Nursing 202

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Author:
stephanie831
ID:
41008
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Nursing 202
Updated:
2010-10-10 02:50:11
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Nursing General Survey Vital Signs
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Description:
General Survey, Measurement and Vital Signs
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  1. What are eight considerations for the general survey?
    • 1) Measure height, weight, BP and TPR
    • 2) Provides an exam gown; ask pt if he/she needs assistance, otherwise repect pt privacy
    • 3) Wash hands before having contact with the pt
    • 4) Explain each step
    • 5) Give encouragement as you proceed
    • 6) Organize the exam for optimal efficiency and patient comfort
    • 7) Use a systematic approach so as not to forget anything
    • 8) Give a summary of findings and give an opportunity for questions
  2. What are the components for general survey?
    • 1) Physical Appearance
    • - age
    • - sex
    • - skin
    • - facial features
    • - signs of acute distress
    • - personal hygiene

    • 2) Body Structure
    • - stature
    • - nutrition
    • - symmetry
    • - posture
    • - position
    • - body build and contour
    • - physical deformities

    • 3) Mobility
    • - gait
    • - ROM

    4) Metal Status and Behavior
  3. Clinical Measurements analyzed in relation to:
    • 1) normal ranges (e.g. B/P, P, R)
    • 2) client's recent values and serial reading (e.g. daily weights for fluid monitoring in heart failure)
    • 3) diagnosis (e.g. with cancer, you may expect the pt to be underweight)
  4. When taking pt's weight you should...
    • 1) remove shoes and heavy clothing
    • 2) take serial weights
  5. What are 5 factors of weight gain?
    • 1) overeating or decreased activity
    • 2) fluid volume excess
    • - 2.2 pound weight gain
    • - more than 2-3 lbs/wk is significant (may be related to heart failure)
    • 3) hypothyroidism (slows metabolism)
    • 4) Drug therapy
    • 5) diabetes
  6. What are 5 factors of weight loss?
    • 1) Anorexia or decreased intake
    • 2) dehydration
    • 3) increased metabolic rate
    • 4) diabetes (new onset or poor control)
    • 5) malignancy, etc.
  7. What are 6 factors temperature is affected by?
    • 1) diurnal cycle (1-1.5 F change)
    • - peak: late afternoon (4 pm)
    • - trough: early am (4 am)
    • 2) menstrual cycle (temp increase 0.5- 1.0 starting at midcycle ovulation through menses due to progesterone secretion
    • 3) moderate/heavy exercise
    • 4) age
    • - children under 8 yo have high fevers with minor illness (e.g. 103-105 F)
    • - older adults (increased risk for hypothermia)
    • 5) illness
    • 6) prolonged exposure to cold
  8. What are the norms for oral, rectal, tympanic, and axillary temperature?
    • Oral: 98.6 F (range- 96.4-99.1)
    • 37 C ( range- 35.8-37.3)
    • rectal: 1 F or 0.5 C higher than oral
    • tympanic: 1 F or 0.5 C higher than oral
    • axillary: 1 F or 0.5 C lower than oral
  9. What is fever defined as?
    101-101.5 F or 38-38.5 C
  10. What is the technique for taking oral, rectal, axillary, and tympanic temperature.
    • 1) Oral temp(use blue tip probe)
    • - insert at base of tongue (sublingual pocket)
    • - wait 15 minutes after hot/cold fluids, 2 min after smoking
    • 2) Rectal (use red tip probe)
    • - insert 1 in (use lubricant)
    • 3) tympanic (use tympanic ear tip)
    • - unreliable with ear infection or local inflammation (tooth)
    • 4) axillary (use red tip probe)
  11. What is sinus arrhythmia?
    pulse increases with inspiration and decreases with expiration (common in children and young adults)
  12. How do you take a child's pulse until 2 yo?
    apical pulse, then radial count x 1 min
  13. What is bradycardia and tachycardia?
    • bradycardia <60 bpm
    • tachycardia >60 bpm
  14. What are 8 factors that affect pulse rate?
    • 1) age (higher in children)
    • 2) female
    • 3) exercise
    • 4) anxiety
    • 5) pain
    • 6) fever
    • 7) dehydration
    • 8) anemia
  15. What is the pulse deficit and what are the normal and abnormal factors?
    • pulse deficit: difference between apical and radial pulse
    • - a healthy heart the apical rate should be the same as the radial rate.
    • - if the apical rate is higher than the radial rate, then this indicates a cardiac arrhythmia
  16. What is the pulse strength and what is the scale?
    pulse strength: force created in the artery by the stroke volume

