Health Assessment Test 1

Vitals, Pain, EBA, Assessment Technique, Safety, General Survey

what do vital signs include?

temperature, respiratory rate, pulse, and blood pressure

cellular metabolism requires a deep body temp of

37 degrees celsius at rest

how does the body maintain steady temperature?

through feedback mechanism regulated in hypothalamus of the brain

what does temperature balance?

heat production and heat loss

what factors influence temp?

diurnal cycle, menstruation cycle, exercise, and age

what is the diurnal cycle?

with trough occurring in early morning hours and peak occurring in late afternoon to early evening

how much does the diurnal cycle affect temperature?

1-1.5 degrees fareinheight

how does the menstruation cycle in women affect temp?

progesterone secretion causes a .5 to 1.0 F rise

what is the mean temp in older adults?

36.2

what is the range of normal temperature for oral?

35.8-37.3 (96.4-99.1)

rectal temp measures how much higher than oral temp?

.4-.5 (.7-1) degree higher

hypothermia is a temp below?

36 degrees celsius

hyperthermia is a temp above?

37.8 degrees celsius

which temp procedure is the most accurate?

rectal

when do you use rectal temp?

only when other routes are not practical

what does the TAT thermometer use?

infared emissions from temporal artery

what is a pulse?

a palpable flow felt in the periphery from pressure wave generation from stroke volume

what does pulse indicate?

rate and rhythm of heartbeat and data on condition of artery

what is the normal heart rate in a resting adult?

50-95

how does heart rate vary with age?

lower in older individuals and higher in younger/infants

how does gender affect heartrate?

higher in females after puberty

a heart rate less than 50bpm in an adult is

bradycardia

when does bradycardia normally occur?

in athletes whos heart muscle develops along with skeletal muscles

a heartbeat over 95 bpm in a normal adult is

tachycardia

when does tachycardia normally occur?

with anxiety, increased exercise to match the body need for increased metabolism

what is sinus arrhythmia?

one irregularity commonly found in children and young adults where the heart beat varies with respiration

an individual with sinus arrhythmia would have an _________ heart rhythm with inspiration

increased

force of pulse is the strength of what?

the hearts stroke volume

a weak, thready pulse _______

reflects

a full, bounding pulse ______-

denotes

pulse force is recorded using what?

the three point scale

what number is considered normal on the three point scale for heart force?

2

what is the average rate of healthy adult breaths?

20 breaths per minute (ranging from 16-25 breaths per minute)

Normally both pulse and respiratory rates ______ as a response to exercise or anxiety

spike

what is tachypnea?

a respiration rate over 25

what is bradypnea

a respiration rate below 8-12

what is blood pressure?

the force of blood pushing against side of its container/vessel wall

what is systolic pressure?

maximum pressure felt during left ventricular contraction

what is diastolic pressure?

resting/elastic recoil

what is pulse pressure?

the difference between systolic and diastolic

what is mean arterial pressure?

needed to maintain adequate tissue/organ perfusion (MAP> or = 60)

how does age affect blood pressure?

rises through childhood and into adult years

how does sex affect blood pressure?

post puberty females show a lower BP than males, but after menopause females show higher

how does weight affect BP?

obesity increases BP

what effect does exercise have on BP?

increases

what effect do emotions have on BP and why?

increase in response to sympathetic nervous system response

the level of BP is determined by what 5 factors?

cardiac output, peripheral vascular resistance, volume of circulating blood, viscosity, and elasticity of blood vessel walls.

an increase in CO leads to an ______ in BP

increase

increased peripheral vascular resistance leads to an ______ in BP

increase

an increase in the volume of circulating blood leads to an_______ in BP.

increase

increase in viscosity leads to an _______ in BP

increase

more elasiticty of vessel wall leads to ______ BP.

decreased

what do automated devices use to monitor blood pressure?

oscillometry

what is BP measured with>

stethoscope and aneroid sphygomomanometer

what is K1

the first clear repetitive tapping sound

what does K1 signifiy

systolic

K2 is

swooshing

K3 is

knocking sounds

KIV

muffling

KV is

silence or diastolic

what is the ausculatory gap?

