Exam 7: General Survey, Measurement, Vital Signs

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Describe various routes of temperature measurement and special consideration for each route.

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The routes of temperature measurement reflect the body's core temperature. The oral temperature is accurate and convenient. The oral route may not be appropriate for comatose or confused persons, those with a wired mandible or facial dysfunction, or those who cannot close the mouth. Axillary temperature is safe and accurate for infants and young children when the environment is reasonably controlled. The rectal route is used when other routes are not practical. Disadvantages of the rectal route are patient discomfort, time-consuming and disruptive activity, and risk of cross-contamination. A tympanic membrane thermometer is a noninvasive, non traumatic device that is quick and efficient. Special consideration is needed for patients with ear disorders.

List the factors that affect blood pressure.

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Several interrelated factors affect blood pressure: age, sex, race, diurnal rhythm, weight, exercise, emotions, and stress. The level of blood pressure is determined by these factors: the pumping action of the heart or cardiac output, peripheral vascular resistance, the elasticity of the walls of the main arteries, the circulating blood volume, and the blood's viscosity.

Describe the appropriate procedure for assessing normal respirations.

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Because breathing is normally relaxed, regular, automatic, and silent, respirations are counted while the hand is still in position for taking the pulse and the patient is unaware that respirations are being counted. Respirations are counted for 30 seconds unless an abnormality is suspected; the rate is then counted for a full minute. A ratio of 4:1 for pulse rate to respiratory rate is common. Assessment findings may be altered on the basis of the patient's condition.

Describe the four qualities considered when one assesses the pulse.

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Discuss measurement of weight and height.

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List the information considered in each of the four areas of a general survey: physical appearance, body structure, mobility, and behavior.

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Discuss relevant developmental care in relation to a general survey.

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Relate the use of a blood pressure cuff of improper size to the possible findings that may be obtained.

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Describe the relationships among the terms blood pressure, systolic pressure, diastolic pressure, pulse pressure, and mean arterial pressure (MAP).

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