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NURS 210 > Vital Signs & Assessment/Physical Exam > Flashcards

Vital Signs & Assessment/Physical Exam Flashcards

1
Q

general survey

A
  • 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

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2
Q

what are some things to look for in a patient’s GENERAL APPERANCE?

A
  • 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?
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3
Q

vital signs definition

A
  • used to DETECT CHANGES IN BODY
  • determines COURSE & RESPONSE OF TREATMENT
  • gives us the BASELINE INDICATOR OF THE PERSON’s HEALTH
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4
Q

what to prep for BEFORE VITAL SIGNS?

A
  • know the PATIENT’S USUAL RANGE
  • know their HISTORY/MEDS etc…
  • use PROPER EQUIPMENT
  • IT IS UR RESPONSIBILITY; don’t delegate the first set
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5
Q

what are our VITAL SIGNS?

A
  • temperature
  • pulse
  • respiration
  • blood pressure
  • pain
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6
Q

temperature

A
  • regulated by our HYPOTHALAMUS
  • invasion of body through PATHOGENS;
    • release of EXOGENOUS PYROGENS&raquo_space; travels to the hypothalamus
    • release of PYROGENIC CYTOKINES when phagocytic cells start attacking these pathogens = prostaglandin E2
  • raising of BODY TEMP SET POINT
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7
Q

how does the BODY GENERATE HEAT/COOL DOWN?

A
  • SHIVERING;
    rapid contraction/relaxtion
  • VASOCONSTRICTION; decrease heat loss
  • VASODILATION; sweating
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8
Q

expected finding of temp

A

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]

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9
Q

where can we take TEMP?

A
  • Oral
  • Rectal - core temp; most accurate
  • Axillary
  • Tympanic
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10
Q

pulse

A
  • occurs during VENTRICULAR HEART CONTRACTION
  • push of blood into the ARTERIAL SYSTEM
  • measures our HR
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11
Q

where can we measure PULSE?

A
  • CAROTID
  • BRACHIAL
  • RADIAL
  • FEMORAL
  • POPLITEAL
  • DORSALIS PEDIS
  • POSTERIOR TIBIAL
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12
Q

expected findings of pulse

A

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
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13
Q

tachycardia

A

> 100

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14
Q

bradycardia

A

<60

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15
Q

what is the PULSE AMPLITUDE?

A

0: Absent
 1+: Diminished, barely palpable
 2+: Expected (Normal)
 3+: Full, Increased
 4+: Bounding

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16
Q

what muscles are used during respiration?

A
  • DIAPHRAGM
  • INTERCOSTAL MUSCLES

INSPIRATION;
d - downward
external intercostal muscles

EXPIRATION;
internal intercostal muscles

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17
Q

expected findings in respiratory rate

A
  • depends on age; inspecting the RISE & FALL OF THE CHEST
    normal rate; 12 - 20 breaths/min
  • tachypnea
  • bradypnea
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18
Q

blood pressure

A

the force of your blood moving through BV with VENTRICULAR CONTRACTION

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19
Q

systolic BP

A
  • force exerted during VENTRICULAR CONTRACTION
  • considers; cardiac output, blood volume, & artery compliance
  • where BP is the HIGHEST
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20
Q

diastolic BP

A

force exerted by PERIPHERAL VASCULAR RESISTANCE during filling of heart or relaxed state
- where BP is the LOWEST

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21
Q

pulse pressure

A

difference between systolic & diastolic pressures

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22
Q

sounds during BP

A

known as KOROTKOFF SOUNDS;

