202GS, Meas., VS

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Anonymous
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7907
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202GS, Meas., VS
Updated:
2010-02-23 21:06:58
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202
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202: General Survey, Measurement, and VS
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  1. General Approach
    • -Measure height, weight, BP, TPR, vision if applicable
    • -Provide exam gown, leave when pt undressing
    • -Wash hand's in front of pt
    • -Explain each step
    • -Give encouragement as you proceed
    • -Organize exam for efficiency & pt comfort
    • -Use systematic approach (top down, in sequence)
    • -Give summary of findings
  2. General Appearance
    (physical characteristics)
    • -Age (look stated age?)
    • -Sex (development appropriate to age?)
    • -Skin (pale, red, flushed, cyanotic, lesions, sores?)
    • -Facial features (symmetric?)
    • -Signs of acute distress (SOB, in pain?)
    • -Personal hygiene (clean, well groomed, oily, BO)
    • -Involuntary movement (twitches, tics)
  3. General Appearance
    (body structure)
    • **WDWN: well developed well nurtured
    • -Stature (height w/in standards)
    • -Nutrition ( well nourished, overweight, obese, thin, cachetic [thin, wasted])
    • -Symmetry (atrophy, hypertrophy, swelling)
    • -Posture (erect, slumped-sign of depression)
    • -Body build (lean muscular)
    • -Physical deformities (limp, one leg shorter)
  4. General Appearance
    (Mobility)
    (& Mental status & behavior)
    • -Gait (how they walk: steady, ataxic, ataxic gait [drunk walk])
    • -ROM (FROM vs. limited ROM)
  5. Clinical Measurements
    • -An essential part of initial data base
    • -Analyzed in relation to normal ranges, client's recent values & serial readings, and dx
  6. Weight
    • -Remove shoes & heavy clothing
    • -Serial weights
    • -Weight gain
    • -Weight loss (intentional, unintentional)
  7. Weight gain
    • -Rapid: liquid; slow: food
    • -Overeating or decreased activity
    • -Fluid vol. excess (2.2lb gain = 1L; > 2-3lbs/wk is significant); kidney dysfunction
    • -Hypothyroidism (underactive = dec secretion of TH = hypometabolism)
    • -Drug therapy (corticosteroids: inc apetite
    • -Diabetes: II overweight b/c excess circulating insulin which alters fat distribution (accumulates)
  8. Height, weight & head circumference
    (children)
    • -Plot on graph, compare to norms
    • -Check head circum. until age 2, & yearly til age 6
    • -hydrocephalus, mental retardation
  9. Vital Signs
    • -TPR
    • -BP
    • -Pain is 5th VS
  10. Temperature
    • -Regulated by hypothalamus
    • -Febrile vs afebrile
    • -febrile seizure: give tepid bath to bring fever down to prevent seizure
  11. Things that affect temperature
    • -Diurnal cycle (1-1.5° change; peak: lowest late afternoon 4PM; trough: highest early am 4AM)
    • -Menstrual cycle: temp inc 0.5-1.0°F midcycle ovulation through menses due to progesterone secretion
    • -Moderate/heavy exercise
    • -Age: Children under 8 may have high fevers w/ minor illness (103-105°); older adults inc risk of hypothermia
    • illness: infection, inflammation
    • -Prolonged exposure to cold
  12. Fever
    Generally defines as temp > 101-101.5°F or > 38-38.5°C
  13. Temp Techniques:
    -Oral
    -Rectal
    -Tympanic
    • O: insert at base of tongue (sublingual pocket), wait 15 min after hot/cold fluids, 2 min after smoking
    • R: insert 1 in using lubricant
    • T: unreliable w/ ear infection or local inflammation (tooth, dental infection)
  14. Pulse:
    -Regular
    -Irregular
    -Sinus arrythmia
    • *Palpate radial pulse for rate and rhythm
    • R: count 30 sec x 2
    • I: count 60 sec
    • SA: pulse inc w/ inspiration, dec with expiration (common in children, young adults)
  15. Pulse:
    -Children
    -Adults
    • C: use apical pulse until 2 yo, then radial (1min)
    • A: normal = 60-100bpm, bradycardia < 60, tachycardia >100
  16. Factors increasing pulse rate
    • -Age (higher in children)
    • -Female
    • -Exercise
    • -Anxiety
    • -Pain
    • -Fever
    • -Dehydration
    • -Anemia (heart works harder to circulate what's present)
  17. Pulse Deficit
    • *Difference between apical pulse and radial pulse
    • -Should both be the same. If not = may mean heart isn't strong enough to push apical pulse to radial pulse; maybe cardiac arrythmia
  18. Force
    4+, 3+, 2+, 1+, 0
    • *Strength of SV
    • 4+ bounding
    • 3+ full (normal during exercise)
    • 2+ normal
    • 1+ weak, thready
    • 0 absent
  19. Elasticity
    • *Artery feels straight, resilient, soft
    • -how rubbery the artery feels, not stiff
    • -atherosclerosis: hardened artery, plaque in vessels
  20. Respirations
    (reg, irreg, children)
    • R: count 30 sec x 2
    • I: count 60 sec
    • C: count 60 sec
  21. Rate of Respirations
    • -Varies w/ age and fitness
    • -Children: age specific
    • -Adults: 10-20/min
    • -bradypnea: < 10/min
    • -tachypnea: > 20/min
  22. Respirations:
    -Rhythm
    -Depth
    • R: eupnic (regular, even, quiet breathing)
    • D: shallow, moderate, or deep
  23. Respirations:
    -Type
    -Abnormal patterns
    • T: thoracic (women breathe through thorax); abdominal (men & infants)
    • AP: hyperventilation, hypoventilation, apnea, dyspnea
  24. Blood pressure
    • *Force exerted against walls of peripheral vessels during the cardiac cycle
    • -Systolic, diastolic, pulse pressure
  25. Systolic Pressure
    *Maximum pressure exerted on arterial walls during ventricular contraction
  26. Diastolic pressure
    *Resting pressure b/t contractions
  27. Pulse Pressure
    *Difference b/t systolic & diastolic BP
  28. Factors Determining BP
    • -CO (sys higher when heart works more)
    • -Vol. of circulating blood
    • -Blood viscosity (inc pressure w/ thicker blood, takes more force to pump)
    • -Peripheral Vascular Resistance (PVR): in pressure is generated to pump against constricted BV, heart works harder to pump
    • -Elasticity of vessel walls: inc pressure w/ stiffer vessels
    • -SNS may inc BP
  29. Normal BP levels
    • SBP < 120 and
    • DBP < 80
  30. Prehypertension levels
    • SBP 120-130 or
    • DBP 80-89
  31. Hypertension levels
    • *must be doc on 2 separate occasions
    • -Medical dx, doc as elevated BP til dx is made; requires serial BP to dx
    • -Take in both arms, take highest reading
    • SBP > or = 140 or
    • DBP > or = 90
  32. Factors Increasing BP
    • -Age, male gender (female after menopause), race (african americans), alcohol, white coat syndrome, obesity
    • -Diurnal rhythm: highest in late afternoon, lowest in early am
    • -Exercise (inc 5 min after exercise)
    • -Emotions, stress & pain (stimulation of SNS)
    • -Smoking/caffeine (wait 30 min before taking BP)
    • -Meds (NSAIDS, pseudoephedrine [decongestants])

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