genreal assessment and vital signs Flashcards
What areas are involved in the physical assessment?
head, eyes, ears, nose, throat, neck, CV, lungs, abdomen, extremities, neuro, psych, skin
Underweight BMI
less than 18.5
Normal weight BMI
18.5-24.9
Overweight BMI
25-29.9
Class 1 obesity BMI
30-34.9
Class 2 obesity BMI
35-39.9
Class 3 obesity BMI
greater than 40
BMI inaccuracies
does not consider muscle mass or body fat percentage
was created over 200 years ago for white race
nothing currently studied to replace BMI clinically
Edema
fluid leaking into tissues or swelling
Causes of edema
heart, kidney, or liver function
medication
inflammation
injury
diet
blood clot/obstruction
pregnancy
Edema grades
1: mild pitting, slight indentation, no visible swelling
2: moderate pitting, indentation subsides quickly, no visible swelling
3: deep pitting, indentation may last up to a minute, visible swelling
4: very deep pitting, indentation lasts 2-5 minutes, significant swelling
Normal body temperature
96.8-99 F
36-37.2 C
Where is body temperature most commonly taken?
rectal (most accurate)
temporal (accurate)
tympanic (accurate)
oral (0.5-1 F lower than rectal)
axillary (1-2 F lower than rectal)
When should you refer for a fever?
temp greater than 104
temp greater than 100.4 plus nonresponsive to medication and lasts longer than 3 days
greater than 100.4 and symptomatic
Normal adult and child (6-12) pulse and respiratory rate
adult:
60-100
12-20
child:
80-120
12-20
How to check pulse rate
using the pads of your first and second fingers, place your fingers on the wrist medial to the radial bone
press down until you can feel the pulse
count the number of beats you feel in 30 seconds and multiply by 2
When should you refer for pulse?
greater than 100 BPM while resting AND chest pain or discomfort, SOB, weakness, dizziness, or fainting
less than 40 BPM while awake AND chest pain or discomfort, SOB, dizziness, fainting, or confusion
How to check respiratory rate
continue to pretend to take pulse
watch patient’s chest and abdomen for respirations
count the number of respirations in 30 seconds and multiply by 2
When should you refer for respiratory rate?
greater than 25 RPM AND low BP or change in consciousness
greater than 25 RPM AND difficulty breathing, coughing, wheezing, and increased mucous
less than 12 RPM AND goes limp, change in consciousness, or turns blue
Systolic BP
maximum pressure on the arteries during contraction of the left ventricle (regulated by stroke volume)
Diastolic BP
resting pressure between ventricle contractions
Systolic/Diastolic BP
most reported
well established CV disease risk factors
MAP
[SBP + (2xDBP)] /3
1/3SBP +2/3DBP
Auscultatory technique
manual/traditional method
brachial artery occluded to stop blood flow
stethoscope to detect appearance and disappearance of Korotkoff sounds
error prone
Oscillometric technique
automatic cuff
read based on amplitude of oscillations recorded in the lateral walls of the upper arm
software on device
What is the proper position the patient should be in when taking BP?
seated
arm supported at heart level
back supported
uncrossed legs
feet flat on the floor
How should the BP cuff be placed on the patient’s arm?
bare skin and not over clothing (rolling up sleeves could create a tourniquet effect)
bottom of cuff should be 1/2 inch above the elbow
once cuff is in place it should be snug and finger should easily fit at the top and bottom
How should you place the stethoscope when taking BP?
stethoscope should be placed over brachial artery at antecubital space
make sure the cuff is aligned so that the artery marker points to the brachial artery
What are the 5 phases of Korotkoff sounds?
phase 1: faint and clear tapping (systolic)
phase 2: swooshing sound
phase 3: more intense, crisp tapping
phase 4: muffled sound
phase 5: sound stops (diastolic)
What patient factors can alter BP?
medications
drugs of abuse
caffeine consumption
nicotine consumption
exercise in the past 30 minutes
time of day
pain/stress
talking during measurement
full bladder
Steps to taking a manual BP
- insert the earpieces of the stethoscope (pointing forward) into your ears
- place the bell of the stethoscope over the palpable brachial brachial artery lightly (with an air-tight seal)
- inflate the cuff rapidly to the maximum inflation level (180 in a normal patient, 220 in hypertensive patients)
- release the air slowly (2-3 mmHg/sec)
- note the pressure when the first sound is heard (systolic pressure)
- note the pressure when the last sound is hears (diastolic)
- continue listening until 20 mmHg below last sound
Normal adult BP
less than 120 and less than 80
Elevated adult BP
120-129 and less than 80
Stage 1 hypertension BP
130-139 or 80-89
Stage 2 hypertension BP
140 or higher or 90 or higherh
Hypertensive crisis BP
higher than 180 and/or higher than 120
Hypertensive urgency
SBP > 180 mmHg
and/or DBP > 120 mmHg
Hypertensive emergency
SBP > 180 mmHg
and/or DBP > 120
AND target organ damage
When should you refer for BP?
SBP > 180 mmHg
and/or DBP > 120
AND target organ damage (chest pain, SOB, numbness or weakness, vision changes, difficulty speaking, severe headache)
Lifestyle changes that can impact BP
weight loss
DASH dietary plan
reduced dietary sodium
increased dietary potassium
physical activity
moderation in alcohol
tobacco cessation
