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NURS 1543 Study Notes.docx

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York University
NURS 1543
Eva Peisachovich

NURS 1543 General Survey – Study of the whole person, covering the general health state and any obvious physical characteristics. Objective parameters are used to form GS. Consider 4 main areas: 1. Physical Appearance  Age – Do they look their age?  Sex – Development is appropriate for gender and age  Level of Consciousness – Person is alert and oriented, can respond appropriately  Skin Colour – Tone is even, no lesions  Facial Features – Symmetrical with movement 2. Body Structure  Stature - Height within normal range for age and heritage  Nutrition – Weight within normal rage for height and built, body fat evenly distributed  Symmetry – Body parts equal bilaterally  Posture – Stands erect  Position – Sits comfortably  Body build/contour – Wing span = height, head to hip = hip to toe 3. Mobility  Gait – Smooth, even and well balanced, symmetrical arm swing  Range of motion – Full range is deliberate, accurate, smooth and coordinated 4. Behaviour  Facial expression – Eye contact, expression fits situation  Mood and affect – comfortable and co-operative  Speech – Clear and understandable  Dress – Appropriate and clean  Personal hygiene – Clean and groomed accordingly Measurement 1. Weight – Measure with balance scale – consider similar clothing and time of day for repeated weighing. 2. Height - Within recommended range of height Vital Signs Consists of 5 factors 1. Temperature  Body core mean of 37.2°C, Oral 35.8 – 37.3°C (37°C)  Hypothalamus = bodies thermostat Influences  Diurnal cycle - 1- 1.5°C  Menstruation cycle – Progesterone causes .5 - 1°F increase  Exercise – Moderate to hard causes increase  Age – Wider range in infants/ young children due to less effective heat control mechanisms – elderly normally lower mean of 36.2°C Routes of Measurement  Oral - Accurate and convenient - Measured by placing thermometer in posterior sublingual pocket - Hot or cold drinks: 20 min wait - Smoked: 2 min wait - Chewed gum: 5 min wait  Axillary – Safe and accurate for infants/ young children if environment is controlled  Rectal (core temp) - Only use if other means are not practical - Disadvantages: discomfort, time consuming, disruptive  Tympanic membrane - Accurate measure of core temp - Advantages: speed, convenience, safety, reduced risk of injury/infection, noninvasiveness 2. Pulse  Stroke volume flares the arterial walls generating pressure wave which is felt in the periphery as pulse  Palpating peripheral pulse gives rate and rhythm of heart beat  Radial pulse is used when measuring vital signs  Regular rhythm: count beats for 30 sec multiply by 2  Irregular rhythm: count beats for full min Assess using 4 criteria 1. Rate  Normal heart rate range is 60 to 100 beats per min  Faster rate in infants, slower in adults  Females slightly faster than males after puberty  Bradycardia less than 60 bpm, common in athletes  Tachycardia over 100 bpm common with anxiety or exercise 2. Rhythm  Sinus arrhythmia common in child and young adults  Heart rate varies with respiratory cycle, speeding up at the peak of inspiration, slowing to normal with expiration 3. Force  Weak = decreased stroke volume, Strong = increase SV  0 = absent, 1+ = weak/thread, 2+ = normal, 3+ = full/bounding 4. Elasticity  Normal elasticity the artery feels springy, straight, resilient 3. Respiration  Do not make client aware you are measuring respirations, may alter pattern  Maintain position of counting radial pulse and count respiration for 30 sec or 1 min if abnormal  Normally more rapid in infants/children  4:1 ratio pulse rate to respiratory rate 4. Blood Pressure  Force of blood pushing against vessel wall  Systolic pressure is the maximum pressure felt on the artery during left ventricular contraction (systole)  Diastolic pressure is the elastic recoil or resting pressure that the blood exerts constantly between each contraction  Pulse pressure is the difference between systolic and diastolic pressure and reflects stroke volume  Mean arterial pressure(MAP) is the pressure forcing blood into the tissues averaged over the cardiac cycle  Average BP is 120/80 mm Hg Influences  Age – Gradual rise from childhood to adult hood  Gender – Before puberty no difference between male and female – After puberty females lower BP than males – After menopause females higher BP than males  Race – Incidence of hypertension twice as high for Africans than European, believed to be linked to genetics and envirorment  Diurnal rhythm – Highest late afternoon or early evening, lowest early morning  Weight – Higher in obese  Exercise – Increased activity = increased BP, usually return to normal within 5 min of resting  Emotions – Fear, anger, pain makes sympathetic nervous system increase BP  Stress - Continual tension because of lifestyle, occupational stress or life problems cause increase Physiological factors controlling BP  Cardiac output – Increased output = increased BP, can increase output by increasing SV and/or HR  Peripheral vascular resistance – opposition to blood flow through the arteries ex. vasoconstriction/dilation, increased PVR = increased BP  Volume of circulating blood – how tightly the blood is packed into the arteries ex. bleeding or intravenous fluid overload , increased VCB = increased BP  Viscosity – How thick blood is based on blood cells, thicker = increased BP ex. increase hematocrit in polycythemia  Elasticity of vessel wall – stiff/rigid = increased BP ex. arteriosclerosis Measurement  Measured using stethoscope and an aneroid sphygmomanometer (mm Hg)  Cuff width = 40% of circumference of persons arm  Cuff length = 80% of circumference of persons arm  Match cuff to persons arm size and shape not their age  Too narrow cuff can give falsely high BP  Person sitting or lying with bare arm supported at heart level  If sitting feet should be flat on floor because BP has false high measurement when legs are crossed  Palpate brachial artery, located just above antecubital fossa medial to bicep tendon  Place cuff 1 inch above brachial artery (tight enough to slip two fingers in)  Inflate cuff until there is no artery pulsation from brachial artery then further inflate another 20-30 mm Hg  Use bell over brachial artery to pick up sounds of blood pressure (bell low pitched (smaller), diaphragm high pitch (bigger))  Deflate cuff slowly and evenly about 2 mm Hg per heartbeat  Note point at which you hear first appearance of sound, phase I of Korotkoff’s sounds, systolic pressure  Note point at which you hear muffling of sound, phase I
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