The General Survey Flashcards
Observations of the General Survey
- Physical Appearance
- Body Structure
- Mobility
- Behaviour
Physical Appearance
- age
- sex
- level of consciousness
- skin colour/ condition (even, rash, pallor, jaundice)
- facial expressions (symmetry with movement)
Level of Consciousness
Alert and Oriented x 3
1. Who they are
2. Where they are
3. When they are (season, date, month)
Consciousness is lost in the reverse order: when –> where –> who
LOC: Alert
awake, readily aroused, oriented, fully aware of external and internal stimuli, responds appropriately
full range of controlled movement
LOC: Lethargic
not fully alert, drifts off to sleep when not stimulated, can be aroused when touched or name is called (in a normal tone of voice), responds appropriately but seems slow, inattentive
spontaneous movement decreased
LOC: Obtunded
transitional state between lethargy and stupor
difficult to arouse (needs a vigorus shake or loud shout), otherwise will only groan, mumble, or move restlessly
LOC: Stupor or Semicoma
spontaneously unconscious, responds only to persistent, vigorous shakes or pain
confused when aroused, mumbles, incoherent speech, moves restlessly
still responds to painful stimuli, moves reflexively
LOC: Coma
completely unconscious, no response to pain or other internal/ external stimuli
light coma: some reflex activity, but no strong movements
deep coma: no reflex activity and no motor response
LOC: Acute Confessional State (delirium)
clouding of consciousness, inattentive, incoherent, impaired recent memory
worse at night when visual stimulation decreases (less stimuli to provoke consciousness)
Glasgow Coma Scale
used to assess patients suspected of a brain injury –> 3 areas:
1. Eye opening response
2. Motor response
3. Verbal response
Max score of 15 points
13-15 = mild
9-12 = moderate
3-8 = severe
GCS Score: 13-15
mild brain injury
GCS Score: 9-12
moderate brain injury
GCS Score: 3-8
severe brain injury
Body Structure
- stature
- nutrition (healthy, cachectic, obese)
- symmetry (bilateral, proportional)
- posture (plumb line)
- position (tripod, resisting laying down, fetal)
- body build, cntour,
Nutritional Assessment
assessments used to determine a patient’s nutritional status
Posture
- tripod sitting
- fetal position
- slumped shoulders
- closed off, reserved
- anxious
- sitting tall
Position
Body Max Index (BMI)
an indicator of optimal weight according to height –> may indicate obesity or malnutrition
BMI = weight/ height (squared)
BMI of <18.5
under weight
BMI 18.5-24.9
normal
BMI 25.0 - 29.9
over weight
BMI 30+
obese
What number can be used to best predict health outcomes?
waist circumference
Height and Weight of Older Adults
- shorten in stature due to compressed/ shortened vertebral discs
- postural changes due to changes in knee and hip flexion
- decrease in weight, bony prominences more visible
Mobility
- Gait (stable, shuffling, uneven, dragging feet)
- Range of Movement (fully mobility of joints, smooth, coordinated)
Behaviour
- Facial Expression
- Mood and Affect
- Speech
- Dress and Personal Hygiene