    • 4+ bounding
    • 3+ full (norm during exercise)
    • 2+ normal
    • 1+ weak, thready
    • 0 absent
  17. What are the 5 factors to assess for respirations?
    • 1) assess rhythm
    • - if rhythm is regular: count for 30 sec and multiply by 2
    • - if the rhythm is irregular: count for 60 seconds
    • - children: count for 60 seconds
    • 2) rate (varies with age and fitness)
    • - children: age specific variations
    • - adult norms: 10-20/min
    • 3) depth
    • - shallow, moderate, or deep.
    • 4) Character
    • - thoracic (women)
    • - abdominal (men and infants)
    • 5) abnormal patterns (hyperventilation, hypoventilation, apnea, dyspnea, etc.)
  18. Define blood pressure, systolic pressure, pulse pressure, mean arterial pressure
    • blood pressure: force exerted against walls of peripheral vessels during cardiac cycle
    • systolic pressure: maximum pressure exerted on arterial walls during ventricular contraction
    • pulse pressure: difference between systolic and diastolic B/P
    • mean arterial pressure: (pressure forcing blood into the tissues averaged over the cardiac cycle)
    • - MAP= DPB + 1/3 pulse pressure
  19. What are the factors determining B/P?
    • 1) Cardiac Output
    • 2) Volume of Circulating Blood
    • 3) Blood viscosity (increased pressure with thicker blood)
    • 4) Peripheral Vascular Resistance (PVR)- increased pressure is generated to pump against constricted blood vessels.
    • 5) sympathetic nervous system stimulation (stress--->stimulates SNS---> vasoconstriction--> increased blood pressure)
    • 6) elasticity of vessels walls (increased pressure with stiffer vessels; occurs with arteriosclerosis)
  20. What is the range for prehypertension and hypertension?
    • prehypertension: SBP 120-139; DBP: 80-89
    • hypertension: SBP more than or equal to 140; DBP more than or equal to 90
  21. What is the goal blood pressure for patient with diabetes?
    less than 130/80
  22. What are some assessments in regard to HTN as a medical diagnoses?
    • - document B/P until the diagnoses is mad; requires serial B/Ps to establish the diagnosis of HTN
    • - check B/P in both arms (use the highest reading)
  23. What are 11 factors that affect blood pressure?
    • 1. Age
    • 2. Male gender
    • 3. Race (e.g. African Americans)
    • 4. Diurnal Rhythm: highest in late afternoon and lowest in early am
    • 5. Obesity
    • 6. Exercise
    • 7. Emotions, stress and pain (stimulation of SNS)
    • 8. Smoking (wait 30 min before taking B/P)
    • 9. ETOH
    • 10. Meds (NSAIDS, pseudoephedrine [decongestants]
    • 11. white coat syndrome
  24. If B/P differs between arms, what reading would you use?
    use the highest B/P reading
  25. What is the Auscultatory Gap?
    If present, there can be an unusually long silence (ranging from 10-40 mm) between the 1st and 2nd heart sound.
  26. What is paradoxical pulse mean? What can it implicate?
    • Normally the difference in SBP between inspiration and expiration = 5 mm Hg
    • paradoxical pulse: If the difference is > then 10 mm Hg
    • -this could mean cardiac tamponade, constrictive pericarditis or great respiratory effort (emphysema)
  27. What is orthostatic hypotension?
    • a significant drop in blood pressure that occurs when changing positions (from standing to sitting to standing)
    • - results from peripheral vasodilation w/o compensatory increase in CO
    • - check B/P and pulse when lying, then reassess B/P and pulse in sitting and
    • standing positions..
    • - wait 5 minutes between position changes before rechecking B/P and pulse
  28. What is orthostasis?
    a drop in SBP >20 mm Hg or pulse increase of >20 bpm between lying, sitting and or standing positions
  29. What are three causes orthostatic hypotension?
    • 1) hypovolemia (dehydration)
    • 2) bedrest
    • 3) medications (vasodilators)

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