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Health Assessment > General Survey, Measurement, Vital Signs Ch. 9,10 > Flashcards

General Survey, Measurement, Vital Signs Ch. 9,10 Flashcards

1
Q

What is a General Survey

A

Looking/Inspecting the General State of Health and Obvious Physical Characteristics of the whole Person

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2
Q

Dysarthria

A

Difficulty w/ speech due to muscle problem

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3
Q

Dysphonia

A

Difficulty w/ speech due to physical disorder or vocal cord (structural damage)

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4
Q

Aphasia

A

loss ability to understand or express speech caused by brain injury

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5
Q

Dysphagia

A

difficulty swallowing

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6
Q

Global Aphasia

A

Affects both receptive (stringing meaningless words, vs Expressive (short phrases and often leads out connecting words)

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7
Q

Expressive Aphasia

A

Difficulty with speech production, short phrases and often leads out connecting words

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8
Q

Receptive Aphasia

A

Fluent but speech may be nonsensical, also trouble with reading and writing.

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9
Q

What are the 4 components of a General Survey?

A

1.Physical Appearance
2. Body Structure
3. Mobility
4. Behavior

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10
Q

What are the components of Physical Appearance of the General Survey?

A

-Age
-Sex
-level of Consciousness (LOC)
-Skin Color
-Facial Features
-Overall Apperance

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11
Q

What are the components of Body Structure of the General Survey?
(BNPPSS)

A

-Stature
-Nutrition
-Symmetry
-Posture
-Position
-Body Build, Contour

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12
Q

What are the components of Mobility of the General Survey?

A

-Gait
-Foot placement
-Range of Motion (ROM)
-Note any involuntary movement

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13
Q

What are the components of Behavior of the General Survey?

A

-Facial Expression
-Mood and Affect
-Speech
-Dress
-Personal Hygiene

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14
Q

What are some Abnormalities in Body height Proportion?

A

-Dwarfism
-Gigantism vs Acromegaly (Hyperpituitarism)
-Anorexia nervosa vs Bulimia Nervosa
-Endogenous Obesity-Cushing’s Syndrome (endocrine disorder, steroids can induce overproduction of cortisol by adrenal glands, moon face)
-Marfan Syndrome(long arms, long legs)

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15
Q

What are Vital Signs?

A

Objective Data that includes:
-Temperature
-Pulse
-Respiratory Rate
-Blood Pressure
-Pain
-SPO2 and FIO2

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16
Q

What affects Temperature?

A

-Circadian/Diurnal cycle(peak in late afternoon)
-Age
-Menstrual Cycle
-Medications
-Where it was taken
-Environment
-Exercise
-Hot or Cold drinks

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17
Q

Where can Temperature by Assessed?

A

-Oral
-Axillary
-Rectal
-Temple

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18
Q

Adult Normal Temperature Readings

A

35.8-37.3 degrees C /96.4-99.1 degrees F

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19
Q

Pulse

A

palpable flow felt in the periphery as a result of pressure wave generation from stroke volume

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20
Q

Adult Normal Pulse Rate

A

50-95 or 60-100 bpm

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21
Q

Bradycardia

A

Slower heart rate, <50/bpm

22
Q

Tachycardia

A

fast heart rate, >95-100/bpm

23
Q

What affects the pulse rate, rhythm and force?

A

-Fever
-Medication
-Anxiety
-Cardiac History
-Athlete
-Exercise

24
Q

Respirations

A

number of breaths per minute, 1 inhale and 1 exhale is one respiratory cycle, never let the patient know you are counting respirations.

25
Q

What can affect Respirations?

A

Narcotics- decrease
Head Injury- increase or decrease
Heart Failure w/ activity intolerance- increase
Anesthesia- decrease
Exercise- increase
Sleep-decrease

26
Q

Adult Normal for Respirations

A

10-20/min

27
Q

Pulse Oximetry (SPO2 and FIO2)

A

Tool used to measure the saturation of oxygen by applying a sensor with a light that measures the relative amount of light absorbed by oxyhemoglobin.

