Physical Assessment: General Survey Flashcards
Weight: Changes
2.2 lbs = 1 kgShoes offNote changes: may be due to fluid retention, muscle, or fat gain/loss.
Weight: Calculation
2.2 lbs = 1 kg
Weight: BMI, calculation and significant ranges
Weight (kg) / Height (m)^2Above 25: assess nutrition, screen-excess body fat or muscle toneBelow 18.5: Concern, suspect-Anorexia, Bulimia, malnutrition
Height: Observations and screening
Short / tallSlender / lankyMuscular / stockyGeneral body proportionsDeformities
Temperature: 4 types
OralRectal: coreAxillaryTympanic: core
Temperature: Normal Limits (F and C)
97-99 F, 36.1-37.7 C
Blood Pressure: 2 parts
Systolic (ventricles contractDiastolic (ventricles at rest)
Blood pressure: Not Static, varies with
positionCircadian rhythmStressNutritional statusdrugsDisease
Pulse Pressure
Systolic-DiastolicNormal is 30-40
Widened Pulse Pressure Disease States (8)AAA - ABE - PT
Aortic CoarctationAortic RegurgitationAtreiovenus FistulaAnemiaBeriberi HeartEmotional StatePatent Ductus ArteriosusThryrotoxicosis
Narrow Pulse Disease States
Ascites (fluid in abdomen)Pericardial Effusion (fluid around heart)Constrictive Pericarditis (thick shell around heart)Severe Aortic Stenosis (AV narrowed)Tachycardia
JNC - 7: Normotensive, Pre-hypertension, Stage 1 hypertension, Stage 2 Hypertension
Normal: < 120 / < 80Pre: 120 - 139 / 80 - 89S1: 140 - 159 / 90 - 99S2: > 160 / > 100
HTN Risk: Diseases
Coronary heart diseaseStrokeCHFEnd-stage renal diseasePVD
HTN: Complications (in General Systems)
CNSOpthalmologicCardiacVascularRenal
Korotkoff Sounds
Phase 1: THUDPhase 2: Sound of turbulent flowPhase 3: Softer thudPhase 4: Softer blowing sound that disappearsPhase 5: Silence
Capillary Refill
Press down on nail bed and release. White spot should disappear in under 3 seconds
Pulse: Location (6)
carotidradialbrachialfemoralposterior tibialdorsalis pedis
Pulse: Normal limits AdultNewborn1yr3yr6yr10yr
Adult:60-100Newborn: 120-1701yr: 80-1603yr: 80-1206yr: 75-11510yr: 70-110
Pressure: SphygmomanometerFalse HighFalse Low
High: Cuff too short or narrow-Anxiety, arm too low, muscle contraction, smokingLow: Cuff too wide or long-Arm too high, bell pressed too firmly/touching cuff, failure to recognize an auscultatory gap.
Pulse Abnormalities: Small Weak
Hypovolemia, aortic stenosis, cold, CHF
Pulse Abnormalities: Large Bounding (6)
Fever, anemia, hyperthyroidism,Patent Ductus Arteriosus (PDA), heart block, atherosclerosis
Pulse Abnormalities: Pulsus Alternans
Varies in amplitude, beat to beatLV failure, S3
Pulse Abnormalities: Paradoxical Pulse
Decreases with inspirationPericardial tamponade (acute type of pericardial effusion) Obstructive Lung disease, constrictive pericarditis.
Breathing Rhythm: Patterns (7)
Bradypnea: under 12; coma, meds, deep sleepTachypnea: above 20; anxiety, heart/lung disease, FEVERHyperpnea: over 20 and deep, exercise, metabolicSighing: normal/anxietyCheyne-Stokes: dysrhythmic breathing due to CNS, drugsKussmal: Rapid deep, DKA, metabolic acidosisStridor: Harsh, high pitched inspiration
Normal Breathing RatesAdultNewborn1 yr3 yr6 yr
Adult: 12-20Newborn: 30-801 yr: 20-403 yr: 20-306 yr: 16-22
Cachexia
Decreased fat and muscle mass
Pallor
Pale/White appearance: Due to anemia, hypoxiaAlso, Normal coloring
Jaundice
Yellow coloration found in the palms, sclera, oral mucosaDue to Liver DiseaseNormal in newborn
Systole
The pressure exerted against the arteries during ventricular contraction
Diastole
The resting pressure when the ventricles are at rest
Auscultatory gap
Silent interval present b/t the systolic and diastolic pressures
Cyanosis
blue color of oral mucosa and nail beds. Associated with anemia and/or hypoxia
Hyperpyrexia
Fever, > 38 C, 100.5 F
Hypothermia
Low Temp < 35 C, 95 F (core)
