General Survey Flashcards
Includes objective data about the patient’s physical appearance, body structure, mobility, behavior, height, weight, and vital signs. It begins in the interview phase of a comprehensive health assessment
GENERAL SURVEY
TRUE OR FALSE:
The general survey begins in the pre-interaction phase of a comprehensive health assessment
FALSE
It begins with the INTERVIEW PHASE
TRUE OR FALSE:
While collecting objective data during the health history, the nurse starts observing and developing initial impressions about the individual’s health and formulating strategies for physical assessment
FALSE
SUBJECTIVE DATA is collected
Should include what is seen, heard, or smelled during the general survey
Initial Impression
TRUE OR FALSE:
The objective data collected during the survey will be used as a guide later on.
TRUE
EQUIPMENT TO BE USED
● (1) T - __________
● (2) S - __________
● (3) S - __________
● (4) S - __________
● (5) S - __________
● (6) A - __________
(1) Thermometer
(2) Standing Scale
(3) Stretcher Scale
(4) Sphygmomanometer
(5) Stethoscope
(6) Analog Watch
TRUE OR FALSE:
CLIENT PREPARATION
● Conduct the general survey with the client sitiing or standing.
● Ask the client to remove shoes and any heavy outer clothing before you measure height and weight.
TRUE
TRUE OR FALSE:
CLIENT PREPARATION
When weighing a hospitalized client, always weigh at a different time of the day, with a different scale, and with the client wearing different clothing.
FALSE
The client must be weighed at the SAME TIME OF DAY, with the SAME SCALE, and with the SAME CLOTHING
● A general survey is an overall review or first impression a nurse has of a person’s well being.
GENERAL OBSERVATION
TRUE OR FALSE:
GENERAL OBSERVATION
● Appearance
● Body Structure/ mobility
● Behavior
● Observe physical and sexual development
● Compare client’s stated age with her apparent age and development stage
● Observe skin condition and color
● Observe dress
● Observe hygiene
● Observe posture
● Observe body build as well as muscle mass and fat distribution
TRUE
Assesses the following:
o Client’s LOC (Level of Consciousness)
o Posture and body movements
o Dress, grooming, & hygiene
o Facial expression
o Speech
o Mood, feelings & expressions
o Thought processes and perceptions
o Cognitive abilities
MENTAL STATUS ASSESSMENT
● If a client has experienced a change in weight:
o Determine the (1) __________
o Assess the (2) __________ over which the weight change occurred
o Determine (3) __________ for weight loss or weight gain
(1) amount
(2) period of time
(3) possible causes
● Weigh clients using a (1) __________
● Use a (2) __________ for clients who are unable to bear weight
(1) standing scale
(2) stretcher scale
TRUE OR FALSE
HEIGHT AND WEIGHT
o Calibrate the scale by setting the weight to one
o Have client stand on the platform scale and remain still
o Adjust scale weight on the balance beam until the tip of the beam registers
in the middle of the mark.
FALSE
The scale must be set to ZERO
TRUE OR FALSE:
HEIGHT AND WEIGHT
● With the client standing erect on a scale, raise the metal rod attached to the scale up and over the client’s head.
● The rod should be placed level horizontally at a 45-degree angle to the measuring stick
FALSE
The rod should be placed horizontally at a 90-DEGREE ANGLE to the measuring stick
TRUE OR FALSE:
HEIGHT AND WEIGHT
● Height is measured in inches or centimeters.
TRUE
TRUE OR FALSE:
● Measurement of height is needed in adults to make an accurate assessment of weight status.
TRUE
● In children, height is monitored on a ___________ to assess growth and, indirectly, nutritional status.
continuum
● A weight gain of (1) __________ in a (2) __________ period is a useful marker in determining issues related to fluid retention, edema, or dehydration, which may indicate conditions such as congestive heart failure or renal disease.
(1) 3 pounds or more
(2) 1-week
● In contrast, unintentional weight loss of (1) __________ of body weight over a month or __________ over (2) __________ is considered clinically significant and warrants attention.
(1) 5% or more / 10% or more
(2) 6 months
_________________________ = % WEIGHT CHANGE
PRIOR WEIGHT - CURRENT WEIGHT / PRIOR WEIGHT X 100
Is widely used to assess appropriate weight for height
BODY MASS INDEX (BMI)
______________________________ = BMI
WEIGHT (kg) / HEIGHT^2 (meters)
WHO (BMI): <18.5
Asia-Pacfic (BMI): <18.5
UNDERWEIGHT
WHO (BMI): 18.5 - 24.9
Asia-Pacfic (BMI): 18.5 - 22.9
NORMAL
WHO (BMI): 25 - 29.9
Asia-Pacfic (BMI): 23 - 24.9
OVERWEIGHT
WHO (BMI): >= 30
Asia-Pacfic (BMI): >= 25
OBESE
● Include body temperature, pulse, respiratory rate, and blood pressure.
