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What are the 5 key measurements of the general survey?
- Height
- Weight
- BP
- TPR (temperature, pulse, respirations)
- Pain
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What are some of the aspects of a client's physical appearance that you should account for?
- Age
- Sexual characteristics
- Skin
- Facial features/symmetry
- Signs of distress
- personal hygiene
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Important things to recognize in general body structure
- Stature - proper height to weight ratio
- Nutrition - well nourished, overweight, obese, thin, cachexia
- Symmetry - atrophy, hypertrophy, edema
- Posture - erect, slumped
- Build and contour - lean, muscular
- Deformities
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Two categories related to mobility:
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What do we compare clinical measurements to?
- Normal ranges - BP, rate and rhythm, BMI - these are also relative to: age, gender, lifestyle, etc.
- Client's recent values or serial readings
- Diagnosis - weight, atrophy, and other characteristics may be affected by disease or illness
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What is one reason for performing serial weights?
Heart failure patients
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What time would you perform serial weight measurements?
At the same time each day; normal weight changes approx. 2-3lbs per day
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What are some of the reasons for weight gain?
- Overeating or inactivity
- Fluid volume excess
- Hypothyroidism (decreases metabolism)
- Drug therapy (corticosteroids)
- Diabetes
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1 Liter of fluid increase will result in how many pounds?
2.2lbs = 1 Liter of fluid volume
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A client has a weight increase of 6 lbs in the last 2 weeks. What may be a cause?
- Heart failure/decompensation
- A weight gain of 2-3 lbs per week is significant
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What are some reasons for weight loss?
- Anorexia or decreased intake
- Dehydration
- Increased metabolic rate
- Diabetes (new onset or poor control)
- Malignancy
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What are the 4 major vital signs?
- TPR - temperature, pulse, respiration
- BP - blood pressure
Pain is considered the 5th
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What part of the brain regulates temperature?
Hypothalmus
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Febrile?
Afebrile?
Has fever
No fever
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What factors affect body temperature?
- Diurnal cycle (1-1.5' F change with peak at 4pm and trough at 4am)
- Menstrual cycle (1' F increase due to progesterone secretion)
- Exercise (moderate to heavy)
- Age (children's temperatures may run high, older adults are more at risk)
- Illness
- Exposure
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What is the normal oral temperature?
Rectal?
Tympanic?
Axillary?
- Oral: 98.6' F (96.4-99.1) or 37' C (35.8-37.3)
- Rectal: +1' F or 0.5' C
- Tympanic: +1' F or 0.5' C
- Axillary: -1' F or 0.5' C
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At what age would you obtain oral temperature in children?
5-6 years old
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What is the definition of fever?
Temperature > 101' F or 38' C
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How long does smoking affect oral temperature?
Hot or cold fluids?
- Wait 2 minutes after smoking and
- wait 15 minutes after hot/cold fluids before taking temperature orally.
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What route would you use with a BLUE tipped thermometer?
RED?
- BLUE tips are for ORAL temps
- RED are for AXILLARY/RECTAL
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How long do you time the pulse rate of a regular rhythym?
An irregular rhythym?
- 30 seconds for a regular rate
- 1 minute for an irregular rate/rhythym
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Your client's pulse rate increases with inspiration and decreases with expiration. What could this signify?
Sinus arrythmia (common in children and young adults)
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Where would you palpate the pulse on a child younger than 2 years old?
Apical pulse
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What is the normal heart rate in adults?
Bradycardia?
Tachycardia?
- Normal: 60-100 beats per minute
- Brady: <60 bpm
- Tachy: >100 bpm
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What factors can increase pulse rate?
- Age (higher in children)
- Female
- Exercise
- Anxiety
- Pain
- Fever (higher fever, higher rate)
- Dehydration
- Anemia (decreased RBC/dehydration, increased rate)
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What is a pulse deficit?
The difference between the apical and radial pulse rate
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Your patient has a radial pulse rate higher than the radial rate. What could this signify?
Sign of Heart Disease
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How is pulse strength measured?
- 4+ Bounding (at rest sign of Heart Disease)
- 3+ Full (normal with exercise)
- 2+ Normal
- 1+ Weak, thready
- 0 Absent
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How long do you count respirations with a normal rhythym?
How long with an abnormal bretahing pattern?
- Normal: count for 30 seconds
- Abnormal: count for 1 minute
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What is the normal respiratory rate in adults?
