NURS 202 - General Survey, Measurement, and Vital Signs

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NURS 202 - General Survey, Measurement, and Vital Signs
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NURS 202 EXAM 1 - General Survey, Measurement, and Vital Signs
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  1. What is the General Approach?
    • - Measure 1. height; 2. weight; 3. blood pressure; 4. TPR (temperature, pulse, respiratory); 5. pain
    • - Provide an exam gown; ask the patient if he / she needs assistance, otherwise respect privacy while changing into exam gown; tell him / her that the ties go in the back
    • - Wash your hands before having contact with the patient (wash hands constantly, 20 second hand wash - Happy Bday twice, use hand sanitizer between the fingers)
    • - Explain each step
    • - Give encouragement as you proceed (Leave abnormality to the end & don't be judgmental)
    • - Organize the exam for optimal efficiency & patient comfort
    • - Use systematic approach so as not to forget anything (start at the head to the feet)
    • - Give a summary of findings & given an opportunity for questions (not done with the exam, I'll give you a summary at the end)
  2. What is consisted in the General Survey?
    • - Physical Appearance
    • - Body Structure
    • - Mobility
    • - Mental Status & Behavior
  3. What is consisted in the Physical Appearance of the General Survey?
    • Age: Appear stated age? Younger/older?
    • Sex: Sexual development appropriate for age? Early development?
    • Skin: Face is pale / red? Skin lesions? Burns?
    • Facial Features: Symmetric?
    • Signs of Acute Distress: Pain shown in face? Grasp Chest? SOB?
    • Personal Hygiene: Body odor? Dirt on skin, disheveled appearance
    • - Poor hygiene may be a sign of physical or mental illness (may not be properly groomed)
  4. What is consisted in the Body Structure of the General Survey?
    • Stature (height w/in standards; under 5' or above 7')
    • Nutrition (well nourished / adequate, overweight, obese, thin, cachectic - loss of body mass)
    • Symmetry (atrophy, hypertrophy, swelling, etc.) - disuse of extremities can lead to dystrophy, swelling = excess fluid like edema (Ex. Congestive Heart Failure, Rheumatoid Arthritis , Heart & Kidney Failure, Pregnancy)
    • Posture (erect, slumped) - erect in bed / sitting up in bed, slumped (can detect mental illness or depression)
    • Position (relaxed, tense, fetal) - peritinitis (fetal position because stomach hurts)
    • Body build & contour (lean, muscular)
    • Physical deformities
  5. What is consisted in the Mobility of the General Survey?
    • Gait - how do they walk?
    • ROM - (FROM vs limited ROM)
    • - FROM = Full Range of Motion
  6. What is the Clinical Measurements?
    • Analyze data: patient's past & normal
    • Analyze in relation to:
    • - Normal Ranges (Ex. B/P, P, R) - look at change over time
    • - Client's Recent Values & Serial Readings (Ex. Daily weights for fluid monitoring in heart failure)
    • - Diagnosis (Ex. With cancer, you may expect the patient to be underweight)
  7. Weight
    • Remove shoes (but doesn't happen b/c of athlete's foot) & heavy clothing
    • Serial weights - patient w/ ineffective pump, accumulate fluid. Morning = lightest weight
    • Weight Gain
    • - Overeating or decreased activity
    • - 2.2 pounds weight gain = 1L of water. Fluid volume excess to weight.
    • - > 2-3 pounds per week is significant (may be related to decompensating heart failure)
    • - Hypothyroidism (slows metabolism) - weight gain
    • - Drug therapy - steroid = weight gain
    • - Diabetes b/c of insulin, metabolism is effected
    • Weight Loss (intentional vs unintentional)
    • - Anorexia or decreased intake
    • - Dehydration
    • - Increased metabolic rate - hyperthyroidism
    • - Diabetes (new onset or poor control)
    • - Malignancy, cancer, etc.
  8. Apple Figure
    Weight above waist
  9. Pear Figure
    • Weight below waist
    • Better figure
  10. Weight in the middle
    Causes heart disease
  11. Vital Signs
    • TPR
    • B/P
    • Pain is 5th Vital Sign
  12. Temperature
    • Regulated by hypothalamus
    • - Febrile: Fever
    • - Afebrile: No fever
    • Temperature affected by:
    • - Diurinal cycle (1-1.5 degrees F change)
    • - Peak: Late afternoon (4:00 p.m.)
    • - Trough: early AM (4:00 a.m.)