● Measurement of oxygen saturation and pain assessmet.
VITAL SIGNS MEASUREMENT
● Nurses measure vital signs to obtain (1) __________, to detect or monitor a change in the patient’s (2) __________, and to monitor patients at risk for (3) __________
(1) baseline data
(2) health status
(3) alterations in health
● __________ occurs because the heat loss mechanisms are unable to keep pace with excess heat production
Hyperthermia
Fahrenheit: 97.6 - 99.6
Celsius: 36.5 - 37.4
ORAL
Fahrenheit: 98.6 - 100.6
Celsius: 37.0 - 38.1
RECTAL
Fahrenheit: 96.6 - 98.6
Celsius: 36.0 - 37.0
AXILLARY
Fahrenheit: 98.6 - 100.6
Celsius: 37.0 - 38.1
TYMPANIC
● The body temperature alternates at regular intervals between periods of fever and periods of normal or subnormal temperatures.
Intermittent
● A wide range of temperature fluctuations (more than 2°C [3.6° F]) which occurs over the 24-hour period, all of which are above normal.
Remittent
● Short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature.
Relapsing
● Body temperature fluctuates minimally but always remains above normal
Constant
PHASES OF FEBRILE EPISODES
● Body’s heat producing mechanism attempt to increase the core body temperature
● Feeling of being cold and shivering
● Skin also appears pale and cool due to vasoconstriction
- Chill Phase
PHASES OF FEBRILE EPISODES
● Occurs when the fever reaches the new higher set point
● The client’s skin feels warm to touch and appears flushed because of vasodilation
● Complaints of general malaise, weakness and aching muscles
- Fever Phase
PHASES OF FEBRILE EPISODES
● Febrile episode
● Client’s experiences profuse diaphoresis, decrease shivering and possible fluid volume deficit
- Flush or Crisis phase
PULSE RATE
● Normal Rate = (1) __________
● Mean / Average = (2) __________
(1) 60 – 100 bpm
(2) 80 bpm
TRUE OR FALSE:
PULSE RATE
● May be as low as 60 bpm in healthy athletes
FALSE
50 BPM
TRUE OR FALSE:
PULSE RATE
● Equal bilaterally in strength / amplitude
TRUE
Pulse Rate Amplitude can be quantified as follows
1+ __________ (easy to obliterate)
2+ __________ (obliterate with moderate pressure)
3+ __________ (unable to obliterate or requires very firm pressure)
(1) thready or weak
(2) normal
(3) bounding
DEVIATIONS FROM NORMAL PULSE RATE
● > 100 bpm = _____________
o Anxiety, fear, nervousness
TACHYCARDIA
DEVIATIONS FROM NORMAL PULSE RATE
● < 60 bpm = _______________
o Prolonged sitting or standing
BRADYCARDIA
DEVIATIONS FROM NORMAL PULSE RATE
● ______________
o Difference between the apical and the radial pulse
PULSE DEFICIT
RESPIRATORY RATE
● Normal Rate = (1) ___________
● Regular and spontaneous rhythm
● Equal bilateral chest expansion of (2) ___________
(1) 12 – 20 cpm
(2) 1 – 2 inches
TYPES OF RESPIRATIONS
● 12-20 cpm and regular
NORMAL / EUPNEA
TYPES OF RESPIRATIONS
● Absence of respiration
APNEA
TYPES OF RESPIRATIONS
● Slow, shallow respiration
BRADYPNEA
TYPES OF RESPIRATIONS
● More than 20 cpm and regular
TACHYPNEA
TYPES OF RESPIRATIONS
● Increased rate and depth
HYPERVENTILATION
TYPES OF RESPIRATIONS
● Decreased rate and depth
HYPOVENTILATION
TYPES OF RESPIRATIONS
● Periods of apnea and hyperventilation
CHEYNE - STROKES
TYPES OF RESPIRATIONS
● Very deep with normal bleeding
KUSSMAUL
★ (1) __________ – occurs with patients with diabetes
○ (2) __________ - excess Ketones
(1) Kussmaul
(2) DKa (Diabetic Ketoacidosis)
Systolic BP (SBP): <120
AND
Diastolic BP (DBP): <80
NORMAL BP
Systolic BP (SBP): 120-129
AND
Diastolic BP (DBP): <80
PREHYPERTENSION
Systolic BP (SBP): 130-139
OR
Diastolic BP (DBP): 80-89
PREHYPERTENSION
Systolic BP (SBP): 140-159
OR
Diastolic BP (DBP): 90-99
STAGE 1 HYPERTENSION
Systolic BP (SBP): >=160
OR
Diastolic BP (DBP): >=100
STAGE 2 HYPERTENSION
● An unpleasant sensory and emotional experience, which is primarily associated with tissue damage or describes it in terms of such damage, or both.
