Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

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

General survey, measurement, vital signs Flashcards

You may prefer our related Brainscape-certified flashcards:
NCLEX-RN® flashcards NCLEX-PN® 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?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Dysarthria

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Dysphonia

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Aphasia

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are the 4 components of the general survey?

A
  1. Physical appearance
  2. Body structure
  3. mobility
  4. Behavior
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What do we assess for physical appearance

A

age
sex
LOC
skin color
facial features

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

what do we assess for body structure

A

Stature
nutrition
symmetry
posture
position
body build, contour

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

what do we assess for mobility

A

Gait and ROM

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What do we assess for behavior

A

Facial expression
mood and affect
speech
dress
person hygiene

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is the normal temperature range?

A

35.8-37.5 C

96.4-99.1 F

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

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

A

30 minutes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What is pulse?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What is stroke volume?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What is the normal stroke volume in adults?

A

70 mL

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Apical pulse should always be

A

taken for 1 minute.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Normal pulse rate

A

60-100/beats per minute

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions