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Vitals, Gen Survey
Vital signs and general survey
| Question | Answer |
|---|---|
| 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 |
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