    • - Menstrual cycle (temperature increase by 0.5-1 degrees Fahrenheit starting at midcycle ovulation through menses due to progesterone secretion)
    • - Moderate / heavy exercise
    • - Age
    • - Children under 8 years old may have high fevers w/ minor illness (Ex. 103-105 degrees F) - minor illness may equal to high temperature
    • - Older Adults (increased risk for hypothermia) - unreliable in elderly
    • - Illness
    • - Prolonged exposure to cold - can cause hyperthermia
  13. Normal Temperatures
    • Oral (benchmark) / Normal Body Temperature: 98.6 degrees F (range = 96.4 - 99.1); 37 degrees C (range = 35.8 - 37.3)
    • - Blue probe
    • - Insert at base of tongue (sublingual pocket)
    • - Wait 15 minutes after drinking hot or cold drinks
    • - Wait 2 minutes after smoking
    • Rectal: 1 degree F or 0.5 degree C higher than oral
    • - Red probe
    • - Insert 1 inch (use lubricant)
    • Tympanic (ear): 1 degree F or 0.5 degree C higher than oral
    • - Unreliable with ear infection or local inflammation (tooth)
    • Axillary (underarm): 1 degree F or 0.5 degree C lower than oral
    • - Red probe
  14. Fever
    • Generally defined as temperature > 101-101.5 degrees F or > 38-38.5 degrees C
    • Afebrile = no fever
  15. What is consisted of the Pulse?
    • Palpate radial pulse for rate & rhythm
    • Factors Increasing Pulse Rate
    • Pulse Deficit (difference between apical & radial pulse)
    • Pulse Strength (force created in the artery by the stroke volume)
  16. Radial pulse for rate & rhythm
    • If rate is regular: count for 30 seconds & multiply by 2
    • If rate is irregular: count for 60 seconds
    • Sinus arrhythmia: pulse increases with inspiration & decreases with expiration (common in children & young adults)
  17. Children's pulse
    Use apical pulse until 2 years old, then radial (count x 1 min.)
  18. Where is the apical rate located?
    Under the apex of the heart
  19. Does artery or vein have a pulse?
    Artery
  20. Adult's pulse
    • Normal Rate: 60-100 beats per minute - SA node fires
    • Bradycardia < 60 bpm (slow)
    • Tachycardia > 100 bpm (fast)
  21. What are the factors increasing pulse rate?
    • Age (higher in children) - as person ages, it slows down
    • Female - higher
    • Exercise
    • Anxiety
    • Pain
    • Fever - higher fever, higher heart rate
    • Dehydration
    • Anemia - decrease in RBC, heart rate increase
  22. What is the Pulse Deficit?
    • Difference between apical & radial pulse
    • In healthy heart, apical rate should be the same as the radial rate, then this indicates cardia arrhythmia
  23. What does it mean when radial rate is slower than apical rate?
    Weak heart
  24. What is the Pulse Strength?
    Force created in artery by the stroke volume
  25. What is the Pulse Strength Scale?
    • 4+ bounding (exercise, heart disease if normal)
    • 3+ full (norm during exercise)
    • 2+ normal
    • 1+ weak, thready
    • 0 absent. no circulation to extremity
  26. Respirations
    • Count breaths up to 30 seconds & multiply it by 2
    • Children = count the full 60 seconds
  27. When assessing rhythm for respiration,
    • If rhythm is irregular, count for 60 seconds
    • Children - count for 60 seconds
  28. What is the respiration rate?
    • Varies with age & fitness
    • Children - age specific variations
    • Adult Norms - 10 - 20 breaths per minute
    • - Bradypnea < 10 breaths per minute (not adequate breaths, slow respiration)
    • - Tachypnea > 20 breaths per minute
  29. What is the respiration depth?
    Shallow, moderate or deep
  30. What is the respiration character?
    • Thoracic (women) - chest breathers (watch chest)
    • Abdominal (men & infants) - (watch abdomen)
  31. What is the abnormal respiration patterns?
    • Hyperventilation
    • Hypoventilation
    • Apnea
    • Dyspnea
  32. What is the "force exerted against walls of peripheral vessels during cardiac cycle?"
    Blood Pressure
  33. What is the maximum pressure exerted on arterial walls during ventricular contraction?
    Systolic Pressure
  34. What is the resting pressure between contractions / lower pressure?
    Diastolic Pressure
  35. What is the difference between systolic & diastolic blood pressure / record for stroke pressure?
    Pulse pressure
  36. What is the pressure forcing blood into the tissues averaged over the cardiac cycle?
    Mean Arterial Pressure
  37. What is the equation for Mean Arterial Pressure?
    MAP = DPB + 1/3 pulse pressure
  38. What are the factors determining blood pressure?
    • Cardiac Output
    • Volume of Circulating Blood (Ex. hemmorhage - decreased)
    • Blood Viscosity (increased pressure w/ thicker blood)

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