genreal assessment and vital signs

Question 1

What areas are involved in the physical assessment?

Answer 1

head, eyes, ears, nose, throat, neck, CV, lungs, abdomen, extremities, neuro, psych, skin

Question 2

Underweight BMI

Answer 2

less than 18.5

Question 3

Normal weight BMI

Answer 3

18.5-24.9

Question 4

Overweight BMI

Answer 4

25-29.9

Question 5

Class 1 obesity BMI

Answer 5

30-34.9

Question 6

Class 2 obesity BMI

Answer 6

35-39.9

Question 7

Class 3 obesity BMI

Answer 7

greater than 40

Question 8

BMI inaccuracies

Answer 8

does not consider muscle mass or body fat percentage
was created over 200 years ago for white race
nothing currently studied to replace BMI clinically

Question 9

Edema

Answer 9

fluid leaking into tissues or swelling

Question 10

Causes of edema

Answer 10

heart, kidney, or liver function
medication
inflammation
injury
diet
blood clot/obstruction
pregnancy

Question 11

Edema grades

Answer 11

1: mild pitting, slight indentation, no visible swelling
2: moderate pitting, indentation subsides quickly, no visible swelling
3: deep pitting, indentation may last up to a minute, visible swelling
4: very deep pitting, indentation lasts 2-5 minutes, significant swelling

Question 12

Normal body temperature

Answer 12

96.8-99 F
36-37.2 C

Question 13

Where is body temperature most commonly taken?

Answer 13

rectal (most accurate)
temporal (accurate)
tympanic (accurate)
oral (0.5-1 F lower than rectal)
axillary (1-2 F lower than rectal)

Question 14

When should you refer for a fever?

Answer 14

temp greater than 104
temp greater than 100.4 plus nonresponsive to medication and lasts longer than 3 days
greater than 100.4 and symptomatic

Question 15

Normal adult and child (6-12) pulse and respiratory rate

Answer 15

adult:
60-100
12-20
child:
80-120
12-20

Question 16

How to check pulse rate

Answer 16

using the pads of your first and second fingers, place your fingers on the wrist medial to the radial bone
press down until you can feel the pulse
count the number of beats you feel in 30 seconds and multiply by 2

Question 17

When should you refer for pulse?

Answer 17

greater than 100 BPM while resting AND chest pain or discomfort, SOB, weakness, dizziness, or fainting
less than 40 BPM while awake AND chest pain or discomfort, SOB, dizziness, fainting, or confusion

Question 18

How to check respiratory rate

Answer 18

continue to pretend to take pulse
watch patient’s chest and abdomen for respirations
count the number of respirations in 30 seconds and multiply by 2

Question 19

When should you refer for respiratory rate?

Answer 19

greater than 25 RPM AND low BP or change in consciousness
greater than 25 RPM AND difficulty breathing, coughing, wheezing, and increased mucous
less than 12 RPM AND goes limp, change in consciousness, or turns blue

Question 20

Systolic BP

Answer 20

maximum pressure on the arteries during contraction of the left ventricle (regulated by stroke volume)

Question 21

Diastolic BP

Answer 21

resting pressure between ventricle contractions

Question 22

Systolic/Diastolic BP

Answer 22

most reported
well established CV disease risk factors

Question 23

MAP

Answer 23

[SBP + (2xDBP)] /3
1/3SBP +2/3DBP

Question 24

Auscultatory technique

Answer 24

manual/traditional method
brachial artery occluded to stop blood flow
stethoscope to detect appearance and disappearance of Korotkoff sounds
error prone

Question 25

Oscillometric technique

Answer 25

automatic cuff read based on amplitude of oscillations recorded in the lateral walls of the upper arm software on device

Question 26

What is the proper position the patient should be in when taking BP?

Answer 26

seated arm supported at heart level back supported uncrossed legs feet flat on the floor

Question 27

How should the BP cuff be placed on the patient's arm?

Answer 27

bare skin and not over clothing (rolling up sleeves could create a tourniquet effect) bottom of cuff should be 1/2 inch above the elbow once cuff is in place it should be snug and finger should easily fit at the top and bottom

Question 28

How should you place the stethoscope when taking BP?

Answer 28

stethoscope should be placed over brachial artery at antecubital space make sure the cuff is aligned so that the artery marker points to the brachial artery

Question 29

What are the 5 phases of Korotkoff sounds?

Answer 29

phase 1: faint and clear tapping (systolic) phase 2: swooshing sound phase 3: more intense, crisp tapping phase 4: muffled sound phase 5: sound stops (diastolic)

Question 30

What patient factors can alter BP?

Answer 30

medications drugs of abuse caffeine consumption nicotine consumption exercise in the past 30 minutes time of day pain/stress talking during measurement full bladder

Question 31

Steps to taking a manual BP

Answer 31

1. insert the earpieces of the stethoscope (pointing forward) into your ears 2. place the bell of the stethoscope over the palpable brachial brachial artery lightly (with an air-tight seal) 3. inflate the cuff rapidly to the maximum inflation level (180 in a normal patient, 220 in hypertensive patients) 4. release the air slowly (2-3 mmHg/sec) 5. note the pressure when the first sound is heard (systolic pressure) 6. note the pressure when the last sound is hears (diastolic) 7. continue listening until 20 mmHg below last sound

Question 32

Normal adult BP

Answer 32

less than 120 and less than 80

Question 33

Elevated adult BP

Answer 33

120-129 and less than 80

Question 34

Stage 1 hypertension BP

Answer 34

130-139 or 80-89

Question 35

Stage 2 hypertension BP

Answer 35

140 or higher or 90 or higherh

Question 36

Hypertensive crisis BP

Answer 36

higher than 180 and/or higher than 120

Question 37

Hypertensive urgency

Answer 37

SBP > 180 mmHg and/or DBP > 120 mmHg

Question 38

Hypertensive emergency

Answer 38

SBP > 180 mmHg and/or DBP > 120 AND target organ damage

Question 39

When should you refer for BP?

Answer 39

SBP > 180 mmHg and/or DBP > 120 AND target organ damage (chest pain, SOB, numbness or weakness, vision changes, difficulty speaking, severe headache)

Question 40

Lifestyle changes that can impact BP

Answer 40

weight loss DASH dietary plan reduced dietary sodium increased dietary potassium physical activity moderation in alcohol tobacco cessation