Unit 6 - General Survey, V/S, Pain Assessments Flashcards
During appraisal of the whole person, what are the four areas that you should consider?
Physical appearance
Body structure
Mobility
Behaviour
What are you assessing for in Physical appearance?
Age, Sex, Level of Consciousness
Skin Colour, Facial features
What are you assess for in Body Structure ?
Statues, Nutrition, Symmetry
Posture, Position, Body Build
What are you assessing for Mobility?
Gait, Range of Motion
What are you assessing for Behaviour?
Facial expression, Mood and Affect
Speech, dress, personal hygiene
Normal limits for Vital Signs
T - 36 to 38 Degrees P - 60 to 100 bpm R - 12 to 20 breaths/min BP - <120-130 / <80-85 130-139 /85-89 = high normal SPO2 - 92 to 100%
What may affect temperature?
Diurnal/circadian cycle,menstruation/menopause
exercise, age, environment and stress
Note: Newborns CANNOT regulate their body temp
What are the considerations for taking temp?
Assess 2 mins if pt smoked
5 mins after chewing gum
20 mins if ingested hot/cold liquids/foods
What does Pyrexia mean?
Fever, also known as febrile
What is Hyperthermia?
Increased temp
Body cannot regulate our temperature, IE: Heatstroke
What is Hypothermia
Decreased temp
What is Hypovolumia?
If the volume of our blood is low, heart rate will go up to compensate for the missing volume.
What may influence pulse?
Age, exercise, Emotions, Pain, Medications
Body positions, hypovolumia.
Considerations for measuring Pulse?
Assess by waiting 5-10 mins after activity
If irregular pulse (A-FIB - extra beat) , count for the full min.
What is Tachycardia?
Rapid pulse of beats over 100 per min
What is Bradycardia?
Slow pulse of under 60 beats per min
How do you assess force/strength of a pulse? (Hint: Numerical)
0- Absent
1+ - weak/thready
2+ - Strong/normal
3+ - Bounding
What may influence respirations?
Exercise, Pain, Anxiety, Smoking, Body positions
Medications, Brain injury, sleep
What is Systolic Pressure measuring?
Ventricular contractions
AKA how hard your heart has to push to pump to your arteries
What is Diastolic pressure measuring?
Resting, filling of the heart
What is mean arterial pressure?
Average pressure over cardiac cycle
What may influence blood pressure?
Age, Ethnocultural background, wt, emotions, gender
Diurnal rhythm, exercise, stress, medications
Considerations when assessing BP
Rest at least 5 mins (wait 60 if pt has ingested coffee or smoked)
Sit supported, feet flat on floor
Arm at level of heart, palm up
Common errors when taking BP measurements ?
Inaccurate cuff size
Taking pressure when patient Is anxious, angry or has been active
Faulty technique (Arm position, failure to palpate radial)
What is Hypotension?
Low Blood Pressure
What is Hypertension?
High Blood Pressure
What is Orthostatic (Postural) Hypotension?
Getting up to fast from a sitting to standing position.
What are some changes in vital signs when pain is experienced?
Temp - Diaphoresis with acute pain (sweating)
Pulse - tachycardia with acute pain, bradycardia with unrelieved or severe pain
Resps - Shallow and increase with acute pain, irregular with severe pain
BP- Increased with acute pain, may decrease with severe pain
Patients may NOT show any changes in vital signs
What is the 4 phases of pain (Nocioception) through the nerve pathway?
Transduction
Transmission
Perception
Modulation
What is acute pain?
Pain that causes a sympathetic response (fight or flight), Usually lasts under 6 months
sudden pain onset, can be relieved
what is chronic pain?
Last over 6 months, persistent and unrelieved pain
may case a parasympathetic response
What is and example of Nocioceptive pain?
Source of pain that is a normal response
Examples are visceral pain or deep and superficial somatic pain
What is an example of Neuropathic pain?
Abnormal response
Phantom Limb pain, or diabetic neuropathy
True or False ?
Pain is whatever a patient say it is??
TRUE!
You can not feel there pain, therefore can not say that it does not exist. No matter what!