when sounds dissapear during the end of K1. This can give false readings

what can lead to higher BP readings?

when physiologically active, following active, emotional labile, narrow cuff size, applied too loose, and reinflating during the procedure

what can lead to lower bp readings?

decreased inflation (not inflating enough) and too large of a cuff size

what can cause high or low bp readings (examiner or observer error)

position of arm or leg, improper cuff size, deflating cuff too quickly

when would we do a palpated blood pressure?

when they are very sick (ER or ICU)

what is orthostatic hypotension?

a drop in systolic less than or equal to 20 and a drop in diastolic less than or equal to ten after position change

what causes orthostatic hypotension>

prolonged bed rest, old age, certain meds, and hypovolimia

when should you take serial measurements of pulse and blood pressure?

suspected volume depletion, hypertension or taking antihypertensive medications, fainting or syncope, position change shows change in systolic pressure

BP is not usually checked in children of what age?

less than 3 years old (unless they are in the NICU)

where should you take an infants temp?

axillary, inguinal, or tympanic

if an infant is critically ill or unconscious where should you take their temp>

rectal

what is the order of vital signs for infants and children?

respiration, pulse, temperature, and BP

at the age of 6-8 years children have higher what?

fever during illness than adults do

where should you palpate in infnats?

an apical rate

in children older than five where should you palpate?

the radial site

how long should you count the pulse for in children?

a full minute because of chance of sinus arrhythmia.

where should you watch for inspirations on an infant?

the abdomen because they are more diaphragmatic than thoracic.

what type of respiratory rate is most accurate in infants?

sleeping

how long should you wait for an infant to become quiet before measuring their BP>

about 5 to 10 minutes because crying can elevate the BP systolic 30 to 50 mmHg

tachypnea in newborns to 2 months is

greater than 60 respirations per minute

tachypnea in 2 month olds to 12 month olds is

greater than 50 beats per minute

when does tachypnea occur in infants?

with fever and pneumonia

an aging person is less likely to have a fever but at a greater risk for what?

hypothermia

aging causes a _____ in vital capacity and a _____ inspiratory reserve volume

decreased

in many older people, both systolic and diastolic _________ making it hard to do what?

increase making it hard to distinguish normal aging values from abnormal hypertension

what is a pulse oximeter?

a noninvasive method of measuring oxygenated hemoglobin and unoxygenated hemoglobin

what does an oximeter compare?

ratio of light emitted to light absorbed and converts ratio to percentage of oxygen saturation

a healthy oxygen saturation in room air is what?

97-99, but over 95 is clinically acceptable.

if there is a lower O2 saturation, probe what?

the ear lobe because it is more accurate and less affected by peripheral vasoconstriction

when is an oximeter inaccurate?

in CO2 poisioning, methemoglobinemia and low perfusion

what does an electronic vital signs monitor provide?

BP, MAP, and pulse, but can also provide temperature and pulse oximetry

what is an EVM used for?

serial measurements and trending data

what is a doppler?

it is used to locate peripheral pulse sites and augments K sounds to hear louder during pulse and blood pressure

what is considered hypotension?

BP under 90/60 mmHg

what is hypotension seen in?

acute myocardial infarction, shock, hemorrhage, vasodilation, and addisons disease

primary hypertension accounts for how many cases of adults?

95%

what is stage one of primary HTN?

130-139 systolic and 80-89 diastolic

what is stage 2 of primary HTN?

140 or greater systolic and 90 or greater diastolic

what are major risk factors that impact target organs (CV) and vasculature?

smoking, dyslipidemia (high cholesterol), diabetes mellitus (above 60 years old), family history of cardiac disease (F under 65 years of age and men under 55)

what are lifestyle modifications of HTN?

weight loss, limit alcohol use, increase aerobic exercise, reduce sodium intake, maintain dietary potassium, calcium, and magnesium, smoking cessation, reduce intake of saturated fats and cholesterol