first sound - systolic
disappreance of sound - diastolic

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23
Q

describe the BLOOD PRESSURE CATEGORIES

A

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+

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24
Q

definition of ORTHOSTATIC HYPERTENSION

A
  • 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
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25
pulse oximetry
measures the PERCENTAGE OF BLOOD HEMOGLOBIN CARRYING OXYGEN - check the OXYGEN LEVEL/SATURATION--measure how much light absorbed
26
where can pulse oximetry be tested?
- toes - fingertips - ear - nose
27
definition of PAIN
- common UNCOMFORTABLE SENSATION + EMOTIONAL EXP asso. with actual/potential tissue damage
28
acute pain
- short duration & has SUDDEN ONSET - does not last longer than 6 months - ex. injury, surgery, acute illness, burns/cuts, labor
29
chronic pain
- duration lasts longer - 6 months to years - ex. joint disease, headaches, cancer, arthritis, nerve pain
30
neuropathic pain
long-term pain associated with damage to CNS/PNS
31
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
32
does everyone respond to pain the same way?
NO; everyone has their own response - different THRESHOLD - different TOLERANCES - different EMOTIONS/BACKGROUNDS/EXPERIENCES with pain
33
what are the types of SELF-REPORT PAIN RATING SCALES?
- UNIVERSAL PAIN ASSESSMENT TOOL - FLACC SCALE - WONG-BAKER SCALE - observation of PAIN BEHAVIORS
34
what are some common behaviors of pain?
- guarding - facial expression of pain - vital sign changes; greater BP + HR - pallor, diaphoresis - pupil dilation - irritable
35
describe the FLACC SCALE
used for nonverbal patients; FLACC; face, legs, activity, cry, consolability
36
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
37
O.L.D.C.A.R.T.
O - onset L - Location D - duration C - characteristics A - aggravating factors R - relieving factors T - treatment
38
nociceptive pain
- pain from potentially harmful stimuli; detected by NOCICEPTORS - ex. bruises, fractures, arthritis, burns
39
cutaneous pain
pain in the skin or subq - ex. paper cuts
40
visceral pain
affecting abdominal cavity, thorax, cranium ex. organ involvement; appendicitis
41
deep somatic pain
pain within ligaments, tendons, bones, BV, or nerves ex. fractures, sprains/strains
42
radiating pain
pain perceived at the SOURCE + and extended tissues ex. sciatica
43
referred pain
pain perceived in BODY AREAS away from the pain source ex. heart attack, gallstones, colonscitis
44
phantom pain
percieved in NERVES - left by missing, amputated, or paralyzed body part
45
inflammatory pain
from activation & sensitization of NOCICEPTIVE PAIN - from mediators released at site of tissue affected
46
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
47
definition of OBJECTIVE DATA
- data that is OBSERVABLE + MEASURABLE - obtained from PHYSICAL EXAM, VITAL SIGNS, or LABS - produces the complete truth
48
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
49
what are our EXAMINATION TECHNIQUES?
- INSPECTION - PALPATION - AUSCULTATION - PERCUSSION
50
inspection
- good lighting - LOOKING AND OBSERVING - only exposing what is being examined - comparing & noting findings
51
palpation
- using parts of hand to TOUCH AND FEEL for characteristics - feeling for; - texture - temperature - moisture - mobility - size - shape - tenderness - pulses
52
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
53
percussion
striking one object against another to produce VIBRATION and subsequent sound waves - helps determining LOCATION, SIZE, SHAPE, DENSITY, or ABNORMAL MASSES
54
what are the PERCUSSION CLASSIFICATIONS?
- TYMPANY - loudest - HYPERRESONANCE - RESONANCE - DULLNESS - FLATNESS - quietest
55
what are the types of PERCUSSION?
- DIRECT/IMMEDIATE - BLUNT - INDIRECT/MEDIATE
56
IMMEDIATE PERCUSSION
striking of finger/hand directly against the body
57
INDIRECT/MEDIATE PERCUSSION
where finger of one hand acts as a HAMMER (PLEXOR) and another finger of another hand acts as your striking surface
58
BLUNT PERCUSSION
used to elicit tenderness from liver, gallbladder, or the kidneys
59
auscultation
- listening to sounds produced by the body - usage of a stethoscope - to AUGMENT the sound
60
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
61
difference between DIAPHRAGM vs. BELL
Diaphragm, high-pitched sounds; bell, low pitched sounds
62
how many times does a patient need a bedside exam?
every 8 -12 hours; every time admitted/admission to new unit
63
what is the RN responsiblity during assessment?
- noting changes in health status - implementing nursing diagnoses/interventions
64
shift bedside assessment
- nursing assessment at each shift; noting condition changes
65
focused assessment
detailed assessment of SPECIFIC BODY SYSTEMS; related to PRESENTED PROBLEM
66
before assessing patient; note the __________
- specific treatments/specific weights - last vital signs - medications
67
during confirmations, confirm ___________
- any LINES; IVs, PCAs etc... - INTAKE & OUTPUT; catheter, NG
68
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
69
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

NURS 210 (15 decks)

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