Bradypnea?
Tachypnea?
- Normal: 10-20 breaths per minute
- Brady: <10 breaths pm
- Tachy: >20 breaths pm
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What are the 5 things to assess in examining repirations?
- Rhythym
- Rate
- Depth
- Character (thoracic in women, abdominal in men and children)
- Abnormal patterns (hyperventilation, hypoventilation, apnea, dyspnea)
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Blood Pressure
Force exerted on vessel walls during cardiac cycle
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Systolic pressure
Force exerted on Arterial walls during Systole
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Diastolic pressure
Resting pressure during diastole
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Pulse pressure
Difference between the systolic and diastolic pressures
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Mean arterial pressure
- Average amount of pressure forcing blood into the tissues throughout the cardiac cycle
- Measured: MAP = Diastolic BP + 1/3 Pulse Pressure
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Your client has a resting BP of 110/75
What is the pulse pressure?
What is the MAP (mean arterial pressure)
- Pulse pressure = 110-75 = 35
- MAP = 75 + 1/3(35) = 87
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WHat factors determine BP?
- Cardiac output
- Volume
- Blood viscosity (thickness increased by: polycythemia, altitude, chronic lung disease)
- PVR (Peripheral Vascular Resistance) - constricted vessels
- Sympathetic nervous system stimulation - SNS causes vasoconstriction
- Elasticity of vessels (arteriosclerosis)
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What is a normal BP?
<120 systolic / <80 diastolic
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What blood pressure range would be considered pre hypertensive?
Hypertensive?
- Pre-hypertensive: Systolic: 120-139 Diastolic: 80-89
- Hypertensive*: Systolic >139 Diastolic >89
*BP checked in both arms. Must be documented 2 times for diagnosis.
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Is HTN a nursing or medical diagnosis?
Medical (the nurse would document elevated BP)
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What is the goal BP of diabetics?
<130 / 80
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What factors increasee blood pressure?
- Age
- Gender (men, females post menopause)
- Race (african americans)
- Diurnal rhythym (higehr late afternoon, lower am)
- Obesity
- Exercise
- Emotions, stress, pain (stimulated SNS)
- Smoking (wait 30 minutes before checking BP)
- Alcohol
- Meds (NSAIDS, pseudophedrine, ibuprofen)
- "White coat syndrome" - stress caused by medical setting
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What level should the client's arm be at when taking BP?
Relaxed, at heart level
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What is the 1st Korotkoff sound during BP?
The 5th?
- 1st - systole (clear tapping heard by the opening of the artery and blood flowing in)
- 5th - diastole (silence)
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How would you find the proper size blood pressure cuff for a client?
- Bladder length = 80% of the arm circumference
- Bladder width = 40% of the arm circumference
*The bladder is only the inflatable portion of the cuff, not the entire length.
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How high do you inflate the blood pressure cuff before realsing the air?
20-30 mm beyond the point of brachial pulse obliteration
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How long do you wait between taking BP measurements in teh same arm?
15 seconds
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Your client has a higher BP in the right arm than the left, which measurement do you use?
Always use the higher of the two measurements
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If you did not pump the cuff up high enough, how would this affect your reading?
this would give you a falsely low BP
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If the BP cuff is too small, how would this affect your reading?
Too large?
- Too small - false high
- Too large - false low
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Errors when taking BP
- Cuff size
- Arm position
- Cuff too loose
- Deflated too quickly
- Not inflated enough
- 15 seconds not waited between measurements
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Paradoxical pulse
- A difference in the systolic BP while during inspiration v. expiration
- A normal difference is 5mm
- A paradoxical pulse is >10 mm
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You find your client has a 15 mm diiference in Systolic BP during inspiration v. expiration. What could this signify?
- This is a paradoxical pulse
- Often indicative of a serious condition (cardiac tamponade, constrictive pericarditis, emphysema)
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Orthostatic hypotension
- A significant drop in BP when position is changed
- Drop in SBP > 20 mm or increase in pulse rate > 20 bpm when position is changed
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What could be a cause of orthostatic hypotension?
orthostatic hypotension is caused by: peripheral vasodilation without a compensatory increase in CO2
- May be found with: Hypovolemia (dehydration)
- Bedrest
- Medications (vasodilators)
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Your client reports dizziness when standing. What would you assess for?
Orthostatic hypotension
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