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What are the 5 key measurements of the general survey?
- TPR (temperature, pulse, respirations)
What are some of the aspects of a client's physical appearance that you should account for?
- Sexual characteristics
- Facial features/symmetry
- Signs of distress
- personal hygiene
Important things to recognize in general body structure
- Stature - proper height to weight ratio
- Nutrition - well nourished, overweight, obese, thin, cachexia
- Symmetry - atrophy, hypertrophy, edema
- Posture - erect, slumped
- Build and contour - lean, muscular
Two categories related to mobility:
What do we compare clinical measurements to?
- Normal ranges - BP, rate and rhythm, BMI - these are also relative to: age, gender, lifestyle, etc.
- Client's recent values or serial readings
- Diagnosis - weight, atrophy, and other characteristics may be affected by disease or illness
What is one reason for performing serial weights?
Heart failure patients
What time would you perform serial weight measurements?
At the same time each day; normal weight changes approx. 2-3lbs per day
What are some of the reasons for weight gain?
- Overeating or inactivity
- Fluid volume excess
- Hypothyroidism (decreases metabolism)
- Drug therapy (corticosteroids)
1 Liter of fluid increase will result in how many pounds?
2.2lbs = 1 Liter of fluid volume
A client has a weight increase of 6 lbs in the last 2 weeks. What may be a cause?
- Heart failure/decompensation
- A weight gain of 2-3 lbs per week is significant
What are some reasons for weight loss?
- Anorexia or decreased intake
- Increased metabolic rate
- Diabetes (new onset or poor control)
What are the 4 major vital signs?
- TPR - temperature, pulse, respiration
- BP - blood pressure
Pain is considered the 5th
What part of the brain regulates temperature?
What factors affect body temperature?
- Diurnal cycle (1-1.5' F change with peak at 4pm and trough at 4am)
- Menstrual cycle (1' F increase due to progesterone secretion)
- Exercise (moderate to heavy)
- Age (children's temperatures may run high, older adults are more at risk)
What is the normal oral temperature?
- Oral: 98.6' F (96.4-99.1) or 37' C (35.8-37.3)
- Rectal: +1' F or 0.5' C
- Tympanic: +1' F or 0.5' C
- Axillary: -1' F or 0.5' C
At what age would you obtain oral temperature in children?
5-6 years old
What is the definition of fever?
Temperature > 101' F or 38' C
How long does smoking affect oral temperature?
Hot or cold fluids?
- Wait 2 minutes after smoking and
- wait 15 minutes after hot/cold fluids before taking temperature orally.
What route would you use with a BLUE tipped thermometer?
- BLUE tips are for ORAL temps
- RED are for AXILLARY/RECTAL
How long do you time the pulse rate of a regular rhythym?
An irregular rhythym?
- 30 seconds for a regular rate
- 1 minute for an irregular rate/rhythym
Your client's pulse rate increases with inspiration and decreases with expiration. What could this signify?
Sinus arrythmia (common in children and young adults)
Where would you palpate the pulse on a child younger than 2 years old?
What is the normal heart rate in adults?
- Normal: 60-100 beats per minute
- Brady: <60 bpm
- Tachy: >100 bpm
What factors can increase pulse rate?
- Age (higher in children)
- Fever (higher fever, higher rate)
- Anemia (decreased RBC/dehydration, increased rate)
What is a pulse deficit?
The difference between the apical and radial pulse rate
Your patient has a radial pulse rate higher than the radial rate. What could this signify?
Sign of Heart Disease
How is pulse strength measured?
- 4+ Bounding (at rest sign of Heart Disease)
- 3+ Full (normal with exercise)
- 2+ Normal
- 1+ Weak, thready
- 0 Absent
How long do you count respirations with a normal rhythym?
How long with an abnormal bretahing pattern?
- Normal: count for 30 seconds
- Abnormal: count for 1 minute
What is the normal respiratory rate in adults?