o Pain comes from the greek word poinē meaning “Penalty”
PAIN ASSESSMENT
BROAD CLASSIFICATION OF PAIN
● Acute
● Chronic pain
TEMPORAL
BROAD CLASSIFICATION OF PAIN
● Malignant
● Nonmalignant
ETIOLOGIC
BROAD CLASSIFICATION OF PAIN
● Nociceptive
● Neuropathic
● Psychogenic
PHYSIOLOGICAL
A type of pain caused by damage to body tissue; receptors that transmit pain are called nociceptors.
NOCICEPTIVE
Type of pain which is the result of current or past damage to the peripheral or central nervous system and may not have stimulus; tissue or nerve damage; long lasting, unpleasant. Burning dull, or aching.
NEUROPATHIC
A pain disorder associated with psychological factors
PSYCHOGENIC
PAIN ASSESSMENT
(1) __________ – “Are you hurting today?”
(2) __________ - “What words describe your pain?” (Sharp, burning, tingling…)
(3) __________ - “Where is your pain? Does it shoot or radiate anywhere else?”
(4) __________ - “Give me a number between 0-10 for your pain.”
(5) __________ - “How long have you had this pain? How long does it last when the pain comes?”
(1) P – Presence of pain
(2) Q – Quality
(3) R – Radiation/Location
(4) S – Severity
(5) T – Timing
NONVERBAL PAIN DESCRIPTION GUIDE
Moaning, Groaning, Crying, Yelling, Sighing, Blowing
Vocalization
NONVERBAL PAIN DESCRIPTION GUIDE
Grimacing, Fearful, Sad, Withdrawn, Tense, Frowning
Facial Expression
NONVERBAL PAIN DESCRIPTION GUIDE
Bracing, Guarding, Walking, Sitting, Stiff Gait/Movements
Body Position
NONVERBAL PAIN DESCRIPTION GUIDE
Rocking, Pulling, Rubbing, Sleeping, Hyper-alert, Responsive, Fidgeting, Distracted, Withdrawn
Activity Patterns
NONVERBAL PAIN DESCRIPTION GUIDE
Immobilization, Purposeless movement, Protective movement, Rhythmic Movement
Body Movement
NONVERBAL PAIN DESCRIPTION GUIDE
Angry, Sad, Withdrawn, Aggressive, Passive, Irritable
Mood Changes
NONVERBAL PAIN DESCRIPTION GUIDE
Less able to assist in care, Actively resists care
Resistance to Care
NONVERBAL PAIN DESCRIPTION GUIDE
Diminished, Loss of interest in food
Appetite
● Does anyone in your family experience pain?
● How does pain affect your family?
FAMILY HISTORY
● What are your concerns about pain?
● How does your pain interfere with the following?
o General activity
o Mood/ emotions
o Concentration
o Physical Ability
o Work
o Relations with other people o Sleep
o Appetite
o Enjoyment of life
LIFESTYLE AND HEALTH PRACTICES
● Client is seated in a quiet, comfortable, and calm environment.
● Explain to the client that the interview will entail questions to clarify the picture of the pain experienced.
PREPARING THE CLIENT
KEY POINTS TO REMEMBER DURING A PHYSICAL EXAMINATION
● Choose an assessment tool that is reliable and valid to the client’s __________.
culture
- Suitable tool for those aged 3 years and over to determine pain scale, but may be unsuitable for those with severe cognitive impairment.
WONG-BAKER FACES PAIN RATING SCALE
PAIN ASSESSMENT TOOL FOR 0-1 Y.O.
NEONATAL/INFANT PAIN SCALE (NIPS)
PAIN ASSESSMENT TOOL FOR 1-3 Y.O.
