202GS, Meas., VS

  1. General Approach
    • -Measure height, weight, BP, TPR, vision (if applicable)
    • -Provide exam gown (leave room when pt undressing)
    • -Wash hand's in front of pt
    • -Explain each step
    • -Give encouragement as you proceed
    • -Organize exam for efficiency and pt comfort
    • -Use systematic approach (sequence, top to bottom)
    • -Give summary of findings
  2. General Appearance
    (Physical characteristics)
    • -Age (appear stated age?)
    • -Sex (development appropriate to age?)
    • -Skin (pale, red, cyanotic, flushed, lesions, sores)
    • -Facial features (symmetrical?)
    • -Signs of acute distress (SOB, in pain?)
    • -Personal hygiene (look clean, well groomed, oily, BO?)
    • -Involuntary movement (twitch, tic)
  3. General Appearance
    (Body structure)
    • *WDWN: well developed, well nourished
    • -Stature (height w/in standards)
    • -Nutrition (well nourished, overweight, obese, thin, cachectic [thin, wasted])
    • -Symmetry (atrophy, hypertrophy, swelling
    • -Posture (erect, slumped--can indicate depression)
    • -Position (relaxed, tense, fetal)
    • -Body build (lean muscular)
    • -Physical deformities (limp, one leg shorter)
  4. General Appearance
    (& mental status and behavior)
    • -Gait (how do they walk--steady, ataxic or ataxia gait [drunk walk])
    • -ROM (FROM vs. limited ROM
  5. Clinical Measurements
    • -Essential part of initial data base
    • -Analyzed in relation to normal ranges, client's recent values & serial readings, and dx
  6. Weight
    • -Remove shoes, and heavy clothing
    • -Serial weights
    • -Weight gain
    • -Weight loss
  7. Weight Gain
    • -Overeating or decreased activity
    • -Fluid vol. excess (2.2 lb weight gain=1L, >2-3lbs/wk is significant)
    • -Hypothyroidism (if underactive thyroid dec secretion of TH causes hypermetabl
Card Set
202GS, Meas., VS
202: General Survey, Measurement, and VS