Health Assessment mid-term: general survey and vital signs
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. What would you like to do?
what is a general survey
- a study of the whole person, covering the general health state and any obvious physical characteristics
- - the overall impression
general survey assess what physical presence?
- - stated age vs. apparent age
- - general appearance
- - body fat
- - stature
- - motor activity
- - body and breath odors
body shape types?
- - mesomorphic
- - endomorphic
- - ectomorphic
- average height, well developed musculature
- - short and stocky
- - apple shaped, pear shape
tall, willowy, fat distribution is not well developed, musculature is poorly developed
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?)
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
the vital signs we look for include....
- T - temperature
- P - pulse
- R - respiration
- B/P - Blood Pressure
- pulse oximetry
- pain assessment
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
normal effortless breathing
fast breathing, has a rate of more than 20 per minute
slow breathing, rate below 10 per minute
labored respiration, shortness of breath
positional difficulty breathing
what are normal findings for infants and adults in respiration rate?
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
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
how is pulse volume distributed across the body?
pulse volume should be the same throughout the body
what are some factors that affect heart rate?
- - age
- - gender
- - activity
- - emotional status
- - pain
- - environmental factors
- - stimulants
- - medications
what are the normal heart rate findings for infants and adults?
infant: 100- 170 BPM
adult: 60 - 100 BPM
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
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)
fast pulse rate over 100 BPM
slow pulse rate, less then 60 BPM
absence of heart beat
irregular pulse rhythm
how do you calculate pulse deficit? what should it equal?
apical pulse rate - peripheral (radial) pulse rate = 0
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
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
routes for measuring temperature?
- - oral
- - rectal
- - axillary
- - tympanic
- - temporal
temperature: oral route advantages and disadvantages
advantage: convenient, accessible
disadvantage: safety, physical ability, accuracy
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
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
temperature: rectal route advantage and disadvantage?
advantage: most accurate
disadvantage: safety, invasive, uncomfortable
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
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
temperature: axillary route advantages and disadvantages
advantage: safe, noninvasive
disadvantage: accuracy? length of time to obtain measurements
temperature: average tympanic route findings and range
average: calibrated to oral or rectal scales
range: same as oral and rectal scales
temperature: tympanic route advantage and disadvantage
advantage: convenient, fast, safe
disadvantage: accuracy? technique affects reading
- - infra red sensor
- - points towards tympanic membrane
temperature: temporal artery thermometer
- - as accurate as rectal and pulmonary artery temps
- - more accurate than tympanic
what are some variables that affect body temperature?
- - circadian rhythms
- - hormones
- - age
- - exercise
- - stress
- low temperature
- - 92.3°F, 34°C
- high temperature
- - 101.5°F, 38.5°C
no temperature whatsoever
what is blood pressure
the force exerted by the flow of blood pumped into the large arteries
korotkoff sounds: phase I
first time you hear a sound coming through. it indicates highest systolic pressure; the top number
korotkoff sounds: phase II
change in quality of sound
korotkoff sounds: phase III
intense tapping sound
korotkoff sounds: phase IV
korotoff sounds: phase V
sound disappears - the diastolic pressure; the bottom number
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
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
with what can you measure blood pressure with?
- by using
- - Sphygmomanometer
- - Aneroid manometer
- - Mercury manometer
how do you get pulse pressure?
its the difference between systolic and diastolic pressure
sites where you can measure blood pressure?
- - brachial
- - thigh
- - avoid AV shunts or fistulas, affects arms of post-mastectomy patient
measuring blood pressure: documentation
- - position of patient
- - location where taken
blood pressure normal findings?
what is the average pulse pressure?
common errors in blood pressure measurments?
- - incorrect cuff size
- - unrecognizable auscultatory gap
- - incorrect cuff placement
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
normal B/P for infant and adult
why do elderly have higher B/P
due the the hardening of the arterial system - systolic pressure may be higher
measurement of the oxygen saturation of the hemoglobin molecule
whats a normal pulse oximetry finding?
what is the 5th vital sign?
what are we assessing for pain
- subjective feelings and an individual response
pulse deficit is the difference between what?
apical and radial
an inadequate level of oxygen in the blood
What would you like to do?
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