Vital Signs & Assessment/Physical Exam Flashcards
general survey
- peforming SYSTEMIC EXAMINATION and recording general traits
- our first glance and IMPRESSION OF PATIENT
includes;
- skin color
- body build
- age
- gender
- dress
- hygiene
- posture/gait
- physical development
- mood/alertness
what are some things to look for in a patient’s GENERAL APPERANCE?
- what is their STATE OF HEALTH?
- how alert/conscious is the patient?
- are they in distress?
- how is their skin color?
- how do they present themselves?
- how is their facial expression?
vital signs definition
- used to DETECT CHANGES IN BODY
- determines COURSE & RESPONSE OF TREATMENT
- gives us the BASELINE INDICATOR OF THE PERSON’s HEALTH
what to prep for BEFORE VITAL SIGNS?
- know the PATIENT’S USUAL RANGE
- know their HISTORY/MEDS etc…
- use PROPER EQUIPMENT
- IT IS UR RESPONSIBILITY; don’t delegate the first set
what are our VITAL SIGNS?
- temperature
- pulse
- respiration
- blood pressure
- pain
temperature
- regulated by our HYPOTHALAMUS
- invasion of body through PATHOGENS;
- release of EXOGENOUS PYROGENS»_space; travels to the hypothalamus
- release of PYROGENIC CYTOKINES when phagocytic cells start attacking these pathogens = prostaglandin E2
- raising of BODY TEMP SET POINT
how does the BODY GENERATE HEAT/COOL DOWN?
- SHIVERING;
rapid contraction/relaxtion - VASOCONSTRICTION; decrease heat loss
- VASODILATION; sweating
expected finding of temp
Expected range – 97.2° F to 99.9° F (36.2° F to 37.7° C)
Fever considered T >100.4° F (38° C) (99° F axillary [37.2° C]
where can we take TEMP?
- Oral
- Rectal - core temp; most accurate
- Axillary
- Tympanic
pulse
- occurs during VENTRICULAR HEART CONTRACTION
- push of blood into the ARTERIAL SYSTEM
- measures our HR
where can we measure PULSE?
- CAROTID
- BRACHIAL
- RADIAL
- FEMORAL
- POPLITEAL
- DORSALIS PEDIS
- POSTERIOR TIBIAL
expected findings of pulse
Count pulsations for 30 seconds (multiply by 2).
Average adult pulse ranges between 60 and 100 beats/min
- should be REGULAR RATE; if irregular; count full min
- feel for the CONTOUR AND AMPLITUDE
tachycardia
> 100
bradycardia
<60
what is the PULSE AMPLITUDE?
0: Absent
1+: Diminished, barely palpable
2+: Expected (Normal)
3+: Full, Increased
4+: Bounding
what muscles are used during respiration?
- DIAPHRAGM
- INTERCOSTAL MUSCLES
INSPIRATION;
d - downward
external intercostal muscles
EXPIRATION;
internal intercostal muscles
expected findings in respiratory rate
- depends on age; inspecting the RISE & FALL OF THE CHEST
normal rate; 12 - 20 breaths/min - tachypnea
- bradypnea
blood pressure
the force of your blood moving through BV with VENTRICULAR CONTRACTION
systolic BP
- force exerted during VENTRICULAR CONTRACTION
- considers; cardiac output, blood volume, & artery compliance
- where BP is the HIGHEST
diastolic BP
force exerted by PERIPHERAL VASCULAR RESISTANCE during filling of heart or relaxed state
- where BP is the LOWEST
pulse pressure
difference between systolic & diastolic pressures
sounds during BP
known as KOROTKOFF SOUNDS;
first sound - systolic
disappreance of sound - diastolic
describe the BLOOD PRESSURE CATEGORIES
NORMAL; 120/80
ELEVATES; 120-129/less than 80
HIGH BP/HYPERTENSION 1; 130-139/80-89
HIGH BP/HYPERTENSION 2; 140+/90+
HYPERTENSIVE CRISIS; 180+/120+
definition of ORTHOSTATIC HYPERTENSION
- sudden DROP in both SYSTOLIC & DIASTOLIC PRESSURE
- when patient moves from lying, standing, or sitting position
- happens due to INABILITY OF BV to compensate quickly to the change
- seen if we have a drop in SBP - 20 mm Hg or pulse increase 10-20 bpm
pulse oximetry
measures the PERCENTAGE OF BLOOD HEMOGLOBIN CARRYING OXYGEN
- check the OXYGEN LEVEL/SATURATION–measure how much light absorbed
where can pulse oximetry be tested?
- toes
- fingertips
- ear
- nose
definition of PAIN
- common UNCOMFORTABLE SENSATION + EMOTIONAL EXP asso. with actual/potential tissue damage
acute pain
- short duration & has SUDDEN ONSET
- does not last longer than 6 months
- ex. injury, surgery, acute illness, burns/cuts, labor
chronic pain
- duration lasts longer - 6 months to years
- ex. joint disease, headaches, cancer, arthritis, nerve pain
neuropathic pain
long-term pain associated with damage to CNS/PNS
tips regarding PAIN ASSESSMENT
- important to check LOCATION + SYMPTOMS
- pain is SUBJECTIVE
- understand INTENSITY + CHARACTER of the pain; if related to diagnosed condition
- is the SIXTH VITAL SIGN
does everyone respond to pain the same way?
NO; everyone has their own response
- different THRESHOLD
- different TOLERANCES
- different EMOTIONS/BACKGROUNDS/EXPERIENCES with pain
what are the types of SELF-REPORT PAIN RATING SCALES?
