General Survey, Measurement, Vital Signs (Chapter 9 and 10) Flashcards
what is a general survey
looking/inspecting at the general state of health and obvious physical characteristics of a person
dysarthria
difficulty speaking caused by brain damage, which results in an inability to control the muscles used in speech
dysphonia
difficulty in speaking due to a physical disorder of the mouth, tongue, throat, or vocal cords
aphasia
loss of ability to understand or express speech, caused by brain damage.
global aphasia
most severe form of aphasia
all languages modulates are affected
brain damage to multiple language centers
expressive aphasia
broca
may eliminate ‘and’ & ‘but’ & speak in short meaningful sentences
receptive aphasia
wernickes
able to speak well and use long sentences but what they say do not make sense
what are general survey 4 components
physical appearance
body structure
mobility
behavior
what make up physical apperence
age
sex
level of consciousness
skin color
facial features
what makes up body structure
stature
nutrition
symmetry
posture
position
body build, contour
what make up mobility
gait
range of motion
what make up behavior
facial expression
mood and affect
speech
dress
personal hygiene
what category does posture belong to
physical appearance
body structure
mobility
behavior
body structure
what category does level of consciousness belong to
physical appearance
body structure
mobility
behavior
physical appearance
what category does speech belong to
physical appearance
body structure
mobility
behavior
behavior
what category does personal hygiene belong to
physical appearance
body structure
mobility
behavior
behavior
what category does gait belong to
physical appearance
body structure
mobility
behavior
mobility
what category does nutrition belong to
physical appearance
body structure
mobility
behavior
body structure
what category does facial expression belong to
physical appearance
body structure
mobility
behavior
behavior
what is the normal temp range for adults
35.8-37.3 (96.4-99.1)
what routes are appropriate for assessing temp
oral, rectal, tympanic, axillary, temporal
is axillary one temp below or above oral
below
is rectal one temp higher or lower than oral
higher
what is normal stroke volume
70 ml
how long should apical pulse be taken
1 min
peripheral pulses should be taken for how long if normal
30 sec
peripheral pulses should be taken for how long if abnormal
1 min
when would you listen to apical pulse
when peripheral pulses are irregular or abnormal
if the site of pulse is not documented it is assumed it is taken where
radial artery
if the site of temp is not documented it is assumed it is taken where
oral
the force of pulse is graded on scale from _ to _
0-3
what number is considered normal for a pulse
+2
a pulse is weak and thready what number is it
+1
a pulse is absent what number is it
0
a pulse is bounding what number is it
+3
what is contained when reporting a pulse
BMP, scale, regular/irregular
normal adult pulse rate
60-100 bmp
what is considered bradycardia
<50 bmp
what is considered tachycardia
> 95-100 bmp
would a long distance runner have a high or low heart rate
low
1 breath consists of
- 1 insipiration
- 1 exhalation
- 1 inspiration and 1 exhalation
1 inspiration and 1 exhalation
how long do you count respiratory rate if normal
30 seconds
how long do you count respiratory rate if abnormal
1 min
do you or do you not let the patient know you are counting respirations
do not
what is the normal adult respiratory rate
10-20/min
pulse ox is used to measure what
saturation of oxygen
what is the normal range for pulse ox
97-99%
what situations could be affecting oxygen saturation
anemia, lung disease, heart disease
systolic
blood pushing against the vessel wall
maximum pressure felt on artery during left ventricular contraction
diastolic
resting blood pressure is pressure against the vessel wall between contractions
when heart is resting
what phase lasts longer
diastolic or systolic
diastole
how do you find pulse pressure
difference between systolic and diastolic blood pressure
adult normal BP
<120/80
hypertension BP
120-129/<80
what is orthostatic hypotension
drop in blood pressure when standing up
what numbers classify orthostatic hypotension
systolic drop in >20
diastolic drop in >10
if the blood pressure drops in orthostatic pressure what will happen to the pulse/heart rate
increase in pulse >20bmp when changing to standing position
what is the correct order to take blood pressure with a patient you suspect has orthostatic hypotension
lying
sitting
standing
what are common causes of orthostatic changes BP
fluid loss
aging and related vascular changes
bedrest
changes blood pressure medication
is orthostatic hypotension temporary or permanent
can be either
why would we take blood pressure in leg
bilateral mastectomy
lymphdema
fistula
blood clot
amputation
what is considered an abnormal difference in limbs for blood pressure
30-40
what are common errors with blood pressure assessment
arm placement
patient holds arm up
legs are crossed
examiner eyes not level with manometer or meniscus
incorrect cuff size
failure to palpate for level of inflation
deflate too fast or too slow
stopping during descent and then reinflating
failure to wait 1-2 mins between reading
what is the first korotkoff sound
systolic number
first clear audible tapping sound
korotkoff V sound
diastolic number
silence
last audible is heard before silence
