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Health Assessment NUR 202 > CH 9 & 10: General Survey, Measurement, & Vital Signs > Flashcards

CH 9 & 10: General Survey, Measurement, & Vital Signs Flashcards

1
Q

What is a general survey?

A

Inspecting general state of health and obvious physical characteristics of the whole person

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2
Q

General survey component 1?

A

Physical appearance:
Age
Sex
Level of consciousness/alertness
Skin color
Facial features
Overall appearance

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3
Q

General survey component 2?

A

Body structure:
Stature
Nutrition
Symmetry
Posture
Position
Body build & contour

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4
Q

General survey component 3?

A

Mobility:
Gait
Foot placement
Range of motion
Note involuntary movements

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5
Q

General survey component 4?

A

Behavior:
Facial expression
Mood and affect
Speech
Dress
Personal hygiene

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6
Q

Speech terminology?

A

Dysarthria: slurred speech
Dysphonia: abnormal voice (hoarseness)
Aphasia: cannot understand or express speech
Dysphagia: difficulty swallowing
Dysphasia: difficulty speaking
Global aphasia: impaired receptive and expressive language
Expressive aphasia: (Broca’s) difficulty producing speech
Receptive aphasia: (Wernicke’s) speech does not make sense

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7
Q

Measurements?

A

Height
Body Mass Index
Waist circumference

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8
Q

Abnormalities in body height and proportion?

A

Dwarfism:
Hypopituitary- short stature, delayed dentition, delayed skeletal maturation
Achondroplasia- bone growth disorder, genetic mutation in arms and legs
Gigantism- hyper secretion of GH before long bone epiphysis fusion, characterized by tall stature
Acromegaly- GH hyper secretion after fusion of epiphysis, leads to large extremities and characteristic facies
Hyperpituitarism- excessive pituitary gland secretion
Anorexia Nervosa- eating disorder caused by obsession of weight, distorted body image
Bulimia Nervosa- eating disorder characterized by binging and purging
Cushing’s Syndrome- extended exposure to high cortisol levels (fatty deposits around face and weight gain in midsection)
Marfan Syndrome- inherited connective tissue disorder (tall and thin)

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9
Q

Convert F to C?

A

(F-32)5/9=C
ex.
F= 97.6
(97.6-32)= 65.6
65.65= 328
328/9= 36.4
C= 36.4
Convenient equivalents:
104F = 40C
98.6F = 37C
95F = 35C

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10
Q

Oral temperature?

A

Accurate and convenient (sublingual site blood supply from carotid arteries, quick response to inner core temp changes)
Blue tipped probe
Normal: 35.8 C - 37.3 C
Smoking: increases for 30 mins
Cold liquids: decreases for 10-15 mins
Hot liquids: affects for 35 mins
When respiratory rate increases, temperature decreases: tachypnea

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11
Q

Rectal temperature?

A

Most accurate, as close to core temp as possible
(generally subtract 1 degree)
Red tipped probe
Procedure: pt on left lateral decubitus (on side). Gloves, probe cover, and lube, insert 2 to 3 cm (1in)
Normal: 0.4 - 0.5 C higher

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12
Q

When not to give rectal?

A

Heart problems- stimulates vagus nerve and drops HR
Kids
Low WBC- neutropenic
Decrease platelets

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13
Q

Tympanic membrane temperature? (TMT)

A

Senses infrared emissions of tympanic membrane (eardrum), accurate for core temp bc shares vascular supply with hypothalamus
Cerumen may lower temp

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14
Q

Temporal artery temperature? (TAT)

A

Slide probe across forehead and behind ear, average of multiple infrared readings- questionable reliability and likely not as accurate

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15
Q

Surface temperatures?

A

Oral, axilla (add 1 degree), skin surface

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16
Q

Pulse rate parameters?

A

Normal adult: 60 - 100 bpm
Bradycardia: less than 50 bpm
Tachycardia: greater than 95-100 bpm

17
Q

Pulse descriptors?

A

Location
Force scale-
0: Absent
1+: Weak, thready
2+: Normal
3+: Bounding
Rhythm: regular even tempo

18
Q

Pulse effectors?

A

Fever, meds, anxiety, cardiac history, athlete, etc

19
Q

Respirations?

A

Normal: 10 or 12 - 20 per minute
*respiratory distress always 1st level priority

20
Q

Respiration descriptors?

A

Relaxed/regular/automatic
Sounds? wheezing, gurgling, etc
Effect? use of accessory muscles? (neck, abdomen, thorax)
Position

21
Q

Respiratory effectors?

A

Narcotics, head injury, heart failure, anesthesia, exercise, sleep

22
Q

Pulse oximetry?

A

Measures oxygen saturation
Normal: 97-99%
*always check hemoglobin to assess blood/bleeding

23
Q

Pulse ox effectors?

A

Anemia (not enough blood cells to transfer oxygen), heart disease, lung disease, inadequate O2

24
Q

Blood pressure?

A

Normal: less than 120/80
Systolic: max pressure on artery during left ventricular contraction (systole)
Diastolic: elastic recoil or resting pressure that blood exerts between contractions (diastole)
Pulse pressure: difference between systolic and diastolic (reflects stroke volume)
Mean arterial pressure (MAP): pressure forcing blood into tissues, average of cardiac cycle (can cause stroke or bleeding issues if too high)

25
Q

BP influencers?

A

Age, race, weight, sex, exercise, medication (steroids), pain, social/financial/emotional stress

26
Q

Blood pressure factors?

A

Cardiac output (how much blood your heart can squeeze out) : increase CO = increased BP
Peripheral vascular resistance (vessels themselves): increased resistance (vasoconstriction) = increased BP
Volume of circulating blood: fluid retention = increased BP, hemorrhages = decreased BP
Viscosity (blood thickness): increase = increased BP
Elasticity of vessel walls: increased rigidity = increased BP
hypertension and diabetes silent killers over time

27
Q

BP parameters?

A

Normal: lower than 120/80
Elevated: 120-129 AND less than 80
Hypertension stage 1 (will definitely start treating if showing other symptoms/factors): 130-139 OR 80-89
Hypertension stage 2: 140+ OR 90+
Hypertensive crisis: higher than 180 AND/OR higher than 120
200+: stroke or heart attack
*lower sodium in diet for elevated levels

28
Q

Korotkoff sounds?

A

Phase I: soft, clear tapping- systolic pressure
Auscultatory Gap: silence for 30-40 mmHg
Phase II: swooshing/softer murmur following tapping
Phase III: crisp, high pitched knocking
Phase IV: abrupt, low pitched murmur
Phase V: silence- diastolic pressure

29
Q

What is orthostatic hypotension?

A

Drop in BP while rising from a seating or reclined position
Drop in systolic BP by >20 mmHg and/or diastolic >10 mmHg

30
Q

How to measure orthostatic hypotension?

A

Patient lies down for 5 minutes- measure BP and pulse rate
Have patient sit up/stand, repeat BP after 1 minute and 3 minutes

31
Q

OH common causes?

A

Fluid loss, aging, bedrest, changes in BP meds

32
Q

Where can you measure BP?

A

Upper arm/brachial artery: most common
Lower arm/radial artery
Upper leg/popliteal artery
Lower leg/tibial artery

33
Q

Common BP assessment errors?

A

Arm placement
Patient holds up arm
Legs crossed
Examiner not eye level
Patient conversing
Incorrect cuff size
Failure to palpate for inflation level
Deflate too fast or too slow

Health Assessment NUR 202 (17 decks)

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