WEEK 2- GENERAL SURVEY Flashcards
vital signs, survey, pain assessment, OPQRSTU
General survey components
General Survey: study of the whole person, covering the general health state and any obvious physical characteristicsShould give an overall impression, a “gestalt” of the patient Objective parameters are used- applies to whole person not just to one body system 4 areas: physical appearance, body structure, mobility & behaviour
physical appearance
Physical Appearance age: appears to be stated agesexlevel of consciousness: alert and oriented skin colorfacial features: symmetrical with movement
body structure
Stature: height within normal rangeNutrition: weight within normal range Symmetry: body parts equal proportion PosturePosition
Body build, contour: normal proportions
mobility
Gait: accurate foot placement, smooth walk ROM: full mobility of each joint, coordinated movement
behaviour
Facial expression: maintaining eye contact, expressions appropriate Mood and affect: comfortable and cooperative
Speech: clear and understandable articulation
oFluent stream of talking, with even pace
oConveying ideas clearly
oWord choice appropriate Dress: clothing appropriate for climate, situation etc. Personal hygiene: appearance clean and groomed appropriately
measurement- weight and height
Weight & Height
Remove shoes and outer clothing
Show comparison to recommended weight Feet, shoulder and buttocks should be in contact with the wall (height)
measurement- BMI
Marker of optimal weight for height Indicator of obesity or malnutrition BMI = weight (in kilograms) divided by height (in metres) OR weight (in pounds) divided by height (in inches) x 703
measurement- waist to hip ratio
Body fat distribution Greater fat proportion in the upper body (especially abdomen) have android obesity
Greater fat proportion in the lower body has gynoid obesity
Waist to hip ratio = waist circumference/hip circumference
Vital sign components
temperature
pulse
respirations
blood pressure
oxygen saturation
average temperature
37 degree Celsius
ways to measure temperature
oral- most common
rectal- most accurate, infants, most invasive
tympanic
axillary
temperature is influenced by what?
-diurnal cycle- daytime cycle
-menstural cycle
- exercise
- age- older=less temp
how to measure each temp, oral, rectal, axillary, tympanic
Oral temperature procedure:
oMercury free glass thermometer and place on inside of mouth on the sides of the tongue
oLeave in place for 3-4 mins if patient is afebrile and 8 mins if febrile
oWait 20 mins if patient just had hot or cold liquids oWait 2 mins if patient just smoked
oUse an electronic thermometer as well Axillary temperature procedure:
oSafe and accurate for infants and young children- not method of choice for adults due to high insensitivity
Rectal temperature procedure:
oMeasure rectal only when other routes are not practical
oWear gloves and insert a lubricated rectal prove cover on an electric thermometeroInsert only 2-3 cm into the adult rectum directed toward the umbilicus
oFor glass thermometer leave it in place for 2.5 mins
oDisadvantages: patient discomfort, time consuming and disruptive nature of activity Tympanic Membrane Temp procedure:
oTMT senses infrared emissions of the tympanic membrane (eardrum)
oThe eardrum shares the same vascular supply that perfuses the hypothalamus – making it accurate
oCover the probe tip with a tip cover and place probe tip into patient’s ear canal
o2-3 seconds
Pulse
stroke volume: with every beat the heart pumps 70 ml of blood into the aorta othis causes the arterial walls to widen and generates a pressure wave, which is felt as the pulsepalpate the radial pulse at the flexor of the wrist laterally along the radius bone – count the # of beats in 30 seconds and multiply by 2 (if beat is regular)count to 60 seconds if beat is irregular (atrial fibrillation) assess the rate, rhythm, force, and equality (when comparing pulses bilaterally)all symmetrical pulses should be assessed simultaneously except for the carotid pulse
pulse consists of 3 components
rhythm
force
rate
rate- pulse
normal resting heart rate is 50-95 beats/min
rate varies with gender-after puberty, girls have faster rate a resting heart rate <50 beats/min = bradycardiaooccur normally in well-trained athlete
othe stronger heart muscle pushes out a larger stroke volume with each beat, tf fewer beats per min to maintain a stable cardiac output
Cardiac Output = stroke volume x rate
A more rapid resting heartrate over 100 beats/min is tachycardia
oRapid rates occur normally with anxiety or exercise
