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Nursing 202 > Unit 4 ~ Assessment Techniques and Vital Signs > Flashcards

Unit 4 ~ Assessment Techniques and Vital Signs Flashcards

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1
Q

What is the general survey?

A

Appraise whole person. The 4 area are physical appearance, body structures, mobility, and behaviour.

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2
Q

What are the extra comments that pertain to physical appearance, body structure, mobility, and behaviour?

A

PA- do they look their age, level of consciousness (alert, responding), face features (symmetry), and skin colour.
BS- proportions, deformities, sitting (relaxed or tense), posture, and nutrition.
M- what is their walk like, range of motion, and gait.
B- facial expression, mood, speech, physical hygiene, and dress.

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3
Q

What is BMI?

A

Body mass index. Calculated by divided weight in kg by height in meters squared. Is flawed.

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4
Q

What is the waist/hip ratio?

A

Assesses the risk for obesity. Divide waist circumference by hip circumference.

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5
Q

What is ranges of TBRBP and SpO2 for normal adults?

A

T= 36-38
P= 60-100 beats/min
R= 10-20 breaths/min
BP= 120-130/80-85, both less than
SpO2= 95-100%

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6
Q

What are the vital signs?

A

Temperature, pulse, respiratory rate, and blood pressure.

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7
Q

How do we take temperature and what are the guidelines?

A

Can talk it oral, rectal, axilla, and tympanic. Rectal is most accurate but we use oral the most. Wait 2 min if smoked, 5 min if patient had gum, and 20 min if they ate something hot/cold.

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8
Q

What is hyperthermia, hypothermia, and prexia?

A

Increased temperature, decreased temperature, and fever.

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9
Q

How do we take pulse, what is it, what is it influenced by, and what are some guidelines for it?

A

Pulse is palpable bounding blood flow (stroke volume). Influenced by meds, exercise, age, temperature, emotions, body positions, and hypovolumia. Wait 5-10 minutes after activity. Count 30 sec and times by 2 for regular rhythm. If nit, count for full minute.

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10
Q

What do we access for pulse?

A

Rate, rythymn, force/strength (full/bounding= 3+, normal= 2+, and weak/threads= 1+, and absent= 0).

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11
Q

What is tachycardia and bradycardia?

A

Rapid pulse (more than 100) and slow pulse (less than 60).

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12
Q

True or false: Altheltes have lower pulses?

A

True

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13
Q

What are respirations influenced by?

A

Exercise, pain, smoking, temperature, body position, meds, brain injury, sleep, hemoglobin function, and anxiety.

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14
Q

How do we measure respirations?

A

Chest rise (inspiration) and fall (expiration) is 1 respiration. Counts 30 seconds times 2. Don’t tell patient you’re assessing their respiration rate.

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15
Q

What do we assess for with respirations?

A

Respiratory rate, pattern/rythym, depth (deep, normal, or shallow), and O2 saturation (% of hemoglobin bound with oxygen).

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16
Q

What is systolic and diastolic pressure?

A

S- ventricular contraction, top number
D- resting, filling heart, lower number

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17
Q

What is blood pressure influenced by?

A

Age, weight, emotions, gender, exercise, stress, meds, diurnal rhythm, and ethnocultural background.

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18
Q

What are some physiological factors of blood pressure?

A

Cardiac output, volume of circulation blood (more there is= higher BP), viscosity of blood, peripheral vascular resistance, and elasticity of vessel walls.

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19
Q

When should patient wait before taking BP?

A

30 minutes for exercise, 60 min for caffeine/smoked, and just wait 5 min in general.

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20
Q

What are the types of Korotkoffs sounds?

A

1- systolic pressure (clear taps)
4- muffling of sounds
5- diastolic pressure (silence)

21
Q

How do we take BP?

A

Palpate for brachial artery, plus cuff 2.5 cm above artery (cuff shouldn’t cover whole arm), palpate artery and inflate cuff until pulse disappears then 30 mmHg higher. Then using stethoscope, inflate to that number and slowly deflate at 2 mmHg and not when sound starts (systolic) and stops (diastolic).

22
Q

What is hypotension, hypertension, and postural hypotension?

A

Decreased BP/lowers than 90 mmHg, increased BP, and blood rushes to feet when standing so they pass out.

