Health Assessment mid-term: general survey and vital signs

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jam110007
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Health Assessment mid-term: general survey and vital signs
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2013-03-05 22:42:18
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Health Assessment mid term general survey vital signs
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Health Assessment mid-term: general survey and vital signs
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  1. what is a general survey
    • a study of the whole person, covering the general health state and any obvious physical characteristics 
    • - the overall impression
  2. general survey assess what physical presence?
    • - stated age vs. apparent age
    • - general appearance
    • - body fat
    • - stature
    • - motor activity 
    • - body and breath odors
  3. body shape types?
    • - mesomorphic
    • - endomorphic
    • - ectomorphic
  4. mesomorphic
    - average height, well developed musculature
  5. endomorphic
    • - short and stocky
    • - apple shaped, pear shape
  6. ectomorphic
    tall, willowy, fat distribution is not well developed, musculature is poorly developed
  7. general survey assess what psychological presence?
    - dress, grooming, personal hygiene (appropriate clothes for weather? are they clean?)

    - mood and manner (inappropriate may indicate psychiatric problems)

    - speech (slurred speech ma indicated intoxication or neurological problem)

    - facial expressions (are they awake and alert? are they responsive?)
  8. general survey assessing for distress
    • - labored breathing, wheezing, cough, labored speech 
    • - painful facial expressions, sweating, guarding
    • - serious or life-threatening complications
    • - emotional distress or anxiety
  9. the vital signs we look for include....
    • T - temperature 
    • P - pulse
    • R - respiration 
    • B/P - Blood Pressure
    • pulse oximetry 
    • pain assessment
  10. vital signs: how do you assess respiration? what is a normal range/finding?
    • count for 30 secs or a full minute if you suspect abnormalities
    • - normal range = 12-20 per minute
  11. Eupnea
    normal effortless breathing
  12. tachypnea
    fast breathing, has a rate of more than 20 per minute
  13. bradypnea
    slow breathing, rate below 10 per minute
  14. apnea
    not breathing
  15. dyspnea
    labored respiration, shortness of breath
  16. orthopnea
    positional difficulty breathing
  17. what are normal findings for infants and adults in respiration rate?
    infant: 30-40/min

    adult: 10-20/min
  18. vital signs: how do you assess pulse
    • using the pads of the first three fingers palpate the radial oulse
    • - regular rhythm: count for 30 sec x 2
    • - irregular: count for full minute
  19. how do you assess pulse volume
    • by checking if its absent or bounding by using a 4-point scale for measuring 
    • - 0 = absent
    • - +1 = weak
    • - +2 = normal 
    • - +3 = strong/ increased
    • - +4 = bounding
  20. how is pulse volume distributed across the body?
    pulse volume should be the same throughout the body
  21. what are some factors that affect heart rate?
    • - age
    • - gender
    • - activity 
    • - emotional status
    • - pain 
    • - environmental factors
    • - stimulants
    • - medications
  22. what are the normal heart rate findings for infants and adults?
    infant: 100- 170 BPM

    adult: 60 - 100 BPM
  23. where is the radial pulse located? how do you find it?
    • - located on the wrist 
    • - you can find it by following the thumb down to the wrist, with light palpation
  24. where is the apical pulse located? what equipment should you use? how should you hear?
    • - located in the 5th intercostal space in the midclavicular line (for men its around the nipples; female under the breast)
    • - use the diaphragm of the stethascope
    • - should hear S1 (Lub) and S2 (Dub)
  25. tachycardia
    fast pulse rate over 100 BPM
  26. bradycardia
    slow pulse rate, less then 60 BPM
  27. asystole
    absence of heart beat
  28. dysrhythmia
    irregular pulse rhythm
  29. how do you calculate pulse deficit? what should it equal?
    apical pulse rate - peripheral (radial) pulse rate = 0
  30. if pulse deficit does not equal zero, what may it indicate?
    • it may indicate cardiac dysrthymias 
    • - extra systolic contraction without enough volume to reach peripheral
  31. how do you convert F to C and vise versa
    Celsius: 5/9 x (temp in F - 32 degrees)

