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NU 309: Vital Signs and General Survey

Terms in this set (64)

True; true; false; false; true
1.Vital signs reflect patient health status, cardiopulmonary function, and overall function of the body.

2. The general survey includes overall appearance, hygiene and dress, skin color, body structure and development, behavior, facial expression, level of consciousness, speech, mobility, posture, range of motion, and gait.

3. Normal pulse rates remain the same across the lifespan.

4.The peripheral pulse is decreased, but the tissue below will have adequate circulation.

5.Height decreases as a person ages because the vertebral discs thin.
Anthropometric; pulse; 10-15; doppler; saturation
1.___________________ measurements include height and weight.

2.The _______ is assessed for rate, rhythm, amplitude, and elasticity.

3.The nurse measures the blood pressure in both arms, if not contraindicated, and should report a difference of ___________ or more between the two arms because this may be a sign of arterial obstruction.

4.The ____________ is used if the pulse and BP are difficult to auscultate or palpate.

5.An oxygen ______________ level less than 85% indicates inadequate oxygenation to the tissues.
Vitals
we check ______:
-To evaluate response to treatment-did their blood pressure med work.
-To establish a baseline-assess and get vitals immediately when you take over a client's care.
-Monitor risks for alterations in health-for example, if BP is elevated, they could be at risk for stroke.
Vital signs
-temperature, pulse, respirations, and blood pressure
-important indicators of the patient's physiological status and response to the environment
Preparation
-Wash hands
-Clean stethoscope
-Have all necessary equipment (objective data collection)
-Remove coat and/or constricting clothing
-May be sitting or supine; rest quietly for 5 minutes
-Establish when patient last ate or drank or smoked
First
-client's physical assessment begins with the _____ moment of encounter with the client
-Assessment continues throughout the health history, during the physical exam, and with each subsequent interaction
General survey
-begins upon first meeting the patient and is ongoing
-observe patients, develop initial impressions, and formulate plans for collecting objective data from the physical examination
Overall appearance
-Obvious deformities?
-Chronological age?
-Face & body symmetrical?
-Look healthy?
-normal: The client appears stated age. Facial features, movements, and body are symmetrical.
-abnormal: Client looks younger or older than stated age. Facial features, movements, and body are asymmetrical.
Hygiene and dress
-Observe clothing, hair, nails, skin.
-Clothing appropriate for weather or gender?
-Does it fit?
-Odor of urine or alcohol?
-Skin clean?
-normal: Dress is appropriate for age, gender, culture, and weather. Client is clean and well kempt. No odors are noted.
-abnormal: Poorly fitting clothes, bad breath, body odor, not well-groomed, eccentric makeup or dress, worn out clothes.
Skin color
-Erythema, pallor, jaundice, cyanosis, lesions.
-Skin tones.
-Texture, quality, distribution of hair.
-normal: Color is even toned, with pigmentation appropriate for genetic background and no obvious lesions or variations in color. Hair is smooth, thick, and evenly distributed.
-abnormal: erythema, pallor, jaundice, and lesions
Body structure and development
-Physical & sexual development consistent with stated age?
-Obese/lean?
-Body parts symmetrical?
-Joint abnormalities?
-normal: Physical and sexual development is appropriate for age, culture, and gender. No joint abnormalities noted.
-abnormal: delayed puberty, markedly short or tall stature, disproportionate height and weight, obesity, emaciation, and barrel chest
Behavior
-Cooperative?
-Flat or animated?
-Appear anxious?
-normal: The client is cooperative and interacts pleasantly.
-abnormal: uncooperative behavior, flat affect, and unusual elation
Facial expression
-Symmetrical face.
-Expression during speech & rest.
-Maintain eye contact appropriate for culture.
-normal: Facial expression is relaxed, symmetrical, and appropriate for the setting and circumstances. The client maintains eye contact appropriate for age and culture.
