Unit 4 ~ Assessment Techniques and Vital Signs

Question 1

What is the general survey?

Answer 1

Appraise whole person. The 4 area are physical appearance, body structures, mobility, and behaviour.

Question 2

What are the extra comments that pertain to physical appearance, body structure, mobility, and behaviour?

Answer 2

PA- do they look their age, level of consciousness (alert, responding), face features (symmetry), and skin colour.
BS- proportions, deformities, sitting (relaxed or tense), posture, and nutrition.
M- what is their walk like, range of motion, and gait.
B- facial expression, mood, speech, physical hygiene, and dress.

Question 3

What is BMI?

Answer 3

Body mass index. Calculated by divided weight in kg by height in meters squared. Is flawed.

Question 4

What is the waist/hip ratio?

Answer 4

Assesses the risk for obesity. Divide waist circumference by hip circumference.

Question 5

What is ranges of TBRBP and SpO2 for normal adults?

Answer 5

T= 36-38
P= 60-100 beats/min
R= 10-20 breaths/min
BP= 120-130/80-85, both less than
SpO2= 95-100%

Question 6

What are the vital signs?

Answer 6

Temperature, pulse, respiratory rate, and blood pressure.

Question 7

How do we take temperature and what are the guidelines?

Answer 7

Can talk it oral, rectal, axilla, and tympanic. Rectal is most accurate but we use oral the most. Wait 2 min if smoked, 5 min if patient had gum, and 20 min if they ate something hot/cold.

Question 8

What is hyperthermia, hypothermia, and prexia?

Answer 8

Increased temperature, decreased temperature, and fever.

Question 9

How do we take pulse, what is it, what is it influenced by, and what are some guidelines for it?

Answer 9

Pulse is palpable bounding blood flow (stroke volume). Influenced by meds, exercise, age, temperature, emotions, body positions, and hypovolumia. Wait 5-10 minutes after activity. Count 30 sec and times by 2 for regular rhythm. If nit, count for full minute.

Question 10

What do we access for pulse?

Answer 10

Rate, rythymn, force/strength (full/bounding= 3+, normal= 2+, and weak/threads= 1+, and absent= 0).

Question 11

What is tachycardia and bradycardia?

Answer 11

Rapid pulse (more than 100) and slow pulse (less than 60).

Question 12

True or false: Altheltes have lower pulses?

Answer 12

True

Question 13

What are respirations influenced by?

Answer 13

Exercise, pain, smoking, temperature, body position, meds, brain injury, sleep, hemoglobin function, and anxiety.

Question 14

How do we measure respirations?

Answer 14

Chest rise (inspiration) and fall (expiration) is 1 respiration. Counts 30 seconds times 2. Don’t tell patient you’re assessing their respiration rate.

Question 15

What do we assess for with respirations?

Answer 15

Respiratory rate, pattern/rythym, depth (deep, normal, or shallow), and O2 saturation (% of hemoglobin bound with oxygen).

Question 16

What is systolic and diastolic pressure?

Answer 16

S- ventricular contraction, top number
D- resting, filling heart, lower number

Question 17

What is blood pressure influenced by?

Answer 17

Age, weight, emotions, gender, exercise, stress, meds, diurnal rhythm, and ethnocultural background.

Question 18

What are some physiological factors of blood pressure?

Answer 18

Cardiac output, volume of circulation blood (more there is= higher BP), viscosity of blood, peripheral vascular resistance, and elasticity of vessel walls.

Question 19

When should patient wait before taking BP?

Answer 19

30 minutes for exercise, 60 min for caffeine/smoked, and just wait 5 min in general.

Question 20

What are the types of Korotkoffs sounds?

Answer 20

1- systolic pressure (clear taps)
4- muffling of sounds
5- diastolic pressure (silence)

Question 21

How do we take BP?

Answer 21

Palpate for brachial artery, plus cuff 2.5 cm above artery (cuff shouldn’t cover whole arm), palpate artery and inflate cuff until pulse disappears then 30 mmHg higher. Then using stethoscope, inflate to that number and slowly deflate at 2 mmHg and not when sound starts (systolic) and stops (diastolic).

Question 22

What is hypotension, hypertension, and postural hypotension?

Answer 22

Decreased BP/lowers than 90 mmHg, increased BP, and blood rushes to feet when standing so they pass out.

Question 23

What are some developmental considerations for general survey and vital signs?