rhythm- pulse
Normally has an even tempo
Sinus arrhythmia: heart varies with the respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration
oInspiration causes a decreased stroke volume from the left side of the heart therefore- heart rate increases
force- pulse
Force of the pulse shows the strength of the heart’s stroke volume
Weak thready pulse: decreased stroke volume (occurs with hemorrhagic shock)
Full bounding pulse: increased stroke volume, as occurs with anxiety, exercise etc,
Pulse force is recorded on a 3-point scaleo3+ full bounding o2+ normalo1+ weak, threado0 absent most healthy adults have a force of +2
respirations
maintain position of counting radial pulse and count the respirationscount for 30 secs to 1 minute inspiration and expiration = 1 full cycle
respiratory rates are higher in children and infants
pulse rate to respiratory rate is constant at 4:1 normal respiratory rates (breaths/min)
neonate: 30-40
o1 year: 20-40
o2 years: 25-32
o4 years: 23-30
o8-10 years: 20-26
o12-14 years: 18-22
o16 years: 12-20
oadult: 10-20
Blood pressure procedure
the force of the blood pushing against the side of the vessel wallsystolic pressure: maximum pressure felt on the artery during left ventricular contraction (systole)
diastolic pressure: elastic recoil, or resting, pressure that the blood exerts constantly between each contraction
pulse pressure: the difference between the systolic and diastolic oreflects stroke volumethe mean arterial pressure (MAP): the pressure forcing blood into the tissues, averaged over the cardiac cycle
average BP is influenced by different factors:
oage: BP rises through childhood and into adult yearsosex: before puberty there is no difference, after puberty girls have a lower BP than males, after menopause BP is higher in women
oethnocultural considerations: African descent usually have higher BP than European oweight: BP is higher in obese patients
oexercise: increasing activity increases BP
oemotions: BP rises with fear, anger and pain as a result of stimulation of the sympathetic nervous system
ostress: BP rises with elevated tensionthe level of BP is determined by 5 factors:
ocardiac output: if the heart pumps more blood into the blood vessels, the pressure on the vessel walls increase
operipheral vascular resistance: opposition to blood flow through the arteries, when blood vessels become smaller (constricted), greater pressure is needed to push the blood through ovolume of circulating blood: refers to how tightly the blood is packed into the arteries. Increasing the volume of blood increases the pressure
oviscosity: the thickness of blood is determined by its formed elements, the blood cells. When blood is thicker, the pressure increases
oelasticity of vessel walls: when walls are stiff and rigid – more pressure is needed to push blood BP is measured with a stethoscope and an aneroid sphygmomanometer oMust be recalibrated once a year and rest at 0 Arm Pressure Procedure: Take 3 measurements separated by 2 minutes – discard the first reading and average the other two Do both arms for the first reading – a 5 to 10 mm Hg difference may occur oIf difference of >20mm Hg continue measuring both arms for duration Feet flat on the floorPalpate the brachial artery, located above the antecubital fossa and centre the deflated cuff about 2.5 cm above the artery and wrap it evenly around arm Auscultatory gap: period when Korotkoff’s sounds disappear during auscultation Inflate the cuff until the artery pulsation is gone and then 20-30mm Hg beyond
Deflate the cuff quickly, then wait 15-30 seconds before reinflating Phase 1 first appearance of soundPhase 4 muffling of soundPhase 5 disappearance of sound oNow used to define diastolic pressure
oWhen variance is greater than 10-12 mm Hg between phases IV and V- record both phases along with the systolic reading Seated BP’s determine and moniter treatment decisions Standing BP’s diagnose postural hypotension
hypotension
In normotensive adults: <95/60In hypertensive adults: >95/60
In children: < expected value for age Occurs with: Acute myocardial infarction
decreased cardiac output
Shock
“Hemorrhage decrease in total blood volume
Vasodilation
decrease in peripheral vascular resistance
hypertension
Essential or primary hypertension – has no cause but is responsible for 95% of hypertension in adults Cardiovascular risk stratification in patients with hypertension
Major risk factors: Smoking
Dyslipidemia
Diabetes mellitus
Age >60 years
Gender (men and postmenopausal women)
Family history of cardiovascular disease