-abnormal: inappropriate affect, inattentiveness, impaired memory, inability to perform activities of daily living, flat or masklike expression, drooping of one side of the face, and protruding eyes
Level of consciousness
-Continually assess mental status throughout all encounters.
-Can client state name, location, date, month, season, time of day?
-Awake, alert, oriented to person, place & time?
-Confused? Agitated? Lethargic? Inattentive?
-normal: The client is awake, alert, and oriented to person, place, and time (A&OX3). Client responds to questions appropriately.
-abnormal: confusion, agitation, drowsiness, or lethargy
Speech
-Speaking rapidly/slowly?
-Clear/articulate?
-Use words appropriately?
-Fluency in language-need an interpreter?
-normal: The client responds to questions quickly and easily. Volume, pitch, and rate are appropriate to the situation. Speech is clear and articulate, flowing smoothly. Word choice is appropriate.
-abnormal: slow, slurred, rapid, loud, and difficulty finding words or using words inappropriately
Mobility
-Note how client sits/stands, are they sitting upright?
-When standing-straight?
-normal: Posture is upright while sitting, with the limbs and trunk proportional to the body height. The client stands erect with no signs of discomfort and the arms are relaxed at the sides.
-abnormal: slumped or hunched posture, long limbs, tripod position, and note position of the head of the bed or if the pt. is lying on the left or right side
Range of motion
-Move all limbs?
-Limitations?
-normal: The client moves freely in the environment.
-abnormal: asymmetrical or limited
Gait
-Ambulatory?
-Are movements coordinated?
-Tremors, involuntary movements, use assistive devices?
-normal: Gait is steady and balanced, with even heel-to-toe foot placement and smooth movements. Other movements are also smooth, purposeful, effortless, and symmetrical.
-abnormal: uncontrolled movements, shuffling, slow, unsteady, note pt. ability to move, reposition, turn side to side, or sit up in bed
Anthropometric measurements
-Scientific measurements of the body obtained for nutritional analysis.
-Specific body measurements such as height, weight, muscle composition, skinfold thickness and measurement of body fat.
-abnormal: decreased height, excessive growth, not able to stand; unexplained weight loss or excessive weight gain and being overweight
Kyphosis
an exaggerated posterior curvature of the thoracic spine associated with aging
Underweight; overweight; obese; extreme obesity
BMI <18.5 is ___________
BMI 25-29.9 is __________
BMI >30 is _____
BMI >40 is _______ ______
Frequency
_________ of vital signs/nurse should take patient's vital signs:
-upon admission to facility
-before and after any surgical procedure
-before, during, and after administration of medications that affect vital signs
-per the institution's policy or physician orders
-any time the patient's condition changes
-before and after any procedure affecting vital signs
-immediately prior to discharging a patient
Flow
vitals are typically on a ____ sheet either on paper or electronically
Temperature
-___________ (98.6) fluctuations:
Diurnal cycle
Exercise
Women of childbearing age
-Electronic thermometers:
Fast, safe, convenient (2-60 seconds) oral (blue tip) rectal (red tip)
-Non invasive routes:
Oral, Axillary, Tympanic membrane, Temporal artery
-Invasive route:
Rectal
-Use dorsal surface of hand to assess client's skin temp
-oral and rectal routes aren't for everyone
Hypothermia
temperature less than 95 degrees from prolonged exposure to cold
Hyperthermia
-AKA pyrexia or fever
-body temperature exceeding 101.5 degrees orally from infections or tissue breakdowns
-fever above 103.1 in adults requires immediate assessment and rapid cooling measures
(F-32)X5/9
Celsius equation
(CX9/5)+32
Fahrenheit equation
Pulse
-Rate: normal range (60-100 bpm) varies with age
-Rhythm: interval between beats
Regular-occurs at regular spaced intervals
Irregular-has a varied interval between beats
-Elasticity: normal artery feels smooth, straight and resilient.
-Strength: ranges from 0 to 4+
-use pads of index and middle finger to palpate
-Contraction of the heart causes blood to flow forward, which creates a pressure wave, or _____.
Tachycardia
more than 100 beats per minute
Bradycardia
less than 60 beats per minute