23
Q

What are some developmental considerations for general survey and vital signs?

A

Infant/children: have bigger heads, parental bonding, vital signs you need co-operativness of child.
Older adults: change to body shape, loss of height, higher BP because of stiffened arteries.

24
Q

What does IPPA stand for?

A

Inspection, palpation, percussion, and auscultation (use stethoscope).

25
Q

What is inspection?

A

Concentrated watching, general then local, uses visual/auditory/olfactory sense, and detects physical signs.

26
Q

What is palpation?

A

Use sense of touch (can only be light). Asses for texture, temperature, moisture, lumps, vibrations, rigidity, tenderness and pain. We can use our fingertips, fingers, back of hands, ball of hands, and palms. Back of hand determines temperature. Fingertips determine texture, swell, lumps, and pulsation. Palm surface best for vibration.

27
Q

What is percussion?

A

Produce vibrations which determine location, size, and density of structures. Always percussion twice. Resonant- hollow. Hperesonant- louder. Tympany- drum like. Dull- thud. Flat- shorter/flat sound. There’s also a striking and stationary hand.

28
Q

What is a stethoscope/parts?

A

Diaphragm- larger end, high pitch sounds, useful for normal heart sounds
Bell- smaller end, low pitch sounds, useful for murmurs.

29
Q

What is auscultation?

A

Listen to sounds produced by parts of the body.

30
Q

What is a noiceptor?

A

Nerve endings that detect painful sensations from periphery and transmit to CNS.

31
Q

What is nociception and the 4 phases?

A

Describes how noxious stimuli are perceived as pain.
1. Transduction- injured tissue release chemicals that propagate pain message, action potential moves along to spinal cord
2. Transmission- pain impulse moves from spinal cord to brain
3. Perception- perception of pain
4. Modulation- neurons form brain release neurotransmitters that block pain impulse

32
Q

What is nociceptive pain, somatic pain, visceral pain, referred pain, and neuropathic pain.

A

NoP- caused by tissue injury, normal response, ache/throb
SP- superficial, deep, bone, muscle, joint, and tendon pain
VP- from larger interior organs
RP- originates in 1 location and experienced at another
NeP- burn, shooting pain, abnormal response

33
Q

what is acute and chronic pain?

A

Acute- short, goes away after injury is healed
Chronic- recurring, lasts longer than 3 months like cancer pain

34
Q

What is the brief pain inventory?

A

Patient rates pain on a scale from 0-10. Pain is subjective.

35
Q

What is the behaviour of people suffering with acute and chronic pain, and behaviour of babies suffering with pain?

A

Acute- patient can’t verbalize
Chronic- adapts over time, can give little indication
Infants- pain depends on behaviour and physiological cues

36
Q

What type of body part do we use to measure temperature for smaller kids and babies?

A

Rectal

37
Q

What is carotid commissioner?

A

Compression of both carotid arteries at the same time which causes blood flow to the brain.

38
Q

What is the doppler technique?

A

Pitch will increase when distance is short and vice versa. it enhances pulse and BP measurement. Locates peripheral pulse sites.

39
Q

What is a core and surface temperature?

A

Core temp of structures is deep within the body (rectum). Surface temp is skin/mouth, it fluctuates.

40
Q

What does the hypothalamus do?

A

It’s our bodies thermostat. It controls body temperature.

41
Q

Why does prexia occur?

A

Heat loss mechanisms unable to keep pace with excess heat production.

42
Q

What are some different pulse sites?

A

Apical (left midclavicular line), carotid (neck), brachial, radial (radial side of wrist), and temporal (head).

43
Q

What does dysrythmia mean?

A

Abnormal rythym.

44
Q

What are some symptoms for high and low BP?

A

High= headache, nosebleed, fatigue
Low= dizzy, pale, restless

45
Q

Can you cross your legs when measuring BP?

A

no

46
Q

What is procedural pain?

A

Associated with medical procedures, usually acute.

47
Q

What does the assessment strategy OPQRSTUV for pain stand for?

A

Onset, provoking/palliating, quality, region/radiation, severity, timing/treatment, understanding/impact on you, and values.

48
Q

What pain scale is used for kids?

A

Faces pain scales.

Nursing 202 (5 decks)

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