Istinye University: Acute Assessment & Vital Signs

• İstinye University was founded in 2015 by the 21st Century Anatolia Foundation.
• İstinye University aims to be among the distinguished universities in Turkey and the world.
• İstinye University aims to expand the boundaries of science and implement scientific findings by providing quality and accessible healthcare services to society.
• Istinye University provides an environment for learning and advancement that encompasses technology and art

General Survey, Vital Signs, and Pain Assessment

• The general survey begins during the interviewing and history taking process.
• Healthcare professionals observe patients while collecting subjective data.
• They also develop initial impressions and form plans for collecting objective physical data.
• Vital signs are key indicators of a patient's physiological condition and how they respond to their surroundings.

Acute Assessment

• Indicators which define an acute situation include: extreme anxiety, acute distress, pallor, cyanosis, and changes in mental status.
• In acute cases, the nurse starts treatments while continuing the assessment.
• He or she obtains all vital signs and asks for assistance.
• A rapid response team should be called if the nurse senses something is wrong or if the patient displays:
  • Respirations of less than 10 breaths/min or greater than 32 breaths/min
  • Increased effort to breathe
  • Oxygen saturation less than 92%
  • Pulse less than 55 beats/min or greater than 120 beats/min
  • Systolic BP less than 100 or greater than 170
  • Temperature less than 35°C or greater than 39.5°C
  • New onset of chest pain
  • Agitation or restlessness

Objective Data Collection require equipment such as

• Scales
• Height bar
• Tape measure(for infants)
• Stethoscope
• Pulse oximeter
• Thermometer
• Watch with second hand

General Survey

• The general survey is the first step in assessment.
• A global impression of the person is formed by mental notes of their overall behavior, physical appearance, and mobility.

Physical Appearance

• Physical appearance includes overall appearance, hygiene and dress, skin color, and body structure and development.
  • Overall appearance:
    • Assess stated age, symmetry, deformities, and signs of distress.
  • Hygiene and Dress:
    • Note appropriateness of clothes, cleanliness, odors, and condition of hair/nails.
  • Skin Color:
    • Observe skin tones, symmetry, lesions, pigmentation, and hair distribution.
  • Body Structure and Development:
    • Check if physical/sexual development aligns with stated age, body proportions, and any joint issues.

Behavior

• Behavior includes facial expressions, level of consciousness and speech
• Facial Expressions:
  • Assess facial symmetry and expressions during rest/speech, eye contact.
• Level of Consciousness:
  • Check orientation to name, location, date, and alertness.
• Speech:
  • Note speech pattern, clarity, vocabulary, fluency, and need for interpreter.

Mobility

• Mobility assessment includes posture and gait.
• Posture:
  • Asses if patient sits and stands, and body alignment.
• Range of Motion:
  • Check for equal limb movement and limitations.
• Gait:
  • Observe coordinated movements, tremors/tics, assistive devices.

Anthropometric Measurements

• Height and weight
• Body mass index (BMI)

Vital Signs

• Vital signs include:
  • Temperature
  • Respiratuins
  • Pain
  • Pulse
  • Blood pressure
  • Oxygen Saturation
• Vital signs reflect health, cardiopulmonary function, and body function.

Temperature

• Normal Ranges:
  • Oral temperature ranges from 35.8°C to 37.3°C.
  • Axillary temperature is around 36.5°C, or 1°C lower than oral.
  • Tympanic temperature is about 37.5°C, similar to oral.
  • Temporal temperature is approximately 37°C, same as oral.
  • Rectal temperature is around 37.5°C, or 1°C higher than oral.

Pulse

• The contraction of the heart causes blood to flow forward, which creates a pressure wave known as a pulse.
• A heart rate of 60 to 100 beats per minute (bpm) is normal in adults.
• A normal apical pulse is 60 to 100 beats/min and regular.

Respiration

• Breathing supplies oxygen and removes carbon dioxide.
• Inspiration and expiration should be observed discretely.
• Respiratory rates for adults are 12 to 20 breaths per minute and regular.

Oxygen Saturation

• Pulse oximetry measures the percentage of hemoglobin filled with oxygen in arterial blood.
• Pulse oximetry does not replace arterial blood gases for abnormalities but indicates abnormal gas exchange.
• Typically a finger is used for reading.
• A normal pulse oximetry reading (SpO2) is 95% to 100.

Blood Pressure

• Blood pressure (BP) measures the force of blood against arterial walls during heart contraction and relaxation.
  • Systolic pressure is maximum pressure during ventricular contraction.
    • This is performed on the arterial walks with contraction of the left ventricle at the start of systole
  • Diastolic pressure is minimum pressure during ventricular relaxation.

Blood Pressure Ratings in Adults

• Hypotension: Systolic less than 90 / Diastolic less than 60
• Normal: Systolic less than 120 and / Diastolic less than 80
• Prehypertension: Systolic 120-139 or / Diastolic 80-90
• Stage 1 Hypertension: Systolic 140-159 or / Diastolic 90-99
• Stage 2 Hypertension: Systolic greater than 160 or / Diastolic greater than 100

Pain

• Location, Duration, Severity, Quality, and Alleviating/Aggravating Factors are assessed.
• Numeric pain intensity scale (0=no pain, 10=worst pain) indicates severity.
• The higher the selected number, the more severe the pain is.

Questions to assess symptoms

• Location: The painful area.
• Duration: When did the pain start and how long have you had it?
• Intensity: Pain level on a scale of 0 to 10.
• Is it worse or better at certain times?
• Quality: the pain feels like?
• Aggrevating/Alleviating Factors:
  • Does heat or cold help?
  • Does a cold pack help?
  • Does activity increase the pain?
  • Does sitting make it better?
  • What makes the pain better/worse?
  • What have you used to manage it?
  • Is the pain decreasing with medication?
• Types of pain
  • Burning
  • Tingling
  • Electric shocks
  • Cold
  • Stabbing