UNIT 5 General survey, Measurement, and Vital Signs; Pain Assessment Flashcards
The 4 areas of the general survey
Physical appearance
Body structure
Mobility
Behaviour
The General survey: Physical Appearance
Age; Sex; Level of consciousness; Skin colour; Facial features
The General survey: Body Structure
Stature (height); Nutrition (weight); Symmetry; Posture; Position; Body build
The General survey: Mobility
Gait; Range of motion (ROM)
The General survey: Behaviour
Facial expression; Mood + affect; Speech; Dress; Personal hygiene
Acceptable Vital Sign Readings for Adults/”Normal” Ranges
Temperature: 36-38
- avg Oral/Tympanic/Temporal: 37
- avg Rectal: 37.5
- avg Auxiliary: 36.5
Pulse: 60-100 beats/min
Respirations: 10-20 breaths/min
Blood Pressure: (less than) 120-130/(less than) 80-85 {130-139/85-89 = high normal}
Oxygen Saturation (SpO2): 95-100%
Factors that may influence Temperature:
Time of day
Menstruation (T increases)
Menopause (T increases)
Exercise
Age (older = lower in temp)
Environment
Stress
Pyrexia/Febrile
Fever
Hyperthermia
Increased T
A prolonged period of increased temperature
Hypothermia
Decreased T
A prolonged period of decreased temperature
Factors that may influence the pulse:
Age
Exercise
Temperature
Emotions
Pain
Medications
Body Position
Hypovolemia
what to take note of when assessing the strength of a pulse
Rate = beats/min
Rhythm = regular?/irregular?
Force/Strength = (3+) Full/bounding; (2+) Normal; (1+) Weak/thready; (0) absent
Equality = compare pulses on both sides of the body
Tachycardia
Rapid pulse (> 100 beats/min)
Bradycardia
Slow pulse (< 60 beats/min)
Factor that may influence respirations
Exercise
Temperature
Pain
Anxiety
Smoking
Body Position
Medications
Brain Injury
Hemoglobin Function
Sleep
When counting respirations, make sure to also assess for…
Respiratory rate = respirations/min
Pattern/rhythm = regular?/laboured?
Depth = deep, normal, or shallow
SpO2 = oxygen saturation/% of hemoglobin bound with O2
Factors that may influence Blood Pressure
Age
Ethnocultural background
Weight
Emotions
Gender
Diurnal rhythm
Exercise
Stress
Medications
Systolic Pressure
Ventricular contraction; pushing blood out
Diastolic Pressure
Resting; filling heart
Pulse Pressure
Systolic P - Diastolic P
Mean Arterial Pressure
over cardiac cycle (avg pressure overall)
diastolic + 1/3 pulse pressure
Physiological Factors:
Cardiac output
Peripheral vascular resistance
Volume of circulating blood
Viscosity of blood
Elasticity of vessel walls
Korotkoff’s Sounds
Phase 1 = systolic P (clear tapping)
Phase 4 = muffling of sounds (tap-swoosh)
Phase 5 = diastolic P (silence)
Pain
Pain is an unpleasant sensory and emotional experience associated w, or resembling that associated w, or resembling that associated w, actual or potential tissue damage
