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Vitals, Gen Survey

Vital signs and general survey

Condition of being without fever Afebrile
Condition of being without spontaneous respiration for more than 10 seconds. Apnea
Absence of pulse Asystole
A period in which there are no Korotkoff sounds during auscultation. Auscultatory gap
The measurement of the force exerted by the flow of blood against the arterial walls. Blood pressure
A heart rate less than 60 beats/min. Bradycardia
Persistent respiratory rate less than 12 breaths/min. Bradypnea
The lowest pressure in blood pressure, which occurs when the left ventricle relaxes between beats. Diastolic blood pressure:
Handheld transducer that senses and ­amplifies blood pressure sounds. Doppler transducer
Difficulty breathing. Dyspnea
First component of the assessment, when the nurse makes mental notes of the patient's overall behavior, physical appearance, and mobility. General Survey
Resting respiration that is deeper and more rapid than normal. Hyperpnea
A blood pressure greater than 140/90 mm Hg. Hypertension
A temperature greater than 100F Hyperthermia
Hyperventilation Deep, rapid respirations.
Systolic blood pressure less than 90 mm Hg. Hypotension
Core temperature less than 95°F (35°C). Hypothermia
Shallow, slow respirations. Hypoventilation
Blood pressure that is calculated by adding one third of the systolic blood pressure to two thirds of the diastolic blood pressure Mean arterial pressure
When going from a supine or sitting position to a standing position, a drop in systolic blood pressure of 15 mm Hg or greater, drop in diastolic blood pressure of 10 mm Hg or greater, or increased heart rate. Orthostatic hypotension
A relative measure of the amount of oxygen dissolved or carried in a given medium. Oxygen saturation
The difference that exists between apical and ­peripheral pulses Pulse deficit
A noninvasive technique to measure oxygen saturation of arterial blood Pulse oximeter
The difference between the systolic and diastolic blood pressures; reflects the stroke volume. Pulse pressure:
Pulse that speeds up during inspiration and slows down during expiration. It is a normal finding in children and some adults. Sinus arrhythmia
The instrument used to measure blood pressure Sphygmomanometer
Maximum pressure on the walls of the arteries with contraction of the left ventricle at the beginning of systole. Systolic blood pressure
A heart rate greater than 100 beats/min in an adult. Tachycardia
A rapid, persistent respiratory rate greater than 20 breaths/min in an adult. Tachypnea
Important indicators of the patient's physiological status and response to the environment. They encompass temperature, pulse, respirations, and blood pressure. Vital signs
May cause patients to appear younger than stated age Deficiency of growth hormone
May cause patients to appear older than stated age Chronic illness, long term sun exposure, or various genetic diseases
Indicates CVA or Bells Palsy Facial Asymmetry
May indicate weight loss or gain Poorly fitting clothing
May indicate poor hygiene, tonsillitis or sinusitis, or allergic rhinitis Halitosis (bad breath)
May be indicative of diabetic ketoacidosis Sweet breath
Unkempt appearance of a previously well kept patient maybe caused by depression
Caused by poor hygiene or overactive sweat glands Body odor
Pallor Paleness
Redness Erythema
Blueness of skin Cyanosis
Yellowing of skin Jaundice
Abnormal findings in skin assessment Pallor, eyrthema, cyanosis, jaundice
Deficiency of growth hormones Delayed puberty may indicate
Altered growth hormones may lead to Markedly short or tall stature
Disproportionate height and weight, obesity, or emaciation can indicate Eating disorder or hormonal disorder
Barrel chest may indicate Long standing respiratory disease
Uncooperative behavior, flat affect, or unusual elation may indicate psychiatric disorder
Inappropriate affect, inattentiveness, impaired memory, and inability to perform activities of daily living may indicate Dementia or other cognitive disorder
A flat or mask-like expression may indicate Parkinson's disease or depression
Drooping of one side of the face may indicate Ischemic attack or CVA
Exophthalmos (­protruding eyes) may indicate Hyperthyroidism
Confusion, agitation, drowsiness, or lethargy may ­indicate Hypoxia, decreased cerebral perfusion, or a psychiatric disorder
Slow, slurred speech may indicate alcohol intoxication or cerebrovascular ischemia
Rapid speech may ­indicate hyperthyroidism, anxiety, or mania.
Difficulty finding words or using words inappropriately may indicate cerebrovascular ischemia or a psychiatric disorder
Loud speech may indicate Hearing difficulties
Slumped or hunched posture may indicate depression, fatigue, pain, or osteoporosis.
Long limbs may indicate Marfan Syndrome
A tripod position when sitting can ­indicate Respiratory disease (COPD)
Asymmetrical motion occurs in Stroke, paralysis, or spinal cord injury
Limited range of motion might be present with injuries or degenerative disease.
Tics, paralysis, ataxia, tremors, or uncontrolled movements may indicate Neurological disease
Shuffling gate may be indicative of parkinsons
result in a slow, unsteady gait Arthritis
result in decreased height from lack of nutrients for proper growth Chronic malnutrition
decreased height may result from osteoporosis
may cause excessive growth, as seen in gigantism and acromegaly, or deficiency in growth, as seen in dwarfism Hormonal abnormalities
How to obtain height when a patient cannot stand, have patient hold arms straight out and measure from middle finger to middle finger Measuring Wingspan
BMI under 18.5 Underweight
BMI of 18.5-25 Healthy weight
BMI of 25-29.9 Overweight
BMI of 30-39.9 Obesity
BMI over 40 Extreme obesity
Regulates body temperature Hypothalaumus
35.9°–36.9°C (96.7°–98.5°F) Average axillary temperature
97.7°–99.5°F Average oral temperature
37.1°–38.1°C (98.7°–100.5°F) Average rectal temperature
Newborn heartrate 70-190 with an average of 120bpm
Newborn respirations 30-40 breaths per minute
Newborn BP 73/55mmHg
Infant HR 80-160 average 120bpm
Infant RR 20-40RR
Infant BP 85/37mmHg
Toddler HR 80-130 average of 110
Toddler RR 25-32RR
Toddler BP 89/46mmHg
Child HR 70-115 average of 85
Child RR 20-26RR
Child bp 95/57mmHg
Preteen HR 65-110bpm average 90
Preteen RR 18-26RR
Preteen BP 102/61mmHg
Teen HR 55-105 average 80
Teen RR 12-22RR
Teen BP 112/64mmHG
Adult HR 60-100 bm average 70-75
Adult RR 12-20RR
Adult BP 120/80 mmHg
Heart failure, hypovolemia, shock, and arrhythmias can Decrease pulse strength
noted with early stages of septic shock, exercise, fever, and anxiety. Bounding pulse strength
Pulse strength "0" Non-palpable or absent pulse
Pulse strength "1" Weak, diminished. Barely palpable pulse
Pulse strength "2" Normal, as expected pulse
Pulse strength "3" Full, Increased pulse
Pulse strength "4" Bounding pulse
Normal BP Adult Systolic less than 120 Diastolic less than 80
Prehypertensive adult Systolic 120-139 Diastolic 80-89
Hypertensive Adult- Stage 1 Systolic 140-159 Diastolic 90-99
Hypertensive Adult- Stage 2 Systolic 160 and higher Diastolic 100 and higher
Hypertensive crisis Systolic higher than 180 Diastolic higher than 110
Exaggerated posterior curvature of the thoracic spine Kyphosis
measurements of height and weight Anthropometric measurments
Popular Nursing sets




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