- Normal: 10-20 breaths per minute
- Brady: <10 breaths pm
- Tachy: >20 breaths pm
What are the 5 things to assess in examining repirations?
- Character (thoracic in women, abdominal in men and children)
- Abnormal patterns (hyperventilation, hypoventilation, apnea, dyspnea)
Force exerted on vessel walls during cardiac cycle
Force exerted on Arterial walls during Systole
Resting pressure during diastole
Difference between the systolic and diastolic pressures
Mean arterial pressure
- Average amount of pressure forcing blood into the tissues throughout the cardiac cycle
- Measured: MAP = Diastolic BP + 1/3 Pulse Pressure
Your client has a resting BP of 110/75
What is the pulse pressure?
What is the MAP (mean arterial pressure)
- Pulse pressure = 110-75 = 35
- MAP = 75 + 1/3(35) = 87
WHat factors determine BP?
- Cardiac output
- Blood viscosity (thickness increased by: polycythemia, altitude, chronic lung disease)
- PVR (Peripheral Vascular Resistance) - constricted vessels
- Sympathetic nervous system stimulation - SNS causes vasoconstriction
- Elasticity of vessels (arteriosclerosis)
What is a normal BP?
<120 systolic / <80 diastolic
What blood pressure range would be considered pre hypertensive?
- Pre-hypertensive: Systolic: 120-139 Diastolic: 80-89
- Hypertensive*: Systolic >139 Diastolic >89
*BP checked in both arms. Must be documented 2 times for diagnosis.
Is HTN a nursing or medical diagnosis?
Medical (the nurse would document elevated BP)
What is the goal BP of diabetics?
<130 / 80
What factors increasee blood pressure?
- Gender (men, females post menopause)
- Race (african americans)
- Diurnal rhythym (higehr late afternoon, lower am)
- Emotions, stress, pain (stimulated SNS)
- Smoking (wait 30 minutes before checking BP)
- Meds (NSAIDS, pseudophedrine, ibuprofen)
- "White coat syndrome" - stress caused by medical setting
What level should the client's arm be at when taking BP?
Relaxed, at heart level
What is the 1st Korotkoff sound during BP?
- 1st - systole (clear tapping heard by the opening of the artery and blood flowing in)
- 5th - diastole (silence)
How would you find the proper size blood pressure cuff for a client?
- Bladder length = 80% of the arm circumference
- Bladder width = 40% of the arm circumference
*The bladder is only the inflatable portion of the cuff, not the entire length.
How high do you inflate the blood pressure cuff before realsing the air?
20-30 mm beyond the point of brachial pulse obliteration
How long do you wait between taking BP measurements in teh same arm?
Your client has a higher BP in the right arm than the left, which measurement do you use?
Always use the higher of the two measurements
If you did not pump the cuff up high enough, how would this affect your reading?
this would give you a falsely low BP
If the BP cuff is too small, how would this affect your reading?
- Too small - false high
- Too large - false low
Errors when taking BP
- Cuff size
- Arm position
- Cuff too loose
- Deflated too quickly
- Not inflated enough
- 15 seconds not waited between measurements
- A difference in the systolic BP while during inspiration v. expiration
- A normal difference is 5mm
- A paradoxical pulse is >10 mm
You find your client has a 15 mm diiference in Systolic BP during inspiration v. expiration. What could this signify?
- This is a paradoxical pulse
- Often indicative of a serious condition (cardiac tamponade, constrictive pericarditis, emphysema)
- A significant drop in BP when position is changed
- Drop in SBP > 20 mm or increase in pulse rate > 20 bpm when position is changed
What could be a cause of orthostatic hypotension?
orthostatic hypotension is caused by: peripheral vasodilation without a compensatory increase in CO2
- May be found with: Hypovolemia (dehydration)
- Medications (vasodilators)
Your client reports dizziness when standing. What would you assess for?