

A

Difficult or unclear articulation of speech that is otherwise linguistically normal.

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3
Q

Dysphonia

A

Difficulty in speaking due to a physical disorder of the mouth, tongue, throat, or vocal cords.

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4
Q

Aphasia

A

a disorder that affects how you communicate; affects language expression and comprehension.

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5
Q

What are the 4 components of the general survey?

A
  1. Physical appearance
  2. Body structure
  3. mobility
  4. Behavior
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6
Q

What do we assess for physical appearance

A

age
sex
LOC
skin color
facial features

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7
Q

what do we assess for body structure

A

Stature
nutrition
symmetry
posture
position
body build, contour

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8
Q

what do we assess for mobility

A

Gait and ROM

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9
Q

What do we assess for behavior

A

Facial expression
mood and affect
speech
dress
person hygiene

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10
Q

What is the normal temperature range?

A

35.8-37.5 C

96.4-99.1 F

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11
Q

If the person has recently drank hot or cold liquids in the last 15 minutes, how long should you wait to assess temperature?

A

20-25 minutes

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12
Q

If the person has recently smoked, how long should you wait to assess temperature?

A

30 minutes

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13
Q

What is pulse?

A

A pressure wave created by stroke volume when the heart is pumping

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14
Q

What is stroke volume?

A

Amount of blood pumped by the left ventricle (during each systolic contraction)

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15
Q

What is the normal stroke volume in adults?

A

70 mL

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16
Q

Apical pulse should always be

A

taken for 1 minute.

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17
Q

When is it okay to take peripheral pulse for 30 seconds?

A

If the pulse has a regular rhythm. If it is irregular, take it for 1 minute.

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18
Q

What should be included when documenting pulse?

A

site pulse is taken ( if not taken at the radial artery)

Force of pulse (0-3)

If pulse is regular or irregular

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19
Q

What is the scale for force of pulse?

A

0 no pulse present
1+ weak, thready
2+ normal
3+ bounding

*some may go on 4+ scale

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20
Q

Normal pulse rate

A

60-100/beats per minute

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21
Q

Bradycardia

A

<50/beats per minute

22
Q

Tachycardia

A

> 95-100/beats per minute

23
Q

What can effect pulse rate, rhythm and force?

A

Fever
meds
anxiety
cardiac history
athlete
activity

24
Q

What do you do when you cannot palpate the pulse?

A

Use a doppler.

25
Q

How to accurately document doppler pulse findings

A

Doppler signal present, and rate.

*When we use a doppler, we are checking for perfusion into the extremities.

26
Q

What does 1 breath consist of?

A

1 inspiration and 1 expiration.

should be relaxed, regular, automatic and silent

27
Q

How long do you count respirations when they are regular? Irregular?

A

Regular: 30 seconds

Irregular: 1 full minute

27
Q

Respiratory distress is considered what type of priority?

A

1st priority

28
Q

What is the regular range for respirations?

A

12-20 breaths (fundamentals)

16-20 (assessment)

29
Q

How do you not let the patient know you’re counting respirations?

A

When palpating pulse, keep fingers on the artery and count respirations for 30 seconds (if regular)

30
Q

What situations affect respirations?

A

Narcotics (decrease)

Head injury (decrease commonly)

Heart Failure with activity intolerance ( increase)

Anesthesia (increase)

Sleep (decrease)

Anxiety (increase)

31
Q

What is pulse oximetry

A

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.

32
Q

What is the normal range for oxygen saturation (SpO2)

A

97-99%

85-92 is seen with pulmonary disease

*Anything under 85 is abnormal!

33
Q

What could affect oxygen saturation?

A

Anemia (decreased blood cells)
Lung Disease
Heart disease
Inadequate O2 given or method of delivery (check tubing, placement, etc)

34
Q

What is blood pressure?

A

Blood pushing against the vessel wall.

35
Q

Systolic pressure

A

maximum pressure felt on the artery wall during left ventricular contraction

36
Q

Diastolic pressure

A

Resting blood pressure is pressure against the vessel wall between contractions (when heart is resting)

37
Q

Which lasts longer? Diastole or systole?

A

Diastole (refilling)

38
Q

What is pulse pressure?

A

Pulse pressure is the difference between systolic and diastolic blood pressure.

systolic-diastolic

39
Q

what affects blood pressure?

A

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

40
Q

What physiologic factors control blood pressure?

A

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)

41
Q

Normal blood pressure range

A

<120/80

42
Q

Hypertension range

A

120-129/<80

lifestyle modification should be implemented

43
Q

Orthostatic hypotension

A

Drop in a systolic B/P >20mmHg

Increase in pulse >20 beats/min when changing to a standing position

44
Q

Who is at most risk for orthostatic hypotension

A

The elderly due to vascular changes with aging.

45
Q

How to assess orthostatic hypotension

A

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

46
Q

common causes of orthostatic hypotension

A

Fluid loss
Aging and related vascular changes
Bedrest (decreased amount of circulation)
Changes in blood pressure medication

47
Q

Where can blood pressure be measured?

A

Upper arm/brachial artery most common site

lower arm/radial artery

lower leg/tibial artery

Upper leg/popliteal artery

48
Q

How many mmHg above the pulse cessation point should the examiner go?

A

20-30 mmHg

49
Q

How many mmHg should the bulb be released?

A

a gradual, even 2 mmHg

50
Q

What sound does Korotkoff I signify?

A

First sound heard is the systolic number.

51
Q

What sound does Korotkoff V signify?

A

When the first sound heard becomes silent. The diastolic pressure

Nurse Assessment (6 decks)

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