FACE, LEGS, ACTIVITY, CRY, CONSOLABILITY (FLACC)
PAIN ASSESSMENT TOOL FOR AGES 3 AND ABOVE
WONG AND BAKER FACES PAIN RATING SCALE
PAIN ASSESSMENT TOOL FOR ADULTS
NUMERIC RATING SCALE
VISUAL ANALOGUE SCALE
PAIN ASSESSMENT TOOL FOR NON-VERBAL ADULT
CRITICAL CARE PAIN OBSERVATION TOOL (CCPOT)
ASSESSMENT IN ADVANCED DEMENTIA (PAINAD)
TRUE OR FALSE:
ASSESSING PAIN
● Understand that different cultures express pain differently and maintain different thresholds and expectations.
TRUE
TRUE OR FALSE
8 BEHAVIORAL INDICATORS OF DISCOMFORT
1. Noisy breathing
2. Negative vocalization
3. Sad facial expression
4. Frightened facial expression
5. Frown
6. Tense body language
7. Fidgeting
8. Physical Violence
FALSE
There are only 7 BEHAVIORAL INDICATORS OF DISCOMFORT; physical violence is NOT INCLUDED
● Received patient leaning on her daughter
● With difficulty of seating down on the chair
● Posture is not upright
● Unable to concentrate and continue an idea
● (+) facial grimace
● (+) frowning
● (+) irritability
● (+) guarding behavior
● With vital signs of:
o PR=108bpm
o RR=22cpm
o BP = 140/90 mmHg
SAMPLE OBJECTIVE DATA
● Readiness for enhanced spiritual well-being related to coping with prolonged physical pain
● Readiness for enhanced comfort level
● Health-Seeking behaviors related to desire and request to learn more about health promotion
WELLNESS DIAGNOSIS
RISK DIAGNOSIS
● Risk for __________ related to chronic pain and immobility
activity intolerance
RISK DIAGNOSIS
● Risk for __________ related to non-steroidal anti-inflammatory agents or opiates intake or poor eating habits
constipation
RISK DIAGNOSIS
● Risk for __________ related to anxiety, pain, life change, and chronic illness
spiritual distress
RISK DIAGNOSIS
● Risk for __________, related to chronic pain, healthcare environment, pain treatment-related regimen
powerlessness
RISK DIAGNOSIS
● Risk for __________ related to depression, suicidal tendencies, developmental crisis, lack of support systems, loss of significant others, poor coping mechanisms and behaviors
self-directed violence
ACTUAL DIAGNOSIS
● __________ related to injury agents (biological, chemical, physical, or psychological)
Acute pain
ACTUAL DIAGNOSIS
● __________ related to chronic inflammatory process of rheumatoid arthritis
Chronic pain
ACTUAL DIAGNOSIS
● __________ related to abdominal pain and anxiety
Ineffective breathing pattern
ACTUAL DIAGNOSIS
● __________ related to pain and anxiety
Disturbed energy field
ACTUAL DIAGNOSIS
● __________ related to stress of handling chronic pain
Fatigue
ACTUAL DIAGNOSIS
● Impaired ___________ related to chronic pain
physical mobility
ACTUAL DIAGNOSIS
● ___________ self-care deficit related to severe pain (specify)
Bathing/Hygiene self-care deficit
ACTUAL DIAGNOSIS
● ____________ related to hearing loss
Impaired verbal communication
ACTUAL DIAGNOSIS
● ___________ - impaired verbal communication related to inability to clearly express self or understand others
Aphasia
ACTUAL DIAGNOSIS
● _______________ related to aphasia, a psychological impairment, or organic brain disorder
Impaired verbal communication
ACTUAL DIAGNOSIS
● __________ self-care deficit related to impaired upper extremity mobility and lack of resources
Dressing/Grooming self-care deficit
ACTUAL DIAGNOSIS
● ___________ self-care deficit related to inability to wash body parts or inability to obtain water
Bathing/Hygiene self-care deficit
ACTUAL DIAGNOSIS
● __________ related to alcohol or drug abuse, psychotic disorder, or organic brain dysfunction.
Disturbed thought processes
● Posture is erect and gait is smooth
● Neatly dressed in light weight clothes appropriate for the summer season.
● Clean nails, well-groomed.
● Well-developed body built for age with even distribution of fat and firm muscle
● Client is alert, friendly, cooperative, and answers questions with good eye contact
● With height of 5’4” and weight of 60 kilos
● With vital signs of
o T = 37.2 ̊C
o PR = 84 bpm, regular, bilateral, equally strong and resilient
o RR = 16 cpm, regular, equal bilateral chest expansion
o BP = 120/80 mmHg, bilateral arms
Sample of Objective Data
