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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
Q

pulse oximetry

A

measures the PERCENTAGE OF BLOOD HEMOGLOBIN CARRYING OXYGEN
- check the OXYGEN LEVEL/SATURATION–measure how much light absorbed

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26
Q

where can pulse oximetry be tested?

A
  • toes
  • fingertips
  • ear
  • nose
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27
Q

definition of PAIN

A
  • common UNCOMFORTABLE SENSATION + EMOTIONAL EXP asso. with actual/potential tissue damage
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28
Q

acute pain

A
  • short duration & has SUDDEN ONSET
  • does not last longer than 6 months
  • ex. injury, surgery, acute illness, burns/cuts, labor
29
Q

chronic pain

A
  • duration lasts longer - 6 months to years
  • ex. joint disease, headaches, cancer, arthritis, nerve pain
30
Q

neuropathic pain

A

long-term pain associated with damage to CNS/PNS

31
Q

tips regarding PAIN ASSESSMENT

A
  • 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
Q

does everyone respond to pain the same way?

A

NO; everyone has their own response

  • different THRESHOLD
  • different TOLERANCES
  • different EMOTIONS/BACKGROUNDS/EXPERIENCES with pain
33
Q

what are the types of SELF-REPORT PAIN RATING SCALES?

A
  • UNIVERSAL PAIN ASSESSMENT TOOL
  • FLACC SCALE
  • WONG-BAKER SCALE
  • observation of PAIN BEHAVIORS
34
Q

what are some common behaviors of pain?

A
  • guarding
  • facial expression of pain
  • vital sign changes; greater BP + HR
  • pallor, diaphoresis
  • pupil dilation
  • irritable
35
Q

describe the FLACC SCALE

A

used for nonverbal patients;
FLACC; face, legs, activity, cry, consolability

36
Q

ways to continue identifying the present problem of pain

A
  • 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
Q

O.L.D.C.A.R.T.

A

O - onset
L - Location
D - duration
C - characteristics
A - aggravating factors
R - relieving factors
T - treatment

38
Q

nociceptive pain

A
  • pain from potentially harmful stimuli; detected by NOCICEPTORS
  • ex. bruises, fractures, arthritis, burns
39
Q

cutaneous pain

A

pain in the skin or subq
- ex. paper cuts

40
Q

visceral pain

A

affecting abdominal cavity, thorax, cranium
ex. organ involvement; appendicitis

41
Q

deep somatic pain

A

pain within ligaments, tendons, bones, BV, or nerves
ex. fractures, sprains/strains

42
Q

radiating pain

A

pain perceived at the SOURCE + and extended tissues
ex. sciatica

43
Q

referred pain

A

pain perceived in BODY AREAS away from the pain source
ex. heart attack, gallstones, colonscitis

44
Q

phantom pain

A

percieved in NERVES - left by missing, amputated, or paralyzed body part

45
Q

inflammatory pain

A

from activation & sensitization of NOCICEPTIVE PAIN
- from mediators released at site of tissue affected

46
Q

definition of SUBJECTIVE DATA

A
  • 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
Q

definition of OBJECTIVE DATA

A
  • data that is OBSERVABLE + MEASURABLE
  • obtained from PHYSICAL EXAM, VITAL SIGNS, or LABS
  • produces the complete truth
48
Q

how do we put both subjective & objective data together?

A
  • use of interviewing (subjective data) and head to toe assessments (objective data)
  • together = ACCURATE CLINICAL PICTURE
49
Q

what are our EXAMINATION TECHNIQUES?

A
  • INSPECTION
  • PALPATION
  • AUSCULTATION
  • PERCUSSION
50
Q

inspection

A
  • good lighting
  • LOOKING AND OBSERVING
  • only exposing what is being examined
  • comparing & noting findings
51
Q

palpation

A
  • using parts of hand to TOUCH AND FEEL for characteristics
  • feeling for;
  • texture
  • temperature
  • moisture
  • mobility
  • size
  • shape
  • tenderness
  • pulses
52
Q

what areas of the hand can we use for different reasons in terms of PALPATION?

A

PALMAR SURFACE;
position, texture, crepitus, fluid

VIBRATION;
ulnar surfaces of the hand/fingers

TEMPERATURE;
dorsal surface

53
Q

percussion

A

striking one object against another to produce VIBRATION and subsequent sound waves

  • helps determining LOCATION, SIZE, SHAPE, DENSITY, or ABNORMAL MASSES
54
Q

what are the PERCUSSION CLASSIFICATIONS?

A
  • TYMPANY - loudest
  • HYPERRESONANCE
  • RESONANCE
  • DULLNESS
  • FLATNESS - quietest
55
Q

what are the types of PERCUSSION?

A
  • DIRECT/IMMEDIATE
  • BLUNT
  • INDIRECT/MEDIATE
56
Q

IMMEDIATE PERCUSSION

A

striking of finger/hand directly against the body

57
Q

INDIRECT/MEDIATE PERCUSSION

A

where finger of one hand acts as a HAMMER (PLEXOR) and another finger of another hand acts as your striking surface

58
Q

BLUNT PERCUSSION

A

used to elicit tenderness from liver, gallbladder, or the kidneys

59
Q

auscultation

A
  • listening to sounds produced by the body
  • usage of a stethoscope - to AUGMENT the sound
60
Q

tips for auscultation

A
  • 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
Q

difference between DIAPHRAGM vs. BELL

A

Diaphragm, high-pitched sounds; bell, low
pitched sounds

62
Q

how many times does a patient need a bedside exam?

A

every 8 -12 hours; every time admitted/admission to new unit

63
Q

what is the RN responsiblity during assessment?

A
  • noting changes in health status
  • implementing nursing diagnoses/interventions
64
Q

shift bedside assessment

A
  • nursing assessment at each shift; noting condition changes
65
Q

focused assessment

A

detailed assessment of SPECIFIC BODY SYSTEMS; related to PRESENTED PROBLEM

66
Q

before assessing patient; note the __________

A
  • specific treatments/specific weights
  • last vital signs
  • medications
67
Q

during confirmations, confirm ___________

A
  • any LINES; IVs, PCAs etc…
  • INTAKE & OUTPUT; catheter, NG
68
Q

quick overview of BODY SYSTEMS

A

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
Q

how should DOCUMENTATION OCCUR?

A
  • 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 (11 decks)

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