- UNIVERSAL PAIN ASSESSMENT TOOL
- FLACC SCALE
- WONG-BAKER SCALE
- observation of PAIN BEHAVIORS
what are some common behaviors of pain?
- guarding
- facial expression of pain
- vital sign changes; greater BP + HR
- pallor, diaphoresis
- pupil dilation
- irritable
describe the FLACC SCALE
used for nonverbal patients;
FLACC; face, legs, activity, cry, consolability
ways to continue identifying the present problem of pain
- ONSET
when did the pain start? how long does it last? - QUALITY
burning, stabbing, sharp… - INTENSITY
0 - 10 - LOCATION
- ASSOCIATED SYMPTOMS
- CAUSE?
- EFFECT OF PAIN ON ADL
O.L.D.C.A.R.T.
O - onset
L - Location
D - duration
C - characteristics
A - aggravating factors
R - relieving factors
T - treatment
nociceptive pain
- pain from potentially harmful stimuli; detected by NOCICEPTORS
- ex. bruises, fractures, arthritis, burns
cutaneous pain
pain in the skin or subq
- ex. paper cuts
visceral pain
affecting abdominal cavity, thorax, cranium
ex. organ involvement; appendicitis
deep somatic pain
pain within ligaments, tendons, bones, BV, or nerves
ex. fractures, sprains/strains
radiating pain
pain perceived at the SOURCE + and extended tissues
ex. sciatica
referred pain
pain perceived in BODY AREAS away from the pain source
ex. heart attack, gallstones, colonscitis
phantom pain
percieved in NERVES - left by missing, amputated, or paralyzed body part
inflammatory pain
from activation & sensitization of NOCICEPTIVE PAIN
- from mediators released at site of tissue affected
definition of SUBJECTIVE DATA
- when patient tells you about their FEELINGS, CONCERNS, or SYMPTOMS
- telling of the PATIENT’S STORY
- colored by the character of the PERSON PROVIDING IT
definition of OBJECTIVE DATA
- data that is OBSERVABLE + MEASURABLE
- obtained from PHYSICAL EXAM, VITAL SIGNS, or LABS
- produces the complete truth
how do we put both subjective & objective data together?
- use of interviewing (subjective data) and head to toe assessments (objective data)
- together = ACCURATE CLINICAL PICTURE
what are our EXAMINATION TECHNIQUES?
- INSPECTION
- PALPATION
- AUSCULTATION
- PERCUSSION
inspection
- good lighting
- LOOKING AND OBSERVING
- only exposing what is being examined
- comparing & noting findings
palpation
- using parts of hand to TOUCH AND FEEL for characteristics
- feeling for;
- texture
- temperature
- moisture
- mobility
- size
- shape
- tenderness
- pulses
what areas of the hand can we use for different reasons in terms of PALPATION?
PALMAR SURFACE;
position, texture, crepitus, fluid
VIBRATION;
ulnar surfaces of the hand/fingers
TEMPERATURE;
dorsal surface
percussion
striking one object against another to produce VIBRATION and subsequent sound waves
- helps determining LOCATION, SIZE, SHAPE, DENSITY, or ABNORMAL MASSES
what are the PERCUSSION CLASSIFICATIONS?
- TYMPANY - loudest
- HYPERRESONANCE
- RESONANCE
- DULLNESS
- FLATNESS - quietest
what are the types of PERCUSSION?
- DIRECT/IMMEDIATE
- BLUNT
- INDIRECT/MEDIATE
IMMEDIATE PERCUSSION
striking of finger/hand directly against the body
INDIRECT/MEDIATE PERCUSSION
where finger of one hand acts as a HAMMER (PLEXOR) and another finger of another hand acts as your striking surface
BLUNT PERCUSSION
used to elicit tenderness from liver, gallbladder, or the kidneys
auscultation
- listening to sounds produced by the body
- usage of a stethoscope - to AUGMENT the sound
tips for auscultation
- quiet environment
- should be on the naked skin
- listen for the INTENSITY, PITCH, DURATION, & QUALITY
- should be carried out last (ex. abdominal examination)
- warm the stethoscope
difference between DIAPHRAGM vs. BELL
Diaphragm, high-pitched sounds; bell, low
pitched sounds
how many times does a patient need a bedside exam?
every 8 -12 hours; every time admitted/admission to new unit
what is the RN responsiblity during assessment?
- noting changes in health status
- implementing nursing diagnoses/interventions
shift bedside assessment
- nursing assessment at each shift; noting condition changes
focused assessment
detailed assessment of SPECIFIC BODY SYSTEMS; related to PRESENTED PROBLEM
before assessing patient; note the __________
- specific treatments/specific weights
- last vital signs
- medications
during confirmations, confirm ___________
- any LINES; IVs, PCAs etc…
- INTAKE & OUTPUT; catheter, NG
quick overview of BODY SYSTEMS
CARDIO;
- heart sounds, pulse, capillary refill
RESP;
- breath sounds or patterns, dyspnea, coughing
GASTRO;
- bowel sounds, tenderness, appetite, weight
URINARY;
- voiding, discharge, catheter
NEUROMUSCULAR;
- Glasgow coma scale, AVPU (alert, voice, pain, unresponsive
INTEGUMENT;
- integrity, color, temp, sweating, wounds
how should DOCUMENTATION OCCUR?
- must be CLEAR PICTURE OF PATIENT STATUS
- proper CARE PLAN REFLECTIVE OF GOALS
- given INFO reported to PROVIDER/RESPONSES
IF NOT CHARTED IT WAS NOT DONE
