vital signs & physical assessment Flashcards
when seeing a pt, what is the quick suggested sequencing for a physical exam?
- general survey = how well they’re groomed, their general appearance
-appearance and mental status = what do I see smell, hear, ect - vital signs
- weight & height
how much is 1 kg in lbs?
- 2.2 lbs
how much is 1 inch in cm
1 in = 2.54 cm
why is height and weight important?
- establishes a baseline
- assist in determining health status
how often are vitals taken?
- THIS VARRIES but often:
- on admission
- Q shift, q 4 hours, q 1 hour (ICU)
- Q day = long term care
- before & after procedure
- during blood transfusions (if reacting to it, they’ll have a fever)
- during major procedures
- Before, during, & after drug administration
- with any change in condition
- when client reports feeling “funny”
what is blood pressure
- force of blood against arterial walls = BP
- 2 step procedure
- sites:
- upper arm = brachial artery
- thigh = popliteal artery
what is # constitutes as hypotension?
- low BP
- less then 90 systolic
- less than 60 diastolic
what # means elevated BP
- systolic = 120 - 129
- diastolic = 80
what is stage 1 hypertension?
- systolic = 130 - 139
- diastolic = 80 - 89
what is stage 2 hypertension?
- greater then or = to 140 systolic
- grater than or equal to 90 diastolic
what is orthostatic hypotension?
- drop in BP when changing from sitting, standing, or lying
- requires 20 mm Hg drop in systolic BP or 10 mm Hg drop in diastolic BP within 1 min of the change for an official diagnosis
- symptoms = dizziness or fainting
what’s a newborn normal pulse rate
- 110 - 160 less then 28 days old
what’s a normal infant heart rate?
- 90 to 160
whats a toddler normal HR?
- 80 to 140
whats a normal preschooler HR
- 70 to 120
whats the normal school aged HR
- 60 to 110
what the normal HR for adolescent (12 to 20)
- 50 to 100
whats the normal adult HR?
- 60 to 100
what are all spots a nurse can get a pulse?
- temporal (side of head)
- carotid
- apical or PMI (under left nipple)
- brachial
- radial
- femoral
- popliteal (back of knee)
when documenting a pulse what should the nurse document?
nurses should document…
- rate = tachycardia / bradycardia
- rhythm = regular / irregular
- volume = 0 through 4+
- equality on both sides
what does a 0 pulse volume rate mean?
- 0 = absent pulse = unable to palpate
what is 1+ pulse volume mean?
- 1+ means diminished (weaker than expected, hard to palpate
what does pulse volume of 2+ mean?
- normal ! able to palpate with normal pressure
what does a volume pulse of 3+ mean?
- increased / strong pulse