    Fahrenheit: (9/5 x temp in C) + 32 degrees
  32. routes for measuring temperature?
    • - oral 
    • - rectal 
    • - axillary 
    • - tympanic 
    • - temporal
  33. temperature: oral route advantages and disadvantages
    advantage: convenient, accessible

    disadvantage: safety, physical ability, accuracy
  34. temperature: average oral route findings and range
    average findings: 37.0 C or 98.6 F

    normal range: 36-38° C or 96.8-100.4° F
  35. temperature: average rectal route findings and range
    average: 0.7°C or 0.4°F (higher than oral)

    range: 36.7-38.5°C or 98.0-101.6°F
  36. temperature: rectal route advantage and disadvantage?
    advantage: most accurate 

    disadvantage: safety, invasive, uncomfortable
  37. differences between a rectal and oral thermometer?
    rectal - has a rounded, bulb end and is colored red 

    oral - straighter than rectal and it identified by the color blue
  38. temperature: average axillary route findings and range
    average: 0.6°C or 1°F (lower than oral)

    range: 35.4-37.4°C or 95.8-99.4°F
  39. temperature: axillary route advantages and disadvantages
    advantage: safe, noninvasive

    disadvantage: accuracy? length of time to obtain measurements
  40. temperature: average tympanic route findings and range
    average: calibrated to oral or rectal scales 

    range: same as oral and rectal scales
  41. temperature: tympanic route advantage and disadvantage
    advantage: convenient, fast, safe

    disadvantage: accuracy? technique affects reading
  42. tympanic thermometer
    • - infra red sensor
    • - points towards tympanic membrane
  43. temperature: temporal artery thermometer
    • - as accurate as rectal and pulmonary artery temps
    • - more accurate than tympanic
  44. what are some variables that affect body temperature?
    • - circadian rhythms 
    • - hormones
    • - age
    • - exercise
    • - stress
  45. hypothermia
    • low temperature
    • - 92.3°F, 34°C
  46. hyperthermia
    • high temperature 
    • - 101.5°F, 38.5°C
  47. A febrile
    no temperature whatsoever
  48. what is blood pressure
    the force exerted by the flow of blood pumped into the large arteries
  49. korotkoff sounds: phase I
    first time you hear a sound coming through. it indicates highest systolic pressure; the top number
  50. korotkoff sounds: phase II
    change in quality of sound
  51. korotkoff sounds: phase III
    intense tapping sound
  52. korotkoff sounds: phase IV
    sound muffles
  53. korotoff sounds: phase V
    sound disappears - the diastolic pressure; the bottom number
  54. blood pressure: is there is a difference of 10 between phase 4 and 5 what will clinicians do?
    they will put phase I over phase IV, over phase V
  55. what are the factors that determine blood pressure
    • - cardiac output
    • - peripheral vascular response
    • - volume of circulating blood
    • - viscosity of the blood
    • - elasticity of blood vessel walls
  56. with what can you measure blood pressure with?
    • by using 
    • - Sphygmomanometer
    • - Aneroid manometer
    • - Mercury manometer
  57. how do you get pulse pressure?
    its the difference between systolic and diastolic pressure
  58. sites where you can measure blood pressure?
    • - brachial 
    • - thigh
    • - avoid AV shunts or fistulas, affects arms of post-mastectomy patient
  59. measuring blood pressure: documentation
    • document
    • - position of patient
    • - location where taken
  60. blood pressure normal findings?
    < 120/180
  61. prehypertension
    120-140/80-90
  62. hypertension
    >140/90
  63. what is the average pulse pressure?
    40
  64. common errors in blood pressure measurments?
    • - incorrect cuff size
    • - unrecognizable auscultatory gap
    • - incorrect cuff placement
  65. factors that influence B/P
    • - age
    • - sex (men slightly higher then females)
    • - race (African American slightly higher)
    • - diurnal rhythm (goes down at night during rest and up during the day)
    • - weight
    • - emotion/stress
  66. normal B/P for infant and adult
    infant: 90/61

    adult: 120/80
  67. why do elderly have higher B/P
    due the the hardening of the arterial system - systolic pressure may be higher
  68. pulse oximetry
    measurement of the oxygen saturation of the hemoglobin molecule
  69. whats a normal pulse oximetry finding?
    >95%
  70. what is the 5th vital sign?
    pain
  71. what are we assessing for pain
    - subjective feelings and an individual response
  72. pulse deficit is the difference between what?
    apical and radial
  73. hypoxemia
    an inadequate level of oxygen in the blood

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