general survey, measurement, vital signs, and pain

general survey physical appearance

age, sex, level on consciousness, skin color, facial features, hygiene, mood

general survey body structure

stature, nutrition, symmetry, posture, position, body build, contour

level of consciousness

sensorium, cognition

what would happen if sensorium and cognition were abnormal?

decreased cerebral perfusion

lethargic

drowsy, decreased interest/spontaneity, requires moderate stimulation to arouse and may fall back asleep

obtunded

more impaired; slow response; decrease interest, requires repeated stimulation

stuporous

responds only to vigorous/painful stimuli returns to unresponsiveness w/o ongoing stimulation

comatose

unarousable and unresponsive to any stimuli

Glasgow coma scale

eye opening response, verbal response, motor response

eye opening response scores

4- eyes open spontaneously

3 eyes open to verbal command, speech or shout

2- eyes open to pain (not applied to face)

1- no eye opening

verbal response scores

5- orientated

4- confused conversation but able to answer questions

3- inappropriate responses, words discernible

2- incomprehensible sounds or speech

1- no verbal response

motor response scores

6- obeys commands for movement

5- purposeful movement to painful stimulus

4- withdraws from pain

3- abnormal flexion, decorticate posture

2- extensor response, decerebrate posture

1-no motor response

minor brain injury

13-15 points

moderate brain injury

9-12 points

severe brain injury

3-8 points

3 points

dead

measurement

height and weight

what is measurement used to evaluate

patients fluid balance, and medication dose

why are vital signs taken?

to determine the relative status of vital organs (heart, blood vessels, lungs)

to establish a baseline

to monitor response to surgery, treatments and medications

to observe for trends in patient’s status

vital signs

temperature, pulse (heart rate), respiration, blood pressure, SpO2, pain (subjective)

at what frequency should you take vital signs?

routine every 4-6 hrs

at what frequency should you take vitals after surgery?

every 15 mins for 2 hrs, then every 30 mins for 2 hrs

what does normal vital signs depend on?

age and disease

what does temperature assess for?

inflammation and infection

what is temp regulated by

hypothalamus

every 1 C of elevation of body temp…

o2 consumption and co2 production increases 10% (HR and RR increase)

hypothermia

body temp below 35 C

body shivers to generate heat

vasoconstriction to conserve heat

decreased oxygen consumption

decreased heart rate and RR

decreased CO2 production

accidental or induced

drowsiness, confusion, dizziness

dialted pupils

last thing to feel is warm

hyperthermia

body temp above 37.5

feels warm to touch

dilation of blood vessels

increased o2 consumption, heart rate and RR, co2 production, muscle spasms, sweating, cool

loss of concentration

weak quick pulse

factors affecting body temp

age, environment, time of day, exercise, stress, gender

which is considered the most accurate temperature site?

rectal

what do you have to evaluate for pulse

rate, rhythm, strength

o2 delivery depends on ability to

pump oxygenated blood

increasing cardiac output to compensate for

hypoxic tissues

what is average heart rate for adults

72

who has the highest pulse rate?

babies

who has the lowest?

athletes

what is rhythm?

equality of intervals between beats

pulse deficit

difference between auscultated beats and peripheral pulse beats. weak heartbeat not generating enough pulse to create a pulse wave

pulse strength

quality of left ventricular contraction an volume of blood flow to periphery

pulsus alternans

alternating strong and weak pulses (heart failure, valvular disease, pericardial effusion)

pulsus paradoxus

decrease strength with inspiration, normal with exhalation

tachypnea

rapid respiratory rate

bradypnea

slower than normal rate

eupnea

normal rate

apnea

no respiration

sighing

normal if occasional; anxiety if frequent

systolic BP

peak force exerted during contraction of the L ventricle

Diastolic BP:

force occurring when the heart is relaxed diastole

when pulse pressure is less than 30

peripheral pulse will be hard to detect; heart failure, decrease SV

how many readings on how many occasions to diagnose hypertension?

3 readings on 2 diagnoses

normal blood pressure

systolic: less than 120

diastolic: less than 80

elevated blood pressure

systolic: 120-129

diastolic: less than 80

hypertension (stage 1)

systolic: 130-139

diastolic: 80-89

hypertension (stage 2)

systolic: 140 or higher

diastolic: 90 or higher

hypertensive crisis

systolic: higher than 180

diastolic: higher than 120

hypotension

BP less than 90/60

mean arterial blood pressure

DP +1/3 (sp-dp)

what must the MAP be to assure organ perfusion?

greater than 60

correct size BP cuff

width should be at last 40% arms circumference

what can falsely lead to high BP

to narrow cuff

applied too tightly

applied too loosely

too much pressure in cuff

what can falsely lead to low BP?

too wide cuff

to much pressure in the cuff can not get diastolic

paradoxical pulse

decreased systolic pressure more than 100 mm during inhalation, pulse may also go down