Asystole
absence of pulse
Temporal, carotid, apical, brachial, radial, ulnar, femoral, popliteal, dorasalis pedis, posterior tibial
pulse sites (10)
120; 55
sudden changes in pulse rates or pulse rates greater than ___ bpm or less than __ bpm may indicate life-threatening emergencies requiring immediate attention
Heart rate
the number of pulsing sensations in one minute
Apical; one
if heart rate is irregular then count the ______ pulse for ___ minute(s)
Carotid
don't check both _______ pulses at once
Carotid; femoral
in an emergency, check the ______ or _______ pulse
Respirations
-Rate: (12-20 breaths/min)
-don't make pt. aware that you are assessing this
-rate is a count of each full inspiration and expiration cycle in 1 minute (count for 30 sec and multiply by 2)
-if abnormal, count for full minute
-could be abnormal from exercise, anxiety/pain, smoking, positioning, medications, neurological injury, or hemoglobin levles
Tachypnea
more than 20 breaths a minute
Bradypnea
less than 12 breaths a minute
Dyspnea
difficulty breathing
Hyperapnea
resting respirations deeper and more rapid than normal
Apnea
absence of spontaneous respirations for more than 10 seconds
Eupnea
normal respiration rate
Hyperventilation
deep, rapid respirations
Hypoventilation
shallow, slow respirations
Oxygen saturation
-Percentage to which hemoglobin is filled with oxygen (92% to 100%)
-<92% get a second opinion
-<85% inadequate tissue oxygenation (emergency)
-SpO2 of 85%-89% may be acceptable for patients with certain chronic conditions such as emphysema
Pulse oximetry
-noninvasive technique to measure oxygen saturation of arterial blood
-place on finger
Blood pressure
-120/80
-factors that contribute to it:
Cardiac output
Peripheral vascular resistance
Circulating blood volume
Viscosity
Elasticity of the vessel walls
-recorded as fraction: SBP/DBP
-variations: age, gender, ethnicity, weight, circadian cycle, position, exercise, emotions, stress, meds, and smoking
-use sphygmomanometer
-measure with arm at heart level
-uncross legs
-place cuff 1 inch above brachial artery
Bell
designed to pick up low-pitched sounds
Low; high
using too large of a blood pressure cuff will result in falsely ___ readings while using too small of a blood pressure cuff will result in falsely ___ readings
Auscultatory gap
-period in which there are no kortokoff sounds during auscultation
-estimating SBP will prevent missing this
Millimeters of mercury
___________ of _______ (mmHg) is standard unit for measuring blood pressure
Systolic
-top number
-maximum pressure exerted on arterial wall at peak of left ventricular contraction
-normal range: 100-120 mm HG
Diastolic
-bottom number
-minimum pressure exerted on arterial wall during left ventricular relaxation
-normal range: 60-80 mm Hg
Hypertension
high blood pressure diagnosed on an average of two or more readings taken on subsequent visits
Hypotension
low blood pressure with SBP less than 90
90; 30; 200/120
-any sudden change in BP may be an emergency
-SBP less than __, or __ mmHg below the pts baseline, needs immediate attention
-sudden drop in BP can signify blood loss or a cardiovascular, respiratory, neurological, or metabolic disorder
-sudden, severe rise in BP (above ___/___ mmHg) is a life-threatening hypertensive crisis
Doppler
-Used when pulse and BP are difficult to auscultate or palpate
-Senses and amplifies changes in sound frequency (swooshing)
-Apply gel, turn on, adjust volume, touch probe lightly to skin at expected pulse site, move until located, wipe off gel, mark location, attempt palpate pulse at this location
Reduction; promotion
risk _________ and health _________:
Disease prevention
Smoking cessation
Diet/exercise
Limit sodium/alcohol consumption
Medication
-every interaction with a client is a teaching opportunity
Infants and children
-Physical exam can be scary! Probes in ears/mouth, tight BP cuff, cold stethoscope, etc.
-Allow parent of young child to remain during assessment.
-Helpful to allow child to touch the equipment.
Adolescents
-prefer not to have parents present
Older adults
-Do not rush them. Allow time for them to respond & ask questions.
-Don't assume they have a deficit
-pp. 105-106 Technique and normal/abnormal findings for older adults.
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