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38 Cards in this Set
- Front
- Back
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General Survey Physical Appearance |
stated age distress body fat posture gait hygiene odors |
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General Survey Psychological Presence |
mood and manner speech facial expression emotional distress eye contact |
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Types of distress |
respiratory pain perspiration crying body language |
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Vital signs |
Temperature pulse respirations blood pressure oxygen saturation |
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Thermoregulatory center |
Hypothalamus keeps temperature nearly constant |
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Surface temperature |
96.8-99.8 |
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Core body temp |
98.0-100.4 |
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Pyrexia |
Fever: helps in fighting disease; may get dangerously high; may be a late symptom of infection antipyretics lower temperature measured and treated by nurse: dont wait for doc order. use wisdom |
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What changes body temp? |
Circadian rhythm Hormones Infection Stress Exercise Environmental |
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Places to take temp |
Oral- 98.6 patient must be cooperative, alert Tympanic- 98.2 easy, convenient Rectal- 99.6 precautions: vagal, imperforate anus Axillary- 97.6 done correctly, accurate Temporal- 98.2 precautions: sweat can impair reading |
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Pulse |
Rhythm- beat to beat pattern can be regular or irregular irregular= arrhythmias |
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amplitude of pulse |
reflects stroke volume reflects peripheral vascular resistance measured 0-3 0-absent 1-weak (thready, easily obliterated when palpated) 2-normal 3-bounding |
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Normal Heart Rate |
60-100 beats per minute |
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Assess heart rate |
palpation: feeling middle 2 fingers gently auscultation: listening stethoscope for apical pulse doppler for peripheral pulse Note: rhythm, rate, and amplitude |
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What causes an increased pulse? |
caffeine activity anxiety medications pain tobacco blood loss anemia |
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what causes a decreased pulse? |
age athletes medications -beta blockers -digoxin |
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Respiratory Cycle |
Inhalation: diaphragm and intercostal muscles contract, chest rises Exhalation: Chest relaxes |
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Normal respirations |
12-20 per minute |
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Apnea |
absence of breathing |
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dyspnea |
breathing that is labored or difficult |
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orthopnea |
difficulty breathing in any position other than upright (difficulty breathing laying down) |
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Tachypnea |
rapid breathing: respiratory rate greater than 20 per minute |
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What causes changes in respirations? |
inhibit or stimulate respiratory muscles -chemoreceptors in aortic arch/carotid arteries -stretch receptors in the lungs -receptors in muscles and joints increased carbon dioxide rate and depth changes: exercise, anxiety, infection, pain |
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Respiratory Center |
medulla and pons |
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Blood Pressure |
force exerted by the flow of blood pumped into the large arteries |
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hypertension |
elevated BP x 3 readings (140/90) -increased risk for heart disease and stroke -silent killer |
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hypotension |
decreased BP (<90/50?) orthostatic hypotension -laying down to standing baroreceptors in great arteries detect hypotension note: initiate vasoconstriction; increase heart rate and BP |
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Measuring Blood Pressure |
Choose appropriate size cuff (cover 80% of arm) Choose appropriate site Equipment needed: stethoscope, aneroid manometer |
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When taking BP |
avoid arms with IV, shunt, or arterial line avoid arm with mastectomy(if double use thigh) position arm at heart level place cuff 1-2 inches above antecubital space thigh alternative site(systolic maybe 10mmHg higher) sitting/standing/lying |
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Systole |
ventricles contracting |
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diastole |
ventricles filling/relaxed |
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pulse pressure |
difference between systolic and diastolic |
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Causes of BP reading errors |
cuff too small/ too large deflate too rapidly/ too slow reinflate without waiting arm above heart/below heart |
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What to do when having abnormal results? |
look at patient(do the appear okay, is the #normal for them) think about diagnosis/ hydration status repeat give medications as ordered report extremes teach your patient about hypertension record findings |
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oxygen saturation |
measured by pulse oximeter: measures oxygen saturation of hemoglobin lower than 90%= abnormal Probe clipped or taped to fingertip, earlobes, toe, and nose |
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Height and Weight (BMI) |
BMI 20-25: normal <18.5: underweight 25-30: overweight >30: obese |
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Why Monitor weight? |
Dosing medications Fluid balance Dietary teaching Dietary surveillance |
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Pulses |
Popliteal FemoralPoplitealDorsal pedisPosterior tibial Dorsal pedis Posterior tibial |
