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Nursing 202 Post Midterm > Unit 6 - General Survey, V/S, Pain Assessments > Flashcards

Unit 6 - General Survey, V/S, Pain Assessments Flashcards

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1
Q

During appraisal of the whole person, what are the four areas that you should consider?

A

Physical appearance
Body structure
Mobility
Behaviour

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2
Q

What are you assessing for in Physical appearance?

A

Age, Sex, Level of Consciousness

Skin Colour, Facial features

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3
Q

What are you assess for in Body Structure ?

A

Statues, Nutrition, Symmetry

Posture, Position, Body Build

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4
Q

What are you assessing for Mobility?

A

Gait, Range of Motion

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5
Q

What are you assessing for Behaviour?

A

Facial expression, Mood and Affect

Speech, dress, personal hygiene

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6
Q

Normal limits for Vital Signs

A 
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%
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7
Q

What may affect temperature?

A

Diurnal/circadian cycle,menstruation/menopause
exercise, age, environment and stress

Note: Newborns CANNOT regulate their body temp

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8
Q

What are the considerations for taking temp?

A

Assess 2 mins if pt smoked
5 mins after chewing gum
20 mins if ingested hot/cold liquids/foods

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9
Q

What does Pyrexia mean?

A

Fever, also known as febrile

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10
Q

What is Hyperthermia?

A

Increased temp

Body cannot regulate our temperature, IE: Heatstroke

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11
Q

What is Hypothermia

A

Decreased temp

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12
Q

What is Hypovolumia?

A

If the volume of our blood is low, heart rate will go up to compensate for the missing volume.

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13
Q

What may influence pulse?

A

Age, exercise, Emotions, Pain, Medications

Body positions, hypovolumia.

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14
Q

Considerations for measuring Pulse?

A

Assess by waiting 5-10 mins after activity

If irregular pulse (A-FIB - extra beat) , count for the full min.

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15
Q

What is Tachycardia?

A

Rapid pulse of beats over 100 per min

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16
Q

What is Bradycardia?

A

Slow pulse of under 60 beats per min

17
Q

How do you assess force/strength of a pulse? (Hint: Numerical)

A

0- Absent
1+ - weak/thready
2+ - Strong/normal
3+ - Bounding

18
Q

What may influence respirations?

A

Exercise, Pain, Anxiety, Smoking, Body positions

Medications, Brain injury, sleep

19
Q

What is Systolic Pressure measuring?

A

Ventricular contractions

AKA how hard your heart has to push to pump to your arteries

20
Q

What is Diastolic pressure measuring?

A

Resting, filling of the heart

21
Q

What is mean arterial pressure?

A

Average pressure over cardiac cycle

22
Q

What may influence blood pressure?

A

Age, Ethnocultural background, wt, emotions, gender

Diurnal rhythm, exercise, stress, medications

23
Q

Considerations when assessing BP

A

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

24
Q

Common errors when taking BP measurements ?

A

Inaccurate cuff size
Taking pressure when patient Is anxious, angry or has been active
Faulty technique (Arm position, failure to palpate radial)

25
Q

What is Hypotension?

A

Low Blood Pressure

26
Q

What is Hypertension?

A

High Blood Pressure

27
Q

What is Orthostatic (Postural) Hypotension?

A

Getting up to fast from a sitting to standing position.

28
Q

What are some changes in vital signs when pain is experienced?

A

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

29
Q

What is the 4 phases of pain (Nocioception) through the nerve pathway?

A

Transduction
Transmission
Perception
Modulation

30
Q

What is acute pain?

A

Pain that causes a sympathetic response (fight or flight), Usually lasts under 6 months
sudden pain onset, can be relieved

31
Q

what is chronic pain?

A

Last over 6 months, persistent and unrelieved pain

may case a parasympathetic response

32
Q

What is and example of Nocioceptive pain?

A

Source of pain that is a normal response

Examples are visceral pain or deep and superficial somatic pain

33
Q

What is an example of Neuropathic pain?

A

Abnormal response

Phantom Limb pain, or diabetic neuropathy

34
Q

True or False ?

Pain is whatever a patient say it is??

A

TRUE!

You can not feel there pain, therefore can not say that it does not exist. No matter what!

Nursing 202 Post Midterm (6 decks)

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