28
Q

Adult Normal for Pulse Oximetry

A

> 95% in Normal Adult
92% in Older adult w/ disease

29
Q

What affects Pulse Oximetry?

A

-Anemia
-Lung Disease
-Heart Disease
-Inadequate O2 given or method of delivery

30
Q

Blood Pressure

A

is force of blood pushing against side of its container, vessel wall.

31
Q

Systolic Pressure

A

Maximum pressure felt on artery during ventricular contraction or systole

32
Q

Diastolic Pressure

A

elastic recoil, or resting pressure that blood exerts constantly between each contraction.

33
Q

Pulse Pressure

A

Difference between systolic and diastolic( reflects stroke volume) 120/80
120-80=40

34
Q

What affects Blood Pressure?

A

-Age
-Race
-Weight
-Emotions
-Sex
-Exercise
-Stress
-Medication (steroids can cause hypertension, beta-blockers can cause hypotension)

35
Q

What 5 factors determine Blood Pressure Level?

A
  1. Cardiac Output
  2. Peripheral Vascular Resistance
  3. Volume circulating Blood
  4. Viscosity
  5. Elasticity
36
Q

Adult Normal for Blood Pressure

A

<120/80

37
Q

Elevated BP

A

120-129/<80

38
Q

Stage 1 Hypertension

A

130-139/80-89

39
Q

Stage 2 Hypertension

A

> 140/90

40
Q

Hypertensive Crisis

A

> 180/120

41
Q

Hypertensive Emergency

A

> 200/140

42
Q

Hypotension

A

> 90/60 with signs and symptoms

43
Q

Orthostatic Hypotension

A

Person experiences a sharp drop in blood pressure (systolic >20mmHg/ diastolic >10 mmHg) when sitting up or standing, can be dizzy and prone to falls.

Increased in Elderly due to vascular changes. (No vascular tone)

44
Q

What are common causes of Orthostatic Hypotension

A

-Fluid Loss
-Aging
-Bedrest
-Changes in BP medication

45
Q

Where can Blood Pressure be Measured?

A

upper arm/brachial artery-most common site
-Lower arm/radial artery
-lower leg/tibial artery site
-upper leg/popliteal artery site
-B/P can be auscultated or palpated depending on situation

46
Q

What are some common errors w/ Blood Pressure assessment?

A

-Arm Placement
-Patient Hold up arm
-legs crossed
-Examiner eyes are not level with manometer or meniscus
-incorrect cuff size
-Failure to palpate for level of inflation
-deflate too fast or too slow
-Stopping during descent and then reinflating
-Failure to wait 1-2 minutes between readings
-Subconscious Bias
-Diminished hearing ability of examiner
-Defective equipment
-Number preferences

47
Q

Which patient would be most likely to present with a pulse rate that is lower than normal?

A. A 70-year-old telephone salesman presenting with dehydration.
B. A 20-year-old runner who had surgery 4 days ago for a fractured leg.
C. A 67-year-old who presented with an exacerbation of his COPD
D. A 80-year old male who was admitted with dyspnea and myocardial infarction

A

B. A 20-year-old runner who had surgery 4 days ago for a fractured leg.

48
Q

What three things may increase body temperature?

A. Illness, fasting, mouth breathing
B. Illness, infection, environment
C. Sleep, cold, malnutrition
D. Exercise, cold water, eating

A

B. Illness, infection, environment

49
Q

A pulse rate of 42 bpm in considered:

A. Bradycardia
B. Tachycardia
C. Bradypnea
D. Apnea

A

A. Bradycardia

50
Q

If your patient’s radial pulse is regular, you may count it for:
A. 30 seconds
B. Always 60 seconds
C. 30 seconds and multiply by 2
D. 15 seconds and multiply by 2

A

C. 30 seconds and multiply by 2

51
Q

Respirations are usually counted:
A. In the evening
B. After the patient exercised
C. After taking a pulse
D. While taking a blood pressure

A

C. After taking a pulse

52
Q

All the following factors tend to increase blood pressure except:

A. Pain
B. Stress
C. Sleeping
D. Exercise

A

C. Sleeping

Health Assessment (7 decks)

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