General Survey

Question 1

Overall impression

Answer 1

physical appearance, behavior, COLDSPA/focused assessment for abnormalities, height, weight, BMI, waist circumference

Question 2

Physical appearance includes

Answer 2

skin color, dress, hygiene, posture, gait, development, body build, appears stated age, LOC

Question 3

Behavior includes

Answer 3

body movement, affect, facial expression

Question 4

How do you take height?

Answer 4

no shoes, standing straight w/ feet/shoulders/bottom against hard surface

Question 5

BMI

Answer 5

optimal healthy weight for height. obesity/nutrition risk assessor. normal = 18-24.9, obese >30

Question 6

Why is waist circumference important?

Answer 6

if carried around waist vs hips = higher risk for heart disease/diabetes II

Question 7

How do you get the height of infants?

Answer 7

straighten legs/mark on paper. get height/weight each visit to determine normal growth patterns/compare w/ general population

Question 8

Measure head circumference

Answer 8

2cm more than chest newborns, same 6mos-2, less >2

Question 9

vital signs

Answer 9

temp, pulse, respirations, bp, o2 sat

Question 10

sites for temperature

Answer 10

oral, axillary, rectal, temporal, tympanic, lowest in morning, peaks med afternoon, older people may have a lower temp.

Question 11

Oral temp

Answer 11

easiest, sublingual pocket

Question 12

Axillary temp

Answer 12

degree lower than oral

Question 13

Rectal temp

Answer 13

degree higher than oral, most accurate, wear gloves/lubricate

Question 14

Temporal and tympanic temp

Answer 14

temporal slide across forehead/behind ear - maybe accurate. tympanic accurate

Question 15

Pulse is

Answer 15

feeling amount of blood pumped with each beat = stroke volume

Question 16

What do you report with pulse?

Answer 16

rate - number, amplitude - 0 absent, 1+ weak, 2+ normal, 3+ bounding. rhythm - regular/irregular

Question 17

Pulse sites

Answer 17

apical (count minute), radial, carotid, brachial, femoral, dorsalis pedis, posterial tibial

Question 18

Respirations

Answer 18

normal = relaxed, regular, automatic, silent, don’t let pt know counting (during pulse), can put hand on chest to help feel (especially in newborns). faster in kids (try to get when quiet)

Question 19

What do you report with respirations?

Answer 19

rate - number, rhythm - regular/irregular, depth - shallow, regular, deep

Question 20

Systolic

Answer 20

ventricles contracted

Question 21

Diastolic

Answer 21

ventricles relaxed

Question 22

Pulse Pressure

Answer 22

systolic - diastolic

Question 23

What can influence BP?

Answer 23

age, race, weight, emotions, stress

Question 24

Tips for BP

Answer 24

right size cuff, if must retake wait 1-2 min, validate electronic with manual

Question 25

Orthostatic

Answer 25

serial measurements of pulse/bp. read lying, sitting, standing - normal <10mm/Hg decrease in systolic

Question 26

orthostatic hypotension

Answer 26

drop in systolic of >20mm/Hg or pulse increase >20 with quick position change - caused by peripheral vasodilation w/o compensatory increase in cardiac output

Question 27

Sites for bp

Answer 27

upper arm, forearm, leg

Question 28

O2 sat

Answer 28

measures light absorbed by unoxygenated hemoglobin, use fingers toes or earlobes, needs to be unpolished nail

Question 29

Developmental considerations

Answer 29

infant - auscultate while sleeping, exam table or parent's lap. toddler - tell what's next asking, can demonstrate on parent or stuffed animal. adolescent - provide feedback that body is healthy, what to expect next. elderly - plan for few position changes

Question 30

What age do you check bp?

Answer 30

3

Question 31

Things to know about older adults

Answer 31

kyphosis, muscle shrinkage 80s/90s, shorter b/c thinning vertebral disks/knee/hip flexion, less sweat glands, stiff arteries, shallow respirations/decreased inspiratory volume, less sq fat - lower body temp (infection w/o fever), higher bp

Question 32

best O2 sat

Answer 32

93-100%

Question 33

What causes low O2 sat?

Answer 33

low hemoglobin which carries O2

Question 34

What is oxygen saturation?

Answer 34

non-invasive measurement of arterial oxygen saturation (SpO2)

Question 35

Kyphosis

Answer 35

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