somatic pain
superficial (superficial somatic or cutaneous pain)- derived from skin surface and subcutaneous tissues or deep (deep somatic pain) derived from joints, tendons, muscles, or bone
visceral pain
originates from the larger interior organs (kidney, intestine, gallbladder and pancreas)
Pain can stem from direct injury to the organ or from stretching of the organ as a result of tumour, ischemia, distension, or severe contraction
Can be constant or intermittent, and may be poorly localized or referred to another area of the body
Ex. Ureteral colic, acute appendicitis, and pancreatitis
referred pain
Originates in one location but is felt at another site Both sites are innervated by the same spinal nerve- difficult for the brain to differentiate the point of origin
oEx. When the appendix is inflamed, pain may be felt in the periumbilical area
2 types of pain
chronic
acute
chronic pain
Pain that has been present for 6 months or longer than the time of expected tissue healing
Malignant (cancer-related pain) or non-malignant oMalignant often parallels the pathological process created by the tumour cellsThe pain is induced by tissue necrosis or stretching of an organ by the growing tumour oNon-malignant pain is often associated with musculo-skeletal conditions (arthritis, low back pain, and fibromyalgia
Unrelieved acute pain can lead to chronic pain through 2 processes:
oPeripheral sensitization: the reduction of the pain threshold and an increased response of the peripheral end of the nociceptors
oCentral sensitization: an increase in excitability of neurons within the CNS
acute pain
Short term and self-limiting
Follows a predictable trajectory and dissipates after an injury heals
Ex. Surgery pain, trauma and kidney stones
Serves a self-protective purpose: it warns of actual or potential tissue damage
developmental considerations- infants
Infants have the same capacity for pain as do adults 20 weeks’ gestation- ascending fibres, neurotransmitters and cerebral cortex are developed and functioning to the extent that the fetus can feel painoinhibitory neurotransmitters are in insufficient supply until birth at full term- preterm infants are more sensitive to painful stimuli repetitive and poorly controlled pain can result in life-long adverse consequences- neurodevelopmental problems, poor weight gain, learning disabilities, psychiatric disorders, and alcoholism
children older than 2 can report pain and point to its location but are unable to rate pain intensity
older adults
- pain is not a normal process of aging
- pain indicates injury or disease
OPQRSTUV
Onset
Palliative or provocative
quality
region/radiation
severity
timing
understanding of pain
values
O- ONSET
O: onset
When did the pain start?To identify onset of pain (when active, or resting) or whether pain is acute/chronic
P- PROVACTIVE/PALLAITIVE
Does your pain increase with movement/activity?Are the symptoms relieved with rest?
Were any previous treatments effective?
To identify quality of pain and differentiate between nociceptive and neuropathic pain mechanisms
To identify alleviating and aggravating factors
To evaluate effectiveness of current txt
Q- QUALITY
Quality of the pain
What does your pain feel like?
What words describe your pain?
To identify mechanism of pain (adjectives
R- REGION/RADIATION
R: region of the body/radiation
Where is your pain?Does the pain radiate/move to other areas?
To identify one or more areas of the body that are affected by pain
S- SEVERITY
S: severity of pain
How would you rate your pain on an intensity scale?To identify intensity
To identify degree of impairment and effect on quality of life or ability to perform ADLs
T- TIMING
T: treatment/timing What treatments have worked for you in the past?
Is it a constant, dull, or intermittent pain?
To identify txt that have been successful in the past
To identify the timing of the pain so that the treatment can be focused on spikes in pain
U- UNDERSTANDING OF PAIN
U: understanding of pain What do you believe is causing the pain?
To understand patient history of pain
To be able to set achievable pain and function goals when reviewing the plan of care
V- VALUES
V: values
What is your acceptable level for this pain?
Is there anything else that you would like to say about your pain?
Are there any other symptoms related to the pain?
To understand and discuss other stressors, spiritual pain
face pain scale
The faces pain scale – revised (FPS-R)
oGood for children or people who do not speak English
o6 faces that show pain intensity from ‘no pain’ to ‘very much pain’
