General Survey

Front 1

age, sex, level of consciousness, skin color, and facial features

Back 1

physical apprearance

Front 2

stature, nutrition, symmetry, posture, position, body build, contour

Back 2

body stucture

Front 3

gait, range of motion

Back 3

mobility

Front 4

facial expressions, mood & affect, speech, dress, and personal hygeine

Back 4

behavior

Front 5

- on admission to healthcare facility (baseline) when assessing the client during home care visits
before and after surgical or invasive diagnostic procedure
routine schedule according to physicians order to facility standards of practice (minimum std) befire and after certain medications and therapies
change codition
before, during and after interventions

Back 5

when to take vital signs

Front 6

balance scale, recommended range of height. it is in kg

Back 6

weight

Front 7

use wall mounted device or the measuring pole on the balance scale. should be shoeless inches to feet

Back 7

height

Front 8

_____ as themostat mechanism influeces on temperature- diurinal cycle, menstrual cycle, excercise, and age. 37.2 C (99F) deep body temp

Back 8

hypothalamus

Front 9

oral temp of a resting person is 37 C (98.6), with a range off 35.8 C to 37.3 C (96.4 F to 99.1F). the rectal temp measures 0.4 C to 0.5 C (0.7F to 1F) higher

Back 9

temperature

Front 10

oral, electronic thermometer, axillary, rectal, tympanic membrane thermometer

Back 10

routes of temp mearurement

Front 11

temperature of deep body tissues, under control of the hypothalamus, maintained within narrow range, temp 36.5-37.5 C (96.8-99.4 F)

Back 11

core temperature

Front 12

skin temps reacts to ________
acceptable temp range for adults depends on age, gender, range of physical activity and state of health

Back 12

environment

Front 13

vasodilation, sweat gland function, pyrexia-fever, environment, temperature site, types of clients and specific settings

Back 13

factors affecting temperature

Front 14

with every beat, the heart pumps an amount of blood into the aorta

Back 14

stroke volume

Front 15

60 to 100 beats per minute start counting with 0 assess the ____, including 1 rate 2 rhythm 3 force and 4 elasticity

Back 15

pulse

Front 16

less than 60 BPM is _______
occurs normally in a well trained athlete whose hear muscle develops along with the skeleltal muscle. a more rapid heart rate over 100 BPM is ______

Back 16

bradycardia
tachycardia

Front 17

the heart rate varies with respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration commonly found in children and young adults

Back 17

sinus arrythmia

Front 18

shows the strength pf the hearts stroke volume. a weak thready pulse reflects a decreased ___ ____. a full bounding pulse denotse an increased ____ _____
3+ full, bounding
2+ normal
1+ weak, absent
0- absent

Back 18

force

Front 19

with normal ____ the artery feels springy, straight, resilient.

Back 19

elasticity

Front 20

if the pulse is ____ count for 60 seconds. assess frequency and pattern of ____ . when pulse is ____ compare radial pulses bilaterally

Back 20

irregular

Front 21

adult 10-20. ratio of ulse rate to ___ ___ should be approximatley ___

Back 21

respiratory rate
4:1

Front 22

less than 10 breaths per minute

Back 22

bradypnea

Front 23

greater than 20 breaths per minute

Back 23

tachypnea

Front 24

respirations increased in depth

Back 24

hyperpnea

Front 25

cease for several seconds

Back 25

apnea

Front 26

assess by observing rate, depth, and rhythm of respiratory movements. determine baseline. observe complete cycle

Back 26

respiratory cycle/rate

Front 27

if irregular less than _ or greater than _ count respirations for 30 seconds and multiply by 2. note depth of respirations- shallow, normal, or deep- dont confuse sighing with abnormal rhythem

Back 27

12
20

Front 28

measures arterial blood o2 saturation % of hgB filled with o2- LED (light emitting diode) probe. non-invasive and reliable

Back 28

pulse oximetry

Front 29

sites (highly vascular to detect light):
-digit-easiest
-earlobe- least effected by decresed blood flow
-disposable- bridge of nose (adult), palm of (infant)
expensive, latex, increased rick of pathogens

Back 29

pulse oximetry

Front 30

90% to 100% normal
abnormal <85%
85%-89% may be acceptable in certain disease.
- no nail polish clean sites, lights must line up, good contact, good waveform, pulse should match actual pulse
BP cuff and peripheral vasoconstrictio will interfere

Back 30

readings and use of the pulse ox

Front 31

maximum pressure felt on the artery during left ventricular contraction

Back 31

systolic pressure

Front 32

resting pressure that the blood exerts constantly between each contraction

Back 32

diastolic pressure

Front 33

is the different between systolic and diastolic and reflects the stroke volume

Back 33

pulse pressure

Front 34

is the pressure forcing blood into the tissues, averaged over the cardiac cycle. it is closer to diastolic pressure plus one third the pulse pressure

Back 34

mean arterial pressure

Front 35

age- higher with age
race- AA have higer BP
weight- is higher in obese persons
emotions- momentarily rises with fear, anger, and pain as a result of stimulation of sympathetic nervous system.
stress- it is elevated on persons feeling continual tension because of lifestyle, occupational stress or life problems

Back 35

influence BP

Front 36

cardiac output- heart pumps more blood into the vessels, the pressure om the container walls increases
peripheral vascular resistance- oppositions to blood flow through the arteries. when vessel becomes smaller the pressure needed to push the contents becomes greater
Volume of circulation blood- how tightly the blood is packed into the arteries. increasing contents increases pressure

Back 36

BP determined by 5 factors

Front 37

Viscosity- thickness of the blood they are thicker oressure increases
elasticity of vessel walls- when the container walls are stiff and rigid the pressure needed to push the contents increases

Back 37

BP is determines by 5 factors

Front 38

I. systolic pressure
IV. muffling of sounds
V. diastolic pressure

Back 38

korotkoffs sounds

Front 39

a drop in systolic pressure of more than 20 mmhg, orthostatic pulse increases of 20bpm or more, occurs with a quick change to a standing position

Back 39

orthostatic hypotension

Front 40

2 step method - estimate sbp to prevent falso-low readings
1 step method- 30mmhg> usual baseline __
- palpate radial while taking BP and pump to 30 mmhg above pulse disappearance 2 sets, 2 minutes apart to establish baseline

Back 40

blood pressure

Front 41

when BP measured at the arm is excessively high, particularly in adolescents and young adults, compare it with thigh pressure to check for ______ of the aorta (a congenital form of narrowing). normally thigh pressure is higher than that in the arm

Back 41

coarctation