Answer 23

Infant/children: have bigger heads, parental bonding, vital signs you need co-operativness of child.
Older adults: change to body shape, loss of height, higher BP because of stiffened arteries.

Question 24

What does IPPA stand for?

Answer 24

Inspection, palpation, percussion, and auscultation (use stethoscope).

Question 25

What is inspection?

Answer 25

Concentrated watching, general then local, uses visual/auditory/olfactory sense, and detects physical signs.

Question 26

What is palpation?

Answer 26

Use sense of touch (can only be light). Asses for texture, temperature, moisture, lumps, vibrations, rigidity, tenderness and pain. We can use our fingertips, fingers, back of hands, ball of hands, and palms. Back of hand determines temperature. Fingertips determine texture, swell, lumps, and pulsation. Palm surface best for vibration.

Question 27

What is percussion?

Answer 27

Produce vibrations which determine location, size, and density of structures. Always percussion twice. Resonant- hollow. Hperesonant- louder. Tympany- drum like. Dull- thud. Flat- shorter/flat sound. There’s also a striking and stationary hand.

Question 28

What is a stethoscope/parts?

Answer 28

Diaphragm- larger end, high pitch sounds, useful for normal heart sounds Bell- smaller end, low pitch sounds, useful for murmurs.

Question 29

What is auscultation?

Answer 29

Listen to sounds produced by parts of the body.

Question 30

What is a noiceptor?

Answer 30

Nerve endings that detect painful sensations from periphery and transmit to CNS.

Question 31

What is nociception and the 4 phases?

Answer 31

Describes how noxious stimuli are perceived as pain. 1. Transduction- injured tissue release chemicals that propagate pain message, action potential moves along to spinal cord 2. Transmission- pain impulse moves from spinal cord to brain 3. Perception- perception of pain 4. Modulation- neurons form brain release neurotransmitters that block pain impulse

Question 32

What is nociceptive pain, somatic pain, visceral pain, referred pain, and neuropathic pain.

Answer 32

NoP- caused by tissue injury, normal response, ache/throb SP- superficial, deep, bone, muscle, joint, and tendon pain VP- from larger interior organs RP- originates in 1 location and experienced at another NeP- burn, shooting pain, abnormal response

Question 33

what is acute and chronic pain?

Answer 33

Acute- short, goes away after injury is healed Chronic- recurring, lasts longer than 3 months like cancer pain

Question 34

What is the brief pain inventory?

Answer 34

Patient rates pain on a scale from 0-10. Pain is subjective.

Question 35

What is the behaviour of people suffering with acute and chronic pain, and behaviour of babies suffering with pain?

Answer 35

Acute- patient can’t verbalize Chronic- adapts over time, can give little indication Infants- pain depends on behaviour and physiological cues

Question 36

What type of body part do we use to measure temperature for smaller kids and babies?

Answer 36

Rectal

Question 37

What is carotid commissioner?

Answer 37

Compression of both carotid arteries at the same time which causes blood flow to the brain.

Question 38

What is the doppler technique?

Answer 38

Pitch will increase when distance is short and vice versa. it enhances pulse and BP measurement. Locates peripheral pulse sites.

Question 39

What is a core and surface temperature?

Answer 39

Core temp of structures is deep within the body (rectum). Surface temp is skin/mouth, it fluctuates.

Question 40

What does the hypothalamus do?

Answer 40

It’s our bodies thermostat. It controls body temperature.

Question 41

Why does prexia occur?

Answer 41

Heat loss mechanisms unable to keep pace with excess heat production.

Question 42

What are some different pulse sites?

Answer 42

Apical (left midclavicular line), carotid (neck), brachial, radial (radial side of wrist), and temporal (head).

Question 43

What does dysrythmia mean?

Answer 43

Abnormal rythym.

Question 44

What are some symptoms for high and low BP?

Answer 44

High= headache, nosebleed, fatigue Low= dizzy, pale, restless

Question 45

Can you cross your legs when measuring BP?

Answer 45

no

Question 46

What is procedural pain?

Answer 46

Associated with medical procedures, usually acute.

Question 47

What does the assessment strategy OPQRSTUV for pain stand for?

Answer 47

Onset, provoking/palliating, quality, region/radiation, severity, timing/treatment, understanding/impact on you, and values.

Question 48

What pain scale is used for kids?

Answer 48

Faces pain scales.