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General Assessment and Vitals PPT

Terms in this set (53)

What is included in the general survey?
health promotion and counseling
general appearance
height and weight
What is included in the health history and what is included in the health promotion and counseling?
health history - common and concerning symptoms
health promotion and counseling - weight, nutrition, exercise
What are the common and concerning symptoms?
fatigue and weakness
fever, chills, night sweats
weight change
pain
Define fatigue
common symptoms of anxiety and depression
Define weakness
neuropathy and myopathy
What are the types of weight change?
change in body tissue
change in body fluid
rapid or long term weight gain
When addressing someone who is experiencing weight gain, ask?
when did the weight gain occur? what are the associated factors?
What is the most common presenting symptom?
pain
How do we assess pain?
scaling
When assessing pain what will you assess?
location
severity
associated features
attempted treatments/medications
related illnesses
impact on daily activities
List the different types of pain
nociceptive/somatic - related to tissue damage
neuropathic - direct trauma to the peripheral or central nervous system
What relates to factors that influence the patien'ts report of pain?
psychogenic -
psychiatric conditions
personality/coping style
cultural norms
social support systems
Health promotion and counseling includes what 4 components?
optimal weight
exercise
blood pressure and dietary sodium
What are the 4 steps to promoting optimal weight and nutrition?
measure the BMI
assess the dietary intake
assess patients motivation to change
provide counseling about nutrition and exercise
Excess salt can cause?
hypertension
Measure the height in?
stocking feet
What are the 4 types of builds?
slender and lanky
muscular
strocky
When assessing height, check for body _ and note general body _.
symmetry and note for general body proportions and any deformities
What are 4 describing words for weight?
obese
plump
emaciated
slender
What is an underweight BMI?
less than 18.5
What is a normal BMI?
18.5-24.9
What is an overweight BMI?
25-29.9
What is an obese stage 1 BMI?
30-34.9
What is an obese stage 2 BMI?
35-39.9
Extreme obesity BMI?
equal to or greater than 40
When assessing changes in weight, assess if the weight gain is _ vs _ and if the weight loss is _ vs _
nutrition vs medical causes
pyschosocial causes vs medical causes
What is a sense of weariness or loss of energy?
fatigue
What is a demonstratable loss of muscle power?
weakness
Fatigue and weakness: _ vs _ causes
medical vs psychosocial
If a patient presents with fever, chills, and night sweats, what do you ask them? Also consider?
ask about exposure to illness or any recent travel; also consider that some medications increase temperature
Blood pressure optimal conditions:
what do you avoid?
avoid caffiene and smoking 30 minutes prior; ensure room is quite and comfortably warm; patient should be seated quitely in chair with feet on the floor for at least 5 minutes; arm should be free of clothing
When recording BP, position the arm so that the brachial artery is at the _ level.
heart
Rest the arm on a table _ their waist, or support the patient's arm with your own at his?
above; mid-chest level
You want the BP cuff to be a width _% of upper arm _.
40% of upper arm circumference
You want the BP cuff to be a length _% of upper arm _.
80% of upper arm circumference
You want the lower border to be _ cm above the antecubital crease.
2.5
When doing BP, make sure the patients arm is slightly?
flexed at the elbow
After palpating the radial artery, how long do you wait to take the BP?
wait 15-30 seconds
What is the silence between the systolic pressure and the diastolic pressure?
ausculatory gap
Normally when recording orthostatic BP, the systolic BP will _ or _; diastolic BP will _.
drop slightly or remain unchanged
rise slightly
Orthostasis is when the systolic BP drops _ mmHg or the diastolic BP drops _ mmHg.
drops more than 20
drops more than 10
Normal systolic BP
less than 120
Normal diastolic BP
less than 80
If BP is elevated, what do you do?
repeat BP and verify in the contralateral arm; consider white coat hypertension; try to relax the pt and record later in the visit
White coat hypertension occurs in what percentage of all patients?
10-20%
What pulse is commonly used to measure the heart rate?
radial pulse
Average oral temperature
37 C or 98.6 F
Diurnal variation:
35.8-37.3 C or 96.4-99.1 F
Rectal temperature is what relative to the oral temperature?
0.5 C or 1 F greater than oral
Axillary temperature is what relative to the oral temperature?
0.5C or 1 F less than oral
Tympanic temperature is what relative to the oral temperature?
0.8C or 1.4F greater than oral
Ask if the pt has a BP arm preference; ask about?
mastectomy or pick line or fistula
When observing for RR:
rhythm: regular or irregular
depth: shallow or gasping
effort: normal or labored
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