Physical Assessment and Vital Signs Lecture

Flashcards covering skin and extremity physical assessment, check-off procedural steps and scoring standards, and baseline adult vital sign ranges.

Skin Color Assessment

Evaluating patient skin color with the descriptor that it is normal for their ethnicity, rather than stating normal.

Skin Temperature Descriptors

The specific terms hot, warm, cool, or cold used to describe skin temperature after palpating with the back of the hand.

Edema

Swelling assessed on upper and lower extremities by evaluating shape, symmetry, water retention, and tissue rebound.

0 Edema

A clinical assessment finding indicating the complete absence of swelling.

+1 Edema

A finding where tissue pits upon finger pressure but rebounds immediately.

+2 Edema

A finding where tissue pits upon finger pressure, stays depressed, and is very slow to rebound.

+3 Edema

A finding where tissue indents upon finger pressure and does not rebound.

K-WIPES

A mnemonic for the procedural check-off beginning steps: knock, wash hands, introduce oneself, provide privacy, explain the assessment, and verify safety.

Safety Assessment

Scanning the room for safety hazards or loose debris, ensuring adequate lighting, confirming wheelchair or bed wheels are locked, and verifying side rails are up.

Check-off Passing Score

A score of at least $78\%$ ($7.8$ out of $10$ points on the first check-off) required to avoid mandatory remediation.

Check-off Schedule

The testing timeline consisting of check-off one in week $4$, check-off two in week $7$, check-off three in week $10$, and the final head-to-toe check-off in week $11$.

Normal Blood Pressure

A baseline arterial blood pressure reading of less than $120/80\,\text{mmHg}$.

Normal Respiratory Rate

A resting breathing frequency of $12$ to $20\,\text{breaths per minute}$.

Normal Temperature Range

A resting body temperature range between $96.4$ and $98.6$, which may sit lower in older adults.

Normal Pulse Oximetry

An oxygen saturation range of $95\%$ to $100\%$ for healthy individuals, compared to an expected baseline of $88\%$ to $92\%$ for COPD patients on oxygen.

Metoprolol

A beta-blocker blood pressure medication that lowers heart rate and must be held if the patient has a heart rate less than $60\,\text{bpm}$.

Inpatient Blood Pressure Treatment Threshold

The reading of $150/80\,\text{mmHg}$ where hospital providers typically initiate blood pressure medications